At 6:30 a.m. on a cool fall morning, University of Tennessee Medical Center looks more like a prison than a hospital--somber, monolithic, a dismal collection of brick fortresses shrouded in mist and gloom. Inside, the ambiance is less foreboding--warmed by soft carpet and gentle fluorescent light--but still implacably sullen, awaiting the bustle and peal of daylight with fathomless calm.
But one particular department of UTMC never really sleeps, and even at this misty-eyed morning hour the Emergency Department (or ED) is abuzz with burbling voices and clattering wheels. It's an unceasing medley of tension, laughter, worry, irritation, and weary determination all bottled up in a tile and fluorescent pressure cooker roughly the size of a corner food mart, a place where diverse human experiences become so irrevocably intertwined that even the gravest circumstances may seem rote, and even the most seemingly insignificant human exchanges may possess a singular poignancy.
Dr. Pat O'Brien, assistant director of UTED, calls the emergency department the "front door of the hospital, the place where you get to see what's going on outside." If that's true, then UTMC lays out the welcome mat for an entire region, boasting the only 24-hour trauma team in the Knoxville area, and hosting nearly 50,000 emergency patients in any given year.
At the moment, only half of the ED's eight adult trauma rooms are full--there's an elderly man with chest pains in one, a middle-aged woman suffering from debilitating stomach cramps in another, and a bewildered teenager with an oversized bug bite in a third ("a case of not thinking before he came in," says O'Brien).
In a fourth chamber, a young black woman, a psychiatric outpatient, paces uneasily, like an excitable cat in a noisy kennel cage. Her attending physicians are standing outside, weighing the risks of sending her home with the abusive lover who necessitated her visit and who now sits in the waiting room on the other side of the ED's oaken double door entrance. (Using funds from the hospital chaplain's fund, the docs eventually call a cab and send her to a psychiatrist.)
For O'Brien, the current patient count adds up to an "unbelievably slow" morning, which goes to show that even when it's slow, things at UTED move pretty fast. It also offers a telling glimpse of the sprawling diversity of medical conditions--blood-soaked traumas, foreign objects lodged in inappropriate orifices, sudden mystifying pains--that emergency physicians treat on a daily basis, and hints at the strange admixture of curiosity, compassion, and courage O'Brien's job requires.
"An emergency doctor is equal parts physician, social worker, fireman, clergyman, and cop," says O'Brien, who actually was a cop for four months in South Carolina before entering medical school.
Now 40, this slight, speckle-bearded father of three has witnessed the evolution of emergency medicine from a bothersome necessity, almost an administrative afterthought, to a full-fledged medical specialty. As an undergraduate at Vanderbilt in the mid-1970s, he gave up his Friday evenings to work as an orderly at the university hospital. The experience whetted his appetite for practicing medicine, but also impressed upon him just how primitive, in terms of both lay-out and staff expertise, the emergency room was in comparison to the hospital's other departments. "If you came into an emergency room back then, you were seen by the least educated physicians, unsupervised medical students, and residents who were learning as they went. I saw the best and worst when I worked at Vanderbilt, but mostly I saw the worst."
By his reckoning, many lingering public perceptions of emergency room physicians--as doctors who are somehow less caring, more jaded--are remnants of that era.
Today, thanks to a proliferation of new programs at medical schools across the country, about half the ED doctors in the United States are certified in emergency medicine (at UT, all but one of the 13 physicians permanently assigned to the ED are board certified in the field.) And O'Brien says the emergence of the specialty has also reformulated the psychological profile of the ED, luring a new breed of doctor who is enamored of both the singular adrenaline rush the job delivers and the undiluted public interface it entails.
"The old profile (of an ED physician) was that of someone who didn't fit anywhere else and couldn't make up their mind about what kind of medicine they wanted to practice," he says. "Nowadays, it's people with inquisitive minds, people with almost a detective mentality. You have to be quick on your feet, and you have to learn the emergency conditions of all areas of medicine."
New arrivals at UTED are evaluated in the triage station, a small, spare office wedged in next to a plush 50-seat waiting room in the rear of the hospital. Each new patient is assigned a letter value from A to D, with A signifying the most dire cases and D encompassing people who probably would have been better served by a primary care physician.
When the casualties are mounting fast--and that can mean more than 20 people holed up in trauma rooms and splayed across hallway stretchers, with a full waiting room outside--those letters enable the attending physicians to set priorities and perform the precarious life-and-death juggling act emergency medicine requires.
