It was my turn to work New Year’s Eve and I was hoping against hope that bad weather, the down economy and fate in general would combine to make it a slow night. I would have settled for even a slow start to the night. But it was not to be. The jammed parking lot was my first clue and it was cause for a deep preparatory sigh and an additional squirt of stomach acid as I trudged through the ambulance doors. Susan, the charge nurse, was the first to see me. She was wearing a festive head band with a sparkling ‘Happy New Year’ which barely held back her sweaty hair. Her face read anything but ‘Happy’.
“It’s been like this all day,” she said with a tone of exasperation. “I’m going to go home and get hammered before I ring in the New Year. We’re holding ten and they just keep coming. The ‘door to doc’ is up to three hours and it just keeps getting longer. Everyone is working as hard and fast as they can. But we’ve just had a lot of sick people.”
She really didn’t need to explain this to me. But I could tell from her expression that she was truly sorry to see this mess dumped in my lap. We really did have a good staff and this wasn’t anyone’s fault. It was just my time.
“Don’t worry about it,” I said with false optimism. “I’ll have this cleaned up by morning.”
“Just get started,” said Kurt, the doctor I was supposed to relieve. “I’ll finish my charts. It’s bad enough. I can’t dump my cases on you too.” It was a small gesture. But I deeply appreciated it as I picked up an armful of charts.
My hopes of clearing out a few quick ones evaporated as soon as I went into the first room. A muscular young man in a hockey uniform was sitting on the bed with an obviously dislocated shoulder. The chart indicated that the PA had attempted a reduction and failed due to the need for deeper sedation, which they weren’t credentialed to use.
“I’m not complaining,” he said through a grimace, “but I’ve been waiting a long time and the pain med is really starting to wear off. Do you know how much longer it will be?”
“I just got here. But I can take care of this right now.” Of course, ‘right now’ meant getting the lines and monitors set up, getting help for counter traction, and getting the meds on board. The procedure itself went smoothly and didn’t take long. But after writing up the case I realized that the entire procedure had taken the better part of forty minutes and I was still walking around with an armful of charts.
Before I could even open the door to chart number two, Susan hailed me with another chart. “This is my last one before going home. But you need to see this one now.” She handed me the EKG with obvious ST elevations in the anterior leads.
“Have you called the cath lab?” I asked, moving toward the cardiac room.
“Yes, but they won’t call the cardiologist on my word. You have to see him first.”
“Time is muscle,” I said with a tone of frustration.
“I know. You’re preaching to the choir.”
“Call them now,” I said. “I’ll be ready to talk to the cardiologist as soon as they can get him on the phone.” Entering the room I was surprised to find the patient still in his expensive business suit feverishly keying away on his cell phone.
“I think you need to put that down and attend to business here,” I said with a note of warning.
“This IS my business,” he said barely raising his head to acknowledge me. “We have a merger that has to be completed by midnight or we could lose a bundle.”
“We need to take you to the cath lab now, or you might not make it to midnight,” I said sternly, finally getting his attention.
“You don’t understand,” he said. “I’ve had chest pain like this off and on for weeks. Just give me another hour. I just need something for the pain. I’m sure you have other sicker patients.”
“No, sir,” I said apologetically. “I think you don’t understand. You’ve run out of time. If we don’t get you to the cath lab in the next few minutes, you could die. I admire your dedication to your work. But it’s time to put it down.”
Just then he looked up and the color seemed to drain from his face as his eyes rolled back. I glanced at the monitor and saw his rhythm change from normal sinus to V tach.
“Crap,” I said under my breath. “I need some help in here!” I shouted. The nurses came running in with the IVs they had been preparing. Putting the armful of charts down I began CPR as Stacey, the night charge, hooked up the chest pads for defibrillation. “I don’t have time for this,” I muttered. “I hope this guy didn’t wait too late.”
Two shocks later the guy was back and this time I had his full attention.
“They’re ready in the lab,” someone said barely sticking their head in the door. I wanted to lecture the man on his misplaced priorities, but I had my own priorities in the pile of charts back in my arms so I let him go with just a shake of the head.
I had been in the ED over an hour and a half and had only seen two patients. But I was still determined to catch up as I raced from room to room quickly apologizing to each patient before charging into a finely focused H & P. Surprisingly I was actually beginning to see a light at the end of the tunnel at a quarter to midnight. Between the PA who was really crushing it all night, my double coverage who decided to stay over an hour out of sheer mercy, and a whole bunch of people simply giving up and going home, we could see the bottom of the “Waiting to be Seen” rack. Most of the people in the halls were simply exhausted and finally drifting off to sleep.
“If you can break free at midnight,” Susan whispered as I whisked by, “we’ve got some sparkling juice in the lounge to ring in the New Year.” I looked up to see one of the administrators making his way through the ED dressed like Father Time.
“I’ll see,” I said over my shoulder as I opened another exam room door. The patient, a frail woman in her seventies, had a calm demeanor. As I opened the chart I noticed that the patient had been in the ED so long that the nurses had taken the liberty of ordering an entire workup, including an abdominal and chest CT. It normally would have irritated me to have so much done without even discussing it with me, but tonight I was thoroughly grateful. Besides, she looked so sick it was obvious she was going to be admitted. Before I even learned of her thirty pound weight loss, her loss of appetite, and now intractable nausea and vomiting, I saw the CT result. “Innumerable areas of metastatic growth throughout the abdomen and chest consistent with carcinomatosis. Suggest further work up to determine primary.”
“Further work up? Duh, you think,” I muttered to myself. Then I made real eye contact with the patient and stopped.
“I’ve got cancer, right?” she said with sadness. “I’ve thought it for a long time, but I didn’t want to face it.”
I paused and took a deep breath before launching into my explanation of her disease. “Yes,” I finally said. “We’ll need to admit you to the hospital.”.
“How long?” she asked calmly.
“Unfortunately,” I started, “we are really short on hospital beds tonight and it might be a while before you get moved up to your bed.”
“No,” she said with a forced courteous smile. “How much time do I have to live?”
The intensity of her look and question was more than I was ready to embrace and my eyes lifted to the ceiling in a gesture of prayer for help in supplying her with an answer. The clock on the wall read 11:59. “Hurry, hurry,” I heard a nurse say to another in the hallway as they scurried to the lounge.
“You have,” I began, summoning the courage to speak, “the same amount of time as I do. You have today. It’s all any of us have,” I said taking a seat at her bedside. “Now why don’t you tell me about yourself.”
“My disease?” she asked.
“No,” I said, taking her hand. “Tell me about you.”
Mark Plaster, MD is Founder and Executive Editor of Emergency Physicians Monthly