We all know what juxtaposition means, but it occurred to me that there is no such thing as a juxtapositionist, one who juxtaposes. So maybe we can claim that made-up word as our own in the ED. We do, after all, deal with the interesting effect of things side by side.
I witnessed one of my partners do it masterfully on a busy shift the other night. “Do you want to sign Carol's birthday card?” a tech asked him. The card was being circulated covertly around the department in anticipation of surprising her. “Sure, give me just a second,” he said.
He had just come out of a room where he was leading the resuscitation of an elderly trauma patient. Once she was stable, she asked how her husband was. He had to tell her that he had died at the scene of their car crash. Her love of more than 50 years was gone.
The Boy and the Businesswoman
I remember a tragic case of a 6-year-old boy ejected in a rollover. He was unbelted in the backseat, and he was difficult to find in the dark. He was finally found in a small pond down a ravine. He was dead, but was transported with CPR in progress.
We tried to resuscitate him for what seemed like forever. In spite of all we knew about blunt trauma arrests, downtime, and signs of life, all that went out the window. No statistics could or should convince us otherwise.
Eventually, we stopped. He was gone. Then his mother came to the ED, and it was so painful to watch. She grabbed his lifeless body and screamed at us to do something. Then she yelled at God and prayed for him not to take her son. I tried to comfort her. What could I say? How could anything help her? The nurses and a chaplain stepped in. I had to see the next patient.
I walked across the hall. Behind a curtain sitting on a gurney was a well-dressed young woman in business attire. She had her calendar out, and was making notes. One of her pumps was off. She demanded that I look at her little toe. She said she had a meeting to attend, and that I had to do something because she absolutely had to wear these shoes to the meeting. I wanted to take her across the hall to the trauma bay to reset her world a bit. But I didn't. I gently gave her the bad news She had a corn and would need to tough it out or get different shoes. Juxtapositionist.
Craig and the Organ Donor
I have a friend named Craig. We met at church about 25 years ago, and it turns out he grew up near where I did. We actually played football against each other back in high school. We had similar upbringings and mutual friends. Lots in common, for sure.
When it comes to our health, however, that is where the similarities end. It has been said that there is only so much disease in the world, and some people get more of it than others. That's probably folklore, but it fits with Craig and me. I have no real health problems, a few aches and pains, musculoskeletal stuff, usually self-inflicted.
He, on the other hand, has a family history of polycystic kidney disease. His kidneys failed, and he received a transplant from his wife that lasted about 10 years. All the immunosuppressive drugs took their toll. Diabetes, sepsis, zoster. The transplant ultimately failed. He went back on dialysis. He tried the peritoneal route but ended up with peritonitis and catheter problems, so he had to give that up too.
He was back at the hemodialysis center three times a week. All the traveling he and his wife loved so much was over; try coordinating dialysis across the planet. He went back on the transplant list. He then missed two kidneys because of the zoster and an upper respiratory infection. He has had a rough go of it for several years now. Our lives juxtaposed caused me to pause and even feel guilty.
A Cosmic Deposit
A while back, a 38-year-old man came in after hanging himself. He had arrested in the field, and the paramedics were doing CPR when he arrived. He was not moving or breathing on his own, and his pupils were fixed. I intubated him. It turned out he had transected his trachea much lower than the larynx. I'll save that story for another time, but it was quite complicated. We finally stabilized him.
His wife and son already knew he wasn't going to make it. He had been depressed for a while and talked about suicide often. They were sad but not surprised. They understood he was on life support and unlikely to survive.
I received a text after that patient went to the ICU that Craig was driving to the University of California, Los Angeles; they had found him another kidney. No snafus this time. He had a successful transplant and a new lease on life. A day or so later, life support was withdrawn from my patient. The family decided to donate his organs. They wanted to somehow make something good out of something so bad. His heart, kidneys, and other organs and tissues went to several people. He made a kind of cosmic deposit into the bank from which Craig had withdrawn.
We all have stories like these. Every shift you are asked to go from room to room, switching between the worst and craziest cases to the silliest and most mundane ones. The effect is interesting, to say the least. Balancing that is perhaps part of the art of medicine, at least in the ED. Or maybe it's the role of the juxtapositionist.
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Dr. Harmonis an emergency physician at Marian Region Medical Center in Santa Maria, CA. Read his past columns athttp://bit.ly/EMN-SameShift.