For me it invariably got louder and louder, because I was the intern assigned to the emergency room— the ER to those who knew and loved it. My duties in the ER could be subsumed under the title of official hospital welcomer to all who came. And come they did — the young and the old, the sleepless, the depressed, the nervous, occasionally even the injured and the sick. There I worked, often feverishly; I frequently ate; I occasionally sat. But, always waiting for the dreaded ambulance, I almost never slept.
Its sound meant trouble, and I was not ready for trouble, nor did I believe I ever would be. Although I had been assigned to the ER for more than a month, and had been an intern for almost half a year now, my most prevalent emotional state was still one of fear. Fear that I would be presented with a problem I couldn't handle and would screw it up. Ironically, I had been plunged into this new environment, one that demanded radically different medical choices, just when I was beginning to develop a certain degree of confidence on the wards and in the OR. Except for a group of highly capable nurses, I was on my own in the ER, solely responsible for what happened. It was not so bad during the day, when other doctors were around — the house staff was only a few seconds away — but at night five minutes, maybe even ten, might pass before anyone else from the house staff arrived. So things could be crucial. Sometimes my hand was forced.
Even the schedule in the ER was different. On duty twenty-four hours, off twenty-four. That doesn't sound so bad until you do it for a solid week. If your work week starts at eight on Sunday morning, by eight Wednesday morning you have already worked forty-eight hours, with another forty-eight to go. The result is that after two weeks your system is in total rebellion: you have headaches, loose bowels, and a slight tremor. The human body is geared to work only so long and then sleep, not go for twenty-four hours straight. Most organs of the body, particularly the glands, must rest; their function actually changes in a time-honored way over a twenty-four-hour period, whether the whole body sleeps or not. So after sixteen hours on duty your glands have more or less gone to sleep, but the same decisions are there to be made, with the same consequences. Life is no sturdier at 4:00 a.m. than it is at 12:00 noon. In fact, some studies suggest that it is frailer. Your patience hardly exists, everything is a struggle, the slightest hindrance becomes a major irritation….
The siren approached, very near now. I listened hopefully for the end of the build-up and the receding Doppler effect that we occasionally got as an ambulance sped off to one of the smaller hospitals nearby. Not this time. I couldn't see it, but I could tell from the way the siren suddenly trailed off that it had entered the hospital grounds. Within seconds it was backing up toward the landing, and I was there to greet it.
Through the small rear windows I could make out the chaotic resuscitation efforts of the ambulance crew. One of the attendants was giving closed-chest cardiac massage by compressing the patient's breastbone; another was trying vainly to keep an oxygen mask on the face. As the ambulance stopped I reached out and twisted open the door. A few passers-by paused and looked over their shoulders. To them the event was closed. The ambulance had arrived, the doctor was waiting with an assortment of strange and miraculous instruments at hand, all was saved. For me it was just the beginning. I was glad that no one could see into my mind as I tried to prepare for what was to come.
"Bring him inside to Room A," I yelled to the crew as they slowed their resuscitative efforts. I helped lift the stretcher out and roll it fast through the short hallway, asking how long it had been since the patient had made any respiratory attempts, any sign of movement or life.
"He hasn't, and we got to him about ten minutes ago."
He was a bearded man of about fifty, and so large it took all of us to lift him onto the examining table. Seconds stretched into what felt like hours as the necessity for making a decision drilled into me — the kind of decision that isn't much discussed outside hospitals. I must either call a cardiac arrest or declare this simply a case of DOA — dead on arrival. Surely it was unfair to demand such a decision based on what I could remember from a textbook! Still, it had to be made, and made fast.
What would happen if I called a cardiac arrest? Six weeks earlier, we had restored a man to life after only eight minutes of clinical death. He lay now in the ICU, a vegetable, alive in a legal sense but dead in every other way. Seeing that man day after day, I had come to feel that in giving him the half life technology made possible we had somehow deprived him of dignity. For six weeks the body had functioned — the heart beating, the lung mechanically pumping, the eyes dilated and empty; and his relatives were being drawn out to the limit of their emotional and financial reserves. Whose hand will dare to pull the plug on the machine that breathes, whose will cut off the IV, whose mind relax the attention necessary to maintain a proper ionic concentration in the blood stream so that the heart can beat on forever without the brain? No one wants to kill the grain of hope that lingers in even the most objective mind.
But there is the problem of the bed. It is needed for others — people who perhaps are more alive, and yet will be just as dead if deprived of the resources of the ICU. It comes down to a decision based on subtle, undefined gradations of life versus death. It isn't a matter of black or white, but of varying shades of gray. What does it really mean to be alive? A perplexing question, the answer to which evades a mind numbed with fatigue.
Where does the exhausted intern look for guidance in these moments? To college, where sterile concepts of truth, religion, and philosophy invariably lead to an automatic acceptance of life as the opposite of death? No help there. To medical school? Perhaps, but in the ivory tower the complexities of the Schwartzman reaction and the sequence of amino-acid cycles have pushed aside the fundamental questions. Nor will there be any help from an attending physician. He always remains silent, perhaps perplexed, but hardened by repetition. And the relative or friend standing by? What would he say if you meekly put forward the proposition that there may be halfway points between life and death? Alas, he cannot think beyond the poor soul that is, or was Uncle Charlie. Unassisted, then, the intern gropes in side himself and makes arbitrary decisions, depending on how tired he is, whether if s morning or night, whether he is in love or lonely. And then he tries to forget them, which is easy if he is tired; and, because he's always tired, he always forgets — except that later the memory may surface from his unconscious. Angry and uncertain, he has once more been tested and found unprepared…
Paradoxically, even with six people around me I was alone, standing there next to the nonbreathing hulk of the bearded man. His extremities were cold, but his chest was quite warm; he had no pulse, no respiration, dilated fixed pupils. One of the ambulance attendants kept talking, telling me what he had heard from the neighbor who had been with the man. The man had called his doctor after an asthma attack that morning, but it had gotten worse — so bad, in fact, that he started toward the ER, driving with a neighbor. In mid trip he had experienced an attack of acute dyspnea, an inability to breathe. He had stopped the car, jumped out, staggered a few steps, and collapsed. The neighbor had run for help and the ambulance was called.
"DOA," I said firmly trying not to show doubt. In fact, my mind was a jumble of loosely connected thoughts racing around in search of a pattern. Strangely, in the ER mornings are an intern's most vulnerable time. Despite the surface refreshment of a night's sleep, his decision-making abilities are undercut by the deep exhaustion of the twenty-four-hour cycle. His experience is insufficient for him to make critical decisions with the certainty not of rational thought, but of pure reflex. One takes for granted the old aphorism that familiarity breeds blind acceptance. And so it is. Very often, in the beginning of his career, the intern is faced with a situation in which his mind is clear enough to think, yet he can find no answers. As with the schizophrenic who cannot handle an overabundance of sensory input, information remains unassociated in his mind. So the intern absorbs these experiences that rush in upon him; they hang around his mind in a loose conglomerate until he is tired enough to relegate them to his unconscious, and eventually he does reach a point at which experience brings familiarity, and familiarity brings acceptance without thought. By then a large part of his humanity has dropped away….