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Holowecky, Brian MD

doi: 10.1097/01.EEM.0000473165.54733.c7
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Dr. Holoweckyis an emergency physician in Miami, FL.

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I was no stranger to violence when I was a resident at Detroit Receiving Hospital, a busy trauma center in the heart of the most dangerous city in America. I treated the victims, perpetrators, and collateral damage of violent crime on every shift. I expected at least a few patients with triage assessment nonchalantly stating, “Assault” on any given evening. Almost all of them were “minding my own business,” a detail often joked about among ED colleagues.

I spent countless hours as an emergency physician in training taking care of people who have no one else. Working with a population of indigent and underserved people is filled with frustration but also with hard-fought rewards. When I matched in Detroit, I figured I would move to a comfortable nearby suburb where many residents live, with the self-awareness to know that I probably wouldn't like it and would eventually try to move to Detroit to live among the people.

I spent my intern year commuting from the suburbs. My life there was comfortable. I would go into work every day and pour my all into helping the people of Detroit, but at the end of the day, I would get in my car and drive to back to the comforts of my life. Having grown up outside Detroit, I always had a personal connection to the city, the city that was always “coming back.” I remember conversations with my father about this once-great city, which he said, half-jokingly but with a hopeful sincerity, would be great again one day soon. I distinctly remember going downtown to the old Tiger Stadium as a child, noticing the urban problems of a city scorned and wondering why we had to walk so fast. I remember wondering how a city once so great could get to a place so low.

Detroit has perpetually been in my thoughts as an unfortunately corrupt city, with monstrous challenges beyond fraud and poverty, suffering to adapt from an industrial powerhouse to the post-industrial knowledge economy. I knew that Detroit Receiving would be the most intense of all the places to train, maybe anywhere, but I hoped it would also be the most rewarding. Treating some of the sickest people in the country in a city full of suffering was sure to be a challenge.

I want to be able to be the doctor who can solve any problem, dispo any patient, alleviate any ache. Quickly I learned delivering real care involves so much more than knowing the PERC criteria or hearing that S3 gallop of CHF.

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Harsh Reality

Just as important would be understanding why my patient won't tell me what really happened on that street corner, why a man is in the ED for bilateral chronic foot pain at 11 p.m. on a Saturday, why that nasty Wonder Bread sandwich they ask for might be all they'll eat today.

Understanding these barriers might make it easier to find ways around them for my patients. I could cure chest pain with a sandwich or foot pain with socks and a temporary bed to rest. Hold the discharge papers for a few hours. I wanted a better understanding of the harsh realities of life. I really wanted to be a part of the community; I wanted them to trust me.

I made the decision to move to Detroit, to become a resident of a city perpetually on the brink. People with nowhere else to go often end up at Receiving on a stretcher with a problem of some kind, often social, hoping the doctor who pulls back the curtain might understand or care.

So I did it.

I moved to Motown. I moved to the newly redesignated Cass Corridor, now called Midtown, “the safe part” of Detroit. Despite questioning glances from friends and inquiries why I would take such a risk, I did it. I moved to Detroit, and the very next week, Detroit declared what everyone in the area and, in fact, the entire state had known for a long time: It was officially bankrupt. If moving to a bankrupt, once-great American city was on my bucket list, I could now cross it off. I was proud to be here.

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Paralyzed by Fear

I was proud but exhausted and mentally drained from the rigorous responsibilities of a second-year resident caring for patients in one of the wildest emergency departments in the country in the most dangerous city in the country. I was taking on awesome responsibility, more stress, but affecting more people faster. I went from one curtain to the next diagnosing metastatic cancer to rewarming a nearly frozen man from an abandoned house to intubating an overdose patient on the verge of death to performing chest compressions on a woman found unresponsive by her 8-year-old son. I was living in the fast lane as an emergency medicine specialist in Detroit. I was the doctor I imagined.

Then it happened.

The first weekend night off after my move, I got together with a few friends and went out, attempting to learn my way around. We had a couple drinks, but nothing out of control, certainly nothing that would foreshadow or explain what happened next. Walking home from the bar, truly minding my own business, less than one block from home, I was approached. Five young men came up to me from behind, and asked to borrow my phone. The encounter was strange, and certainly a group of five young guys out would have a working phone among them. I was reassessing the situation, but it was too late.

