Christmas Eve in the ER

It's 10:00 am on the 25th and I just got home from a long and bloody Christmas Eve in the emergency department. The wife's still finishing a 30-hour shift in the hospital, so here I am sitting alone at home, exhausted, but not quite ready to sleep.

Last night was as busy and challenging as any other night in the ER. There were victims of heart attacks, assaults, and motor vehicle crashes. There were the suicidal, psychotic, and just kind of lost. I worked to control a spurting arterial head bleed while the patient cried about losing his girlfriend. I took care of a man who was riding his bicycle without a helmet and came in with his scalp half torn off, slumping down to reveal a broad tract of his skull.

I find myself thinking about why I wanted to get into emergency medicine in the first place. Partly it was a sense of adventure and of pushing myself to the utter limits of capability. A large part of it was a desire to take part in the extremes of the human experience. And I liked the fact that the emergency medicine, more than most other branches of medicine, is directly connected to the world outside the hospital.

Early in the morning the paramedics brought in a forty-something woman in cardiac arrest. I ran her resuscitation. We gave her all the medicines that might get her heartbeat back. We defibrillated her, and I struggled to place a breathing tube. But it was hopeless, and despite everything we know about physiology and pharmacology and the art of healing, there was nothing more we could do.

Stopping a resuscitation is termed “calling the code” and is fraught with a mixture of emotions. It's hardest when the person is young, when you know the family is waiting just outside (or, sometimes, in the room with you). I asked if anyone in the room had any other ideas for resuscitation: no answer. I asked if anyone in the room had any objections to calling the code: again, no reply. And then I announced the time of death.

I stripped off my blood- and vomit-stained gown and gloves, steeling myself for the talk with the family, checking my scrubs to make sure they were clean. One of the paramedics who had brought the patient in stepped up and complimented me on how well the code had been run. There's very little positive emotion to take away when a resuscitation fails, and I'll admit, his comment meant a lot to me. But now it was time to talk to the family. I was well aware that we were several hours into Christmas day, and that now and forever this family's grief would be tied to this day.

It turned out that her adult sons were, in their grief, verging on hysteria and violence. (This is not unusual; sometimes family members will become so violent on hearing the news of a death that they must be restrained by police officers to prevent injury to staff or others.) There were several of us present, and I briefly explained what had happened and that their mother had died. As I finished talking, one of the sons was literally crushed to his knees with emotion and began wailing. Another brother grabbed him, and without another word pulled him out the door, disappearing into the night.

When a patient dies in the ER we place them in a private patient room with as much dignity and repose as possible, and then allow family members time alone with their lost loved one. Several hours later I was collecting equipment for a procedure and happened to walk past the room where my patient was lying on a gurney. There was nobody there, and the lights were off, but somebody had turned on the overhead operating room-style light and trained it on the head of the bed. A small shaft of bright light cut through the darkness and glowed over her head. It was a moment of utter peace, of a strange chapel-like beauty. It was an image that will stay with me for a long time.

Eventually we reached the last hour of the shift. My fellow resident on duty and I congratulated each other on making it through another long night; too soon, as it turned out. Twenty-five minutes before the day team was to come on, we started to get patients from an MCI, a mass casualty incident -- a four-car crash, in this case. I ended the morning taking care of one of the passengers, a young woman. Just before I left she started being rude to her nurse about not fulfilling her requests quickly enough. When the social worker who had provided invaluable help with the family of the woman who died asked for her last name, she snapped “You couldn't pronounce it anyway.” My colleague asked her to spell it, and she spat out an unintelligible burst of letters. I was well past the end of my shift and trying to get out and go home, but still felt as protective of the staff as I did of my patients. I walked over and politely (I hope) but firmly explained that these people were trying to help her and deserved her respect. And then she slowly spelled her last name.

When I left the hospital I walked home in the gray Christmas morning light through the Mission District, past middle-aged men drinking malt liquor in doorways, past homeless people asking passing hipsters for change, past Spanish-speaking street evangelists in suits. In some ways it was a typical shift, but there was something about last night that was a little different; hopeful, somehow. Anyway, I'm too exhausted and sleep-deprived to draw any lessons now. Time to get some sleep and recuperate for tomorrow's shift.

Merry Christmas, everyone.