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Swimming: [Commentary]

Coulehan, Jack MD, MPH

Medicine and the Arts

Dr. Coulehan is professor, Department of Preventive Medicine, and director, Institute for Medicine in Contemporary Society, the State University of New York at Stony Brook Health Sciences Center.

As an intern at the Hospital of the University of Pennsylvania, I was assigned for a month to the Emergency Department at Philadelphia General Hospital, which was a block away but an alien world. At PGH the Penn interns worked 12-hour shifts for 27 of 30 days. That left three days off, which were never on weekends. The city hospital had its own interns, who worked the ER side-by-side with their Penn counterparts, but subject to a somewhat different schedule. Shifts were staggered so that the Penn doc arrived to relieve the night shift at 6:30 AM and for the next 30 minutes was the whole shebang, the interface between PGH and West Philly. This meant the night docs signed out all of their patients—in general, nocturnal catastrophes—to the incoming Penn intern, who then carried them on his or her frail shoulders for as long as it took to deliver them into a hospital or prison or other institution. The PGH interns arrived bright and fresh with clean slates at 7:00 AM. This was a setup, of course, but unlike our indigenous colleagues we left after a month, that is, after 27 days.

One day I arrived to discover a litter containing a drowsy young woman who had jumped off a bridge into the Schuylkill River and almost drowned. Alert members of a crew team had fished her out. She was moderately well dressed and pregnant. By the time I arrived, the unidentified patient had been in the ER all night, and it seemed as if she was stable—no lung damage, no brain damage. We attributed her lethargy and delirium to alcohol, or maybe tranquilizers. The plan was wait and see.

At times the woman was assertive, but incoherent, complaining that the sun was roaring at her and wouldn't stop. She wanted to get up and go home. She said her name was Althea Cotton* and she lived in North Philly. At other times, when Althea closed her puffy, mascara-lined eyes, her whole body drifted away.

Althea was no end of trouble. Neurologic checks every 15 minutes. Skull films, chest films, funduscopic checks, psych checks, check checks, you name it. The cops were definitely interested in what had happened. Psych was interested in turfing her to the state hospital. But the medical service was completely aloof, an unassailable wall—the Great Wall of Philadelphia. No beds. Not a bed in the house. Didn't you hear me the first time? We have no beds. So we observed her. She seemed to be lightening up. She even tried batting her eyes at one of the cops, a guy named Hubie. OK, so we'll send her to Psych. Not our Psych, though, but Psych across town.

That's the way it was. Patients poured in. We were swimming in it. I took a look, made decisions, and wrote scripts. I went behind the curtain where Althea was and tried to raise a conversation. How do you feel? Aren't you lucky to have survived? Althea, we're going to take good care of you. At some point the psych attendants came to pick her up. Before I left for the day, though, late as usual, I received word that Althea Cotton had died an hour or so after arriving at the state hospital. A big bleed into her brain. That's precisely what we were looking for. That's precisely what she did.

I was angy that we hadn't admitted her for observation. I was angry at the neurosurgeon, pissed off at the pulmonary guy. I was angry with myself for not being more persuasive. But no one else seemed upset. Maybe they were upset, but were unwilling to share their concern with this diffident young doc on loan from the Ivy League hospital around the corner. Later, back at Penn, I tried to explain how terrible I felt to a couple of my fellow interns, but they blew off the incident as inevitable. We had followed the guidelines. The outcome was a random event—no one's fault, no one could predict it.

Nearly 20 years later I wrote “Swimming,” which speaks to the persistence of pain in the memory of pain.

*Not her real name.
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