A Medical Experience that Taught Me About Humanism in Medicine: Burn In : Academic Medicine

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Gold Foundation Essay

A Medical Experience that Taught Me About Humanism in Medicine: Burn In

Kohler, Jonathan Emerson MD

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I began to hear of the woman in Trauma One in the whisper that made its way around the ER when there was a particularly terrible case. A terrible case was not the same as a gruesome trauma … those were often spoken of in loud, even boisterous tones:

“Did you hear that Trauma Two has a guy with both hands amputated?”

“Whoa. Motorcycle?”

“Is there any other way?”

When something really terrible happened, it wasn’t heralded that way. The terrible cases were almost never the really ugly cases, the ones with a lot of blood and gore. The terrible cases usually did not have disfiguring, bloody things happen to them; they tended to be more sedate, because the worst ones for us were not the ones that came in through the door of the trauma bay. Traumas were usually drunk, or unconscious, or both, and if they were really seriously injured, they were usually quickly paralyzed by drugs and intubated, reduced to a manageable set of physiological processes. For a terrible case, one that caused a whisper, the patient had to be someone we couldn’t make ourselves forget was a real person.

The woman now in Trauma One had come in on her own power, walking with the help of her husband into the waiting room. She had walked to the bulletproof triage window like a hundred others that day, looking no worse than the rest of them. She had apologized to the triage nurse for the inconvenience, and had smiled a grandmotherly smile at the young resident who first evaluated her.

At 65, she was a thin woman with white hair and a face that was beginning to show the first true fissures of age. But her eyes were young, with vitality and kindness that attracted even the jaded staff of the ER. Her only real problem, she said, was that she was coughing. She had been coughing for some time. Why had she come in tonight? Well, her husband had made her. He explained: tonight, she had started coughing up blood.

Hemoptysis is cause for concern. The nurses got a resident, and the resident, without the usual hubris of self-sufficiency, got the attending. It was quickly decided that although she was not in serious condition, she should stay for a few hours of observation, maybe even be admitted to rule out the more serious diagnoses.

All of this I heard in the whispers that made their way around the ER about the woman in Trauma One. I was in Trauma Three, standing around as another drunk patient from another MVA threatened us for touching him.

“There’s a bad one in Trauma One. Lady came in with hemoptysis, and she just crumpled, right there in Urgent Care. She was just coughing, and there was this little bit of blood … .” And then the drunk on the bed started to yell again, and his pulse oximeter fell off, and the alarms began, and when I had reattached the probe the whisperer was gone.

I heard it again going through triage a few minutes later, the triage nurse telling it in hushed tones to one of the nurses from the back.

“She seemed OK to me, I mean, she was coughing a little, but it was nothing serious.”

And again in the back, among the curtains of the exam rooms and in the administrative island that ran the length of the room.

“Pulmonary embolism, they think. The clot just let go. She was coughing, and then … .”

“The sweetest little lady. She was just talking about her grandson, who wanted to be a doctor, and it just started coming … .”

“It’s a terrible one. She won’t make it, you know. They moved her to Trauma One, they’re giving her blood, but she won’t make it.”

For months, I had walked the halls of that ER, had become deaf to the suffering of the trauma patients rolling through the door in ambulance after ambulance. Gunshot wounds, knifings, industrial accidents, MVAs. I had seen the ambulances backed up into the street, with no room to park. I had held open wounds and pulled them to make the broken bones duck back into wet, hot, gaping holes, the marrow flowing red and yellow onto the skin. And always it had had a distance, a surrealist’s brush, a reduction to basic principles of physics and physiology. Not this time.

I wandered back, past the stinking isolation rooms, through the x-ray department, with its constant traffic of the infirm and the unlucky. Past the CT scanner, with its dark control room plastered with digital slices of heads and abdomens, a thousand black and white Rorschach blots shining down as the technician plotted the next scan. Left at the end of the hall, and there on the right, the Woman in Trauma One: the terrible case.

The room was filled with people, and cannot have been as dark as I remember. Still, it seemed as though she was there alone in the darkness, solitary in a pool of bright white light. The operating lamps, not usually on, drove away all shadow from her pale form, sitting straight up, struggling to breathe.

Her skin was ivory, a perfect white that erased the lines of age and blurred against the white sheet and her white gown. She was ethereal, intangible, beautiful. From her mouth pulsed a river of arterial blood, a crimson streak that ran down her chin at a leftward angle, arcing down her neck to stain a bright white towel.

Standing in the hallway, I looked at her. She, in the midst of it all, turned and looked at me. Her surprised eyes said, “Would you look at this? I never thought it would be like this. Here, like this.” And my eyes said to her, “I know. And I am sorry. And I would help you, if I could.” And then the doctors and the nurses moved in around her again, around that terrible case, and I moved down the hall to another trauma, where I could help; and I would.

© 2005 Association of American Medical Colleges