Thirty-five years after I became an emergency physician I walked into an ED to work my final shift. Some things will never change. Some things I’ll never understand.
As I drove to the ER for the last time, I wondered out loud to myself, “What will this last shift be like?” Thirty five years ago to the day I had started my career in emergency medicine with my last night of training at Shock Trauma in Baltimore. Our team of EM and surgery residents had drawn the last night of call and our sub-team had drawn the last patient. A young male motorcyclist with “Helmet Laws Suck” tattooed on his left shoulder had tried to do battle with a drunk girl in a convertible. He had survived only because of his aerial launch. He ended the night with four limb fractures, a closed head injury, and a flail chest that required an intracranial pressure monitor, a “head bolt”, an ET tube, an NG tube, bilateral chest tubes, two femoral vein catheters, and a foley. As each procedure was completed by the team members, they said their good-byes to one another and peeled off to launch their careers. I was last to leave as I completed closing up the open peritoneal lavage. Stable for the moment, our patient was ready to be shipped to the OR for orthopedics and then to CCRU (critical care resuscitation unit) and then passed to the next group of arriving residents. I looked into his dull eyes and reviewed the years that had brought me to this moment. In a show of mock ceremony, I shook his limp hand and congratulated myself on the beginning of my new life.
35 years later I rounded the corner into the parking lot, and it was . . . almost completely empty. Really? I thought. Will I end 35 years of being an adrenaline junkie with a night of deadly boredom? Suddenly I felt old.
At least I could go out with some style, I thought, like my dear friend Greg Henry. In his monthly column he wrote about how he’d given a beautiful pen, and a note, to his last patient. But what if tonight was just a bunch of sore throats and a few worried well? Oh well.
I got a cup of coffee from the call room with near-ceremonial intentionality. As I walked down the hall to the nurses station I saw each staff member with a new warmth and more than a little regret that I hadn’t gotten to know each one a little better. They knew what this night meant, and they greeted me with congratulations and lots of questions about the future. Then we settled into the night’s work.
Before long I picked up the chart of a young girl with an extensive laceration beneath her left eye. The whole family was in the room. Each of us saw this cut as a momentous occasion, but for different reasons. In my career as an EP, I had seen literally thousands of wounds like this one. But this would be my last. For this young girl, on the other hand, this would probably be a once-in-a-lifetime experience. I sat down at the bedside and took her shaking hand while looking into her eyes. I wanted to calm her nerves. But I also wanted to enjoy this experience of healing just one more time. After assuring her that I would not hurt her, I set about my work. Taking my time, I achieved a picture perfect repair that would be a footnote to her family story for a lifetime.
A little later I encountered a middle-aged bartender with an upper GI bleed. Talkative and tanned, she was undoubtedly the life and laughter of the bar. But like so many others, I knew she probably put down a fifth of vodka each night. Just as I expected, she admitted to drinking heavily, but she was quick to deny taking any drugs. Her hemoglobin was 9, but I suspected it was lagging far behind the pace of her bleed. The slug of ibuprofen she was taking for her arthritis certainly wasn’t helping. Sure enough, after a large bloody bowel movement, her pressure dropped significantly. A liter of Ringers helped, but it was time for blood and admission to the ICU. Hopefully she’d make it through the night without having to be taken to the OR by some sleepy senior resident. She was still talking to everyone she passed as she was wheeled past the nurses station. It must have been the cocaine that popped up positive in her urine drug screen. I just waved to her and shook my head. Some things just don’t change. I’ll miss this.
It was nearing the end of my shift, and I was beginning to wonder who would “get the pen.” I had a stack of charts and most of them seemed pretty benign from the chief complaint. But when I got to the last one, reading the chart on the way to the room, I suddenly realized that this patient was much sicker than the complaint suggested. The arrival pO2 was in the upper 80’s. I reflexively introduced myself as I entered the room before I noticed that the elderly man was swaddled in a blanket with a nasal oxygen catheter AND and non-rebreather oxygen mask. The nurse followed me into the room announcing proudly that he had gotten the patient’s pO2 into the low 90’s. I started to chastise him for not notifying me of his condition on arrival, but then I stopped. I’m here now. And this is the last night. Let’s not end it on a sour note.
I looked into his eyes, trying to make a connection. Not just to get a history, but standing there I realized that this man would be my last emergency medicine patient. I stood silently for a while, just studying his face, before asking any questions. Experience told me that this conversation was likely to be one sided. He could speak, but it was soon evident that he could not help me. When did the shortness of breath begin? Maybe weeks? Really? Chest pain? A blank look. All my questions were met with either something unintelligible or unreliable. The exam revealed little more than evidence of mild failure. We did a cardiac workup, but I suspected a PE. His kidneys were mildly insufficient. Did I still want to give him contrast for the CT, the tech asked. We still hadn’t gotten his D-dimer back. Yes, I explained. The risk was worth it. “OK,” she said with a little eye roll. It’s on you, her face said.
Minutes later the D-dimer came back at over 8, followed shortly by a call from the radiologist. “Your patient is in a world of hurt,” he said without introducing himself. “He has a massive saddle embolus extending bilaterally all the way down to the pulmonary artery bifurcations.”
My mind snapped back 30 years to a beautiful young nine-month-pregnant woman with a similar diagnosis who had died in the ER. It had happened so suddenly that no intervention was possible. Not even her baby survived. The memory of that code lived within me. Now this man. How ironic.
I called Shock Trauma to discuss a transfer. First, I talked to CT surgery. He was 80, suffered from dementia, and was a DNR. “I’m not taking this case,” the fellow demurred. “I wouldn’t take him to the OR.” He was right, and I didn’t press him. The ICU chief was more expansive in his explanation, but the answer was the same. Since we really had no idea how long he had been building these clots, thrombolysis could do more harm than good. In the end, despite the dramatic diagnosis, the treatment was simply anti-coagulation, which I’d already done, and hoping for the best. We had a stroll down memory lane as I explained that this case was the bookend to my career that had started where he now stood.
As the shift ended, I arranged admission to a step down bed and began the process of notifying his family. No limp ceremonial handshakes this time. No pens or pictures. I simply held his hand and looked into his dim eyes.
After saying my goodbyes to the staff, I walked out of the ER to a beautiful sunrise. I sat for a long time in my truck, staring at the sign that reads, “Physician Parking Only.” It will be a long time before I fully understand what just happened.