“On tough days, remember that you chose this path. Remember why you chose this path.”

Unknown, attributed to many authors and speakers.

     At St. Mary’s Hospital, the overhead paging system was used to announce any of a number of emergent situations.  There were security alerts, fire alerts, or the “someone’s-trying-to-steal-a-baby” alert.  There were mainly two alerts that concerned the surgical residents and the medical residents, the Trauma Alert and the Code Blue.  The Trauma Alert was sounded when an unstable trauma victim was in the Emergency Room, or en route to the Emergency Room.  It could be a car accident, or the victim of a stabbing or gunshot wound.  The ER doctors would make the decision that the patient was seriously injured and initiate the Trauma Alert.  The surgical team on call for trauma would respond instantly, dropping whatever they were doing to literally run to the ER to meet the patient and initiate care.  Usually an intern, a second year, a senior resident, and a chief resident would go.  A variety of others also responded to the alert – someone from anesthesia to help with intubation, respiratory therapy, a blood bank representative, lab personnel, the x-ray tech.  An OR room was instantly freed up and staff made ready in case the patient needed urgent operation.  To care for a major trauma, it was vital to have all the people and resources needed in place quickly.  It was considered very poor form for the intern to show up after everyone else had arrived, so we usually really hustled and got to the ER fast. 

     The Code Blue was called for cardiac or respiratory arrest, usually due to some medical problem, like a heart attack or a stroke or a drug overdose.  The medical residents had to respond to these calls, dropping whatever they were doing to go run the code.  These most often occurred in the ER, but also took place on the floors and in the intensive care unit.  We would go to a code if it was one of the surgical patients, so after hearing the room number and knowing it wasn’t one of ours, we could relax.  Both the Trauma Alert and the Code Blue announcements were preceeded by the same three long, loud, monotonous blasts of something that resembled a bull horn.  They would sound the horns even in the middle of the night, ripping you out of your sleep with your heart pounding, half dazed and disoriented because of being awoken so rudely.  The three BONGS were followed by this endless, dramatic pause, when everyone just momentarily froze, awaiting the announcement.  Then the operator would say either “Trauma Alert, Emergency Room.  Trauma Alert, Emergency Room”, or “Code Blue, Room whatever.  Code Blue, Room whatever”.  There would be three more BONGS, and the whole series would repeat once or twice.  During that long, long pause, after the horns had sounded but before you knew if it was a trauma or a code, all the surgical residents were desperately hoping for a code, and all the medical residents were praying for a trauma.  A code or a trauma meant at least an hour gone, if you were lucky.  It could drag out to three or four hours, and totally screw up your entire day, or keep you up all night. There were countless occasions when I had just managed to find ten minutes for lunch, and my tray had just touched the cafeteria table top, when the alert sounded.  The table of surgical residents would stare at the table of medical residents, and they would stare back at us, our eyes locked during that long pause, holding our breath in anticipation.  Each table was hoping the other would have to get up and leave.  As the losers quickly gathered their things, pushed their lunches aside and ran, the other table would taunt them. 

“So sorry you have to eat and run. Or not eat and run!” 

“Come again when you can stay awhile!”  

“Could I put that in a box for you?  You could probably eat it between defibrillator shocks.” 

     Neither the surgery residents nor the medical residents liked to miss any opportunity to rub a little salt into the other’s wound, though this was mostly good-natured ribbing.  But the sense of relief when it wasn’t going to be you skipping another lunch was very real.    

     This day, however, was not the surgery residents’ lucky day.  It was about two pm, a little early for the typical trauma patient.  But the alert had sounded, and I was off and running to the ER.  This one had been found on a sidewalk outside his friend’s apartment.  They had been drinking most of the night and morning, and doing some variety of illegal drugs – smoking crack among them.  Someone finally noticed our patient had disappeared, and noticed the window was open and the screen was pushed out.  The apartment was on the fourth floor.  The patient was lying on the sidewalk below.  It is not clear whether he passed out and fell through the window, or if he fell out and became unconscious when he bounced off the awning and then hit the pavement four floors down.  One of the “friends” in the apartment finally called 911 when they looked out the window again about twenty minutes later and he hadn’t gotten up yet.  None of the witnesses knew how long he had been down there, as their perception of time and events was somewhat impaired.