I was jacked by a fist in the back of the head and neck and tackled. They threw me to the ground, held my face in the dirt, and emptied my pockets. I was initially trying to fight back, and my sympathetic drive kicked in. Then, the attack continued, and I realized that I could easily end up dead. I just begged them not to kill or hurt me. They took my phone, then one yelled, “Get his wallet.” They took a knife, cut my pants open and stole my wallet. The final act of unsolicited malice that still hurts my psyche to this day: One stomped on my face with his boot.

I laid on the ground in shock with a busted lip and blood streaming down my face and gushing from my broken nose. A million thoughts ran through my mind. Everything I had been attempting to do by moving to Detroit flashed before my eyes. Here I was in the city giving everything of myself to improve the lives around me, and my very own community maliciously attacked me. I cannot even really portray how those three or four minutes affected my life — and world view. Was everyone right? Was I a naive fool? Had I made a horrible mistake?

Fear paralyzed me there in the dirt for a minute before I got up and ran the three houses to my house. I went up the stairs, ran inside, and assessed myself as any good emergency physician would. Methodically but in a panic, I ran through what I always want to know with my patients who were victims of trauma. I had no loss of consciousness. I had no neck pain. I was ambulatory at the scene. I had no obvious bony deformities, and I didn't need a finger up my rear. There was no penetrating trauma to my chest or abdomen. I was making coherent thoughts, or so my assessment revealed. I was alive. Maybe barely but alive. I had a boot print on my face, blood gushing from my nose, a cut lip, and pain in my stomach. I was naked. I thought I might have some fractures in my face, but I know from my training that those really aren't emergencies.

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A New Dimension of Care

With no way to call for help, I knew I needed to find someone, and I was scared. The only people I knew were the very ones I spend all my time with, the great people of Detroit Receiving. I took a few pictures of my face, and decided to do what I vowed never to do. I made myself a patient at my own hospital. I biked the three blocks there like a rocket, stopping for nothing past the very same area, my heart racing from fear that I might be attacked again. I walked into the ambulance triage bay, through the double doors, and the charge nurse looked at me in shock.

I was a bloody mess. I wanted to cancel my credit card and clean myself up. One of my attendings who saw me said, “Sit yourself down. You need to be checked out, and you are not leaving AMA so sit down.” I appreciated the concern. I told him that I had not lost consciousness, no shots were fired, and that I just wanted to clean myself up. I made it very clear that I would not be a trauma code, and no resident surgeon was going to be sticking a finger anywhere.

Thankfully, after four hours in the ED, my only diagnoses were nasal bone fracture, abrasions, and a lip laceration. Those are the diagnoses we make in the ED, but as I learned, we miss the meaningful diagnosis. The real injury we have no way to effectively treat in the ED is the damage to the psyche.

Have I had flashbacks? Yes. Do I still have anxiety? Sometimes. Has it affected my practice of medicine? Most certainly. I view my patients through a new lens with a better understanding of what it feels like, trauma or not, to end up helpless on the stretcher.

Certain patient encounters are still triggers for me, months out from my experience. To be honest, I have had to hide in the bathroom a few times during a busy shift, where my moments of weakness won't show to my colleagues. Why can't we as EPs show our emotions? We all need a brief respite from the war zone, from the screaming and bleeding, from the hysteria. Maybe pretending to be strong is actually weakness. We need to admit to ourselves, this job is hard.

Occasionally I find myself overwhelmed again in the bathroom, laying on my back on the cold tile, slowing my breathing, staring up at the flickering fluorescent light, listening to the steady drip of the leaking faucet. My thoughts wander to how I ended up here. I now see my assault patients, indeed all my patients, with an entirely new perspective, having personally met “those two guys.” I didn't deserve what happened, and we must remember the same is true of our patients even when their stories don't seem to add up. My care takes on an entirely new dimension: empathy. I wanted to better understand the hardships of my patients. Now I do.

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