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Tuesday, August 27, 2013
Ahead of Print: The PTSD-Worthy Sights in an ED

Editor:
So there comes Edwin Leap again, into my home with my dog and my filtered light and my feet up and my cup of hot liquid tranquility reminding me that I am neither beast nor fowl, but a creature formed of the emergency departments I have known. Like Charity New Orleans, with 273,000 patient visits each year to the first floor, which includes the ortho clinic, the peds ER, psych, the accident room, and the MER (medical emergencies). (“Stop Sucking It Up,” EMN 2013;35[8]:11; http://bit.ly/16wYsiD.)

A gunshot to the head every five minutes on a Friday night. I remember that shift. Oh, there were grazes, and there were juniors in high school screwing around with their guns, but there were machine guns, too. I remember a man busted for drugs who had just killed the husband of a wounded woman on the gurney next to him. He yelled, "Get her! She has a gun!" Sure enough, she was pulling a machine gun out of her clothing, and was about to spray her husband’s killer with bullets. We pushed the gurney hard, and she fell to the floor, and then she had blunt as well as penetrating trauma. Plus she was head injured, but we had done it to save the scene.

And there was the time a demented HIV patient grabbed the blood gas syringe and tried to stab the phlebotomist. We all yelled, "Shoot him!" to the ever-present police, but they wouldn't. So we threw a mattress on him.

I have told a nun and a 9-year-old they were pregnant, and watched a father tear up an ER in Slidell with an e-cylinder when he was told his wife had rolled over on their child. The 1-month-old, who was being lined and tubed, then coded, and the father had to be subdued after he ripped the lines and ETT out of the infant’s mouth.

I once had to board a helicopter for Ochsner Health Center coding a kid, though I knew he would die. And there was the time I was radioed to come look at a head on the bumper of the car that had hit a person on the freeway. And the time that I closed St. Claude, an ER in the Lower Ninth Ward, for an hour so I could go in the ambulance to Charity with a woman whose infant’s feet were sticking out of her vagina. I almost lost my job for that.

There was also the day four cops were killed, and a fifth came in shot up. I was on the ramp, and received him to a gurney from the back of a rig, but he died in Room 4. The cops went on the rampage, and we had trauma from hell all night long.

Another time, I saw a woman with a dog in triage, and the dog's penis had swelled up inside her. One time I saw a domestic dispute that ended with a man putting a fork in his wife's breast and she a fork in his testicle. Then there’s the cocaine MI guy who spit in my mouth and … and … and….

I’ve been an ED doc for 17 years, mostly nights, because that was where the action was the most interesting. I do have post-traumatic visions. I have seen genital warts that looked like cauliflower. One man said something is "down there," and he had a spaghetti squash with sprouting green foliage. I have seen 30 feet of piano wire threaded up the penis into the bladder, and a variety things pushed up toward the prostate, including a vibrator (still on), a frozen trout, a jar of mayonnaise, a sausage, and a gerbil taped up alive.

I was in emergency medicine residency at Charity Hospital from 1993 to 1997, which prepared me for four years at St. Claude. The enormity of the experience was tamped down when I moved to Portland, OR, where the work was less surgical, more medical. Still, horror happened. Hearts were broken. Love was lost. There was internecine warfare between the ED docs under siege and the administrators who pushed us. Trauma, for sure. Sort of like the time in Oakland General when I did a full mouth extraction of all of the teeth of a homeless man. I feel as if I, too, have been on the floor of a hall and have had teeth extracted, but those teeth were not rotten; they were decent and strong. Still, they were pulled from me like some white dream wafting away, as if it were easy to lose that innocence. Till the sting is felt. The loss known like a toothache lingers.

But what I feel is not sadness or regret. Rather, it is a cold and a broken hallelujah. Leonard Cohen and sometimes Bob Dylan have always played backup in my brain as the visions came in. And I have kept a journal, and as Dr. Leap mentioned, writing helps. Every day I pick a case that made the cut to posterity and have written about it. I have boxes of journals that I never read. I write to rid myself of the need to remember. And I tell stories; my parents love the stuff. And my husband. He is a doctor, too, and he enjoys the advanced pathology, the strangeness, the old, the young, the worst of every subspecialty: emergency medicine.

I do not avert my eyes. There will be years to be dead. They are not now. Now I fully engage in every story, and I ask for details. And I get them. I call it "venue.” We have venue. I do not do a victory march. No one wins in my estimation. We meditatively consider options; we do not argue, judge, or deny. We pass through, and the thoughts pass through, like a meditation.

I would agree with Dr. Leap; perhaps breaks are good. I feel I have been on break for three years since I cut back to just two 12-hour shifts per week and urgent care more than emergent. When it does hit the fan, I can hang without second-guessing too long or hard after. Sleep does not evade me.

Perhaps we turn to friends for fun and affection; perhaps art, music, or exercise resets the energy meter. I know that empathy erodes with stress and sleeplessness; that is known to happen to everyone. What makes a good ED doc, I think, is the same thing that would make you good at whatever else you do: you show up, fully present. When away, you are away, far away, running in Forest Park with the dog listening to African drums.

The sound of a siren is like the sound of a morning alarm clock, and I throw a PVC every time. But it is in its little place, and a tower of song surrounds it, belting out the blues. I hear that drum louder than I feel the worry of what is going wrong.

It has been a good life. The best. Collaborative, educational. I could quit. I don't. And I don't add to the water in my vision with tears over what I've seen. There is enough water in Oregon's skies.

Plus if it all falls apart with the Republicans hijacking the government and the markets failing, I know how to live out of a shopping cart. I asked a guy about that once.

Christine Bugas, DO
Portland, OR

About the Author

Lisa Hoffman
Editor, Emergency Medicine News

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