     Unfortunately for us, however, he was conscious when he got to the ER.  His vital signs had been stable at the scene, and he was actually awake when the EMT crew had picked him up.  In fact, he tried to refuse to be brought to the hospital.  When a patient is injured, but also under the influence of drugs or alcohol, they can’t refuse treatment.  The EMT’s are obligated to bring them in, and we are obligated to treat them, despite the patient’s best efforts to alienate everyone who is attempting to help them.  He was pretty stable, but had been called a Trauma Alert because of the unclear circumstances of his injury and the undetermined length of time he was unconscious.  Most of the senior residents were scrubbed in cases.  Grant had quickly popped into the room as I started to go in, and we downgraded him to a trauma evaluation.  That meant the Chief resident didn’t need to rush down, we didn’t need anesthesia to come, and most of the other support staff could go back to their normal routine stuff.   

     I went and got his chart, then pulled the curtain back to take a better look at him.  The nurse had warned me he was a spitter.

“He works hard for it, too.  Brings it up from the depths of his lungs and goes right for the face,” she stated as she wiped at a green stain on her shoulder.

     He was in soft restraints to prevent him from hurting himself or escaping.  He had a splint on his left arm, which was likely broken.  The restraint was tied over the splint, so if he moved too much, it should have hurt.  But with the assortment of drugs he had in his system, he wasn’t feeling much of anything.  The ER doctor had ordered a bunch of x-rays, but nothing was done yet.  The patient was being combative and uncooperative.  Just great, I thought.  This is going to take the rest of the day and be nothing but a huge pain in the ass.

     I stepped in and introduced myself.

“You must be Mr. Donovan.  I’m Dr. Sawmiller, from surgery…”

“Fuck you, bitch!!!!” he interrupted.  “I’m getting the hell out of here!”

     He started to make some snorting gagging noises and rose up on the gurney as much as he could, turning his face towards me.  He launched a sizable, thick, green wad of mucous in my general direction, which I was able to sidestep.

Charming, I thought.  It’s not even dark yet, and I am being cursed at and spit on.

“You know, you fell four floors and landed on a sidewalk.  You could have a broken neck, or could be bleeding into your brain.  You could die at any second.  You need x-rays and a head CT at least.”

“Fuck you, bitch!!”

“Are you having pain anywhere?” I asked, trying to proceed with some kind of a history and physical.

“Fuck you, bitch.  I’m getting the hell out of here!!” he replied.  Okay, we were not going to get too far with this line of questioning.  I needed another course of action.

“Okay, let’s see how you like a board and collar.  I really don’t know why you came in without C-spine precautions.”  It was standard procedure to place an injured patient on a stiff backboard and immobilize their head and neck if a head or spine injury was possible, to minimize the risk of increasing the injury.  He had apparently been too combative at the scene to allow this.  I went out in the hall looking for Reggie.  

    Every ER had a Reggie – the big, intimidating orderly who could quickly convince an uncooperative guy to be a lot more cooperative.  Reggie was about six foot six, and must have weighed in around two hundred and eighty pounds.  He had big bushy black hair, a handle-bar mustache, and tattoos up and down his arms.  He was actually a fairly quiet, nice guy, who was always willing to help out whenever needed.

I found him back in the storeroom, restocking some shelves.

“Hey, Reg, how you doing?” I asked.

“Oh, Doc, I’m good.  Is that guy in ten giving you trouble?  Cause I’d be more than happy to have a talk with him.  We’ve all had to listen to him for the last half hour, and he could use a lesson in good manners.”

“Yes, yes I could use your help.  We need to get him in a board and collar, and convince him to behave for his x-rays.”

Reggie’s face lit up with a big smile.  “You got it, Doc.”

With Reggie and two ER nurses with me, I went back to room ten.

“We need to get you in a collar to protect your spine, Mr. Donavan,” I began to explain, before being interrupted again with the standard “Fuck you, bitch.”

Reggie stepped into his line of sight and said “I think what you meant to say was ‘Yes, Dr. Sawmiller, thank you for taking such good care of me’.” 

     Mr. Donovan’s eyes got big for a minute, then he mumbled something we couldn’t understand.  With Reggie securing his head and shoulders, we rolled him sideways, slid the cervical collar around his neck and got the board underneath him.  As I was securing the front of the collar, I heard that disgusting hacking and gagging.  Before I could get my arm out of range, I was hit with the sticky, gooey green glob.  A direct hit to bare skin on my upper arm.

“God damn it,” I muttered as I wiped my arm across the sheet.

The guy yelped in pain as Reggie leaned hard against the splinted arm. He whispered something to him.

“You can’t do that, you fucker!” the patient whined.

Reggie leaned close and said, “Try me.” Mr. Donovan settled down.

I had the feeling this was going to be a long painful night for me.