It's late morning on this day before the ED sees what the staff might consider a respectable lunch time rush. It begins when a Rural-Metro paramedic brings in a new patient, a transfer from another hospital under surveillance for an allergic reaction, a long, haggard, swarthy man with a red do-rag kerchief wrapped around his head and a withering stare written indelibly across his face.
Then, with six rooms already full, the day's first trauma case crackles over the two-way radio in the corner of the nurses' station--"coming in by ground...male in his forties...neck injuries...possible internal injuries...five minutes..."
At the same time, an elderly nursing home patient in a flannel shirt and a tractor cap is also wheeled into the front hall. O'Brien sighs almost imperceptibly as he hustles across the room, files in hand, and picks up one of the dozen or so phones in the nurses' station. His tones are still measured--"wavering baselines...platelet count...CKMB less than one...the patient had no other chest or jaw pain..."--but the stress level has risen audibly in his voice.
But if there is some tension in the room, it's an oddly jovial tension, the sort of chuckling, resigned ambivalence you find at almost any workplace, very different from the tight-lipped urgency witnessed on TV hospital shows. As members of the trauma team, a group of residents led by trauma specialist Dr. Blaine Enderson, get ready for the incoming patient, they act more like neighbors suiting up for a bush league softball game than doctors prepping for a man who may have a broken neck; laughing, joking, scarfing last minute snacks as they pull on blue scrub jerseys and yellow gloves.
"Why trauma? I don't know, I just like it," Enderson says with eyes that twinkle beneath gold-rimmed specs and an elfish smile that threatens to crawl out from under the woolen blanket of hair that covers the lower half of his face. A native of South Dakota, the triple-certified Enderson cut his teeth on trauma cases in Chicago and Seattle before coming to UTMC nine years ago, and now splits his work week between the ED, the critical care unit, and general surgery.
"I knew when I was a sophomore in high school I would be a surgeon, so the idea of bloodletting never really bothered me," he says. "My time in Chicago really sold me on trauma, on the improvisational aspect of thinking on your feet. Sometimes you have to make things up as you go along. That always keeps it interesting."
But while Enderson and his charges exhibit a loose-limbed nonchalance in the minutes before the ambulance arrives, their collective demeanor changes drastically once the double doors part and the stretcher rolls in. According to a paramedic, the hulking, bearded mountain man laid out in front of them suffered his injuries during the course of a failed suicide attempt (involving a noose and an ill-chosen tree). "It's his 43rd birthday," he adds, out of earshot, with a knowing sigh. "They always pick their birthday."
The victim is shuttled into trauma five, the largest of the eight trauma rooms at roughly the size of an executive office, an ominously busy room crowded with pumps and dials and computer screens and IV bags and cylinders on wheels, all set around a lone stretcher-bed and a domed space-age surgery light hanging from a retractable arm on the ceiling.
Ten doctors and nurses swarm the man, strip off his clothes, stick needles in his beefy arms. He looks homely and pitiful splayed naked across the adjustable stretcher-bed beneath the looming pod-alien surgery light-- a sad fleshy crucifix on a linen cross, arms spread wide with IV needles nailed in the crooks instead of the wrists.
When the trespassing pumps and probes are finally removed from his body some 15 minutes later, the doctors find little more than some rope burns and a broken ankle, and whisk him off down the hall. "If he was trying to kill himself, he did a pretty bad job," someone mutters, also out of earshot.
Outside, O'Brien scribbles on files in the nurses' station, watching through the plexiglass windows as the remaining physicians assess the worst of the other ED patients. In trauma three, the nursing home resident lies in a glassy-eyed stupor, black John Deere cap riding high on his brow, his ashen pallor offset by burning cheeks. A nurse gently leads a plump 75-year-old grandmother in a bright red frock into trauma four. Her gait is slow, hobbled, and when she points to her chest and speaks, she grimaces in obvious pain. Other ills around the ED include a bumped head, a chipped tooth, pelvic pain...
The man in the red do-rag has his spider arms tucked behind his head in trauma seven, but that dour expression is still set like a stone etching on his hard dusky face.
"When you work down here, you end up with a lot of intermittent time with a lot of different patients," O'Brien says. "I'm not always sure why the system works so well, but it does. It's a lot like being a waiter."
That analogy holds true for O'Brien's schedule as well. In addition to his ED post, O'Brien teaches and performs administrative chores at the hospital and serves as medical director for the Knoxville Fire Department, approving care protocols for the organization's paramedics. "Those are my patients out there, too."
While most UTED physicians work between 12 and 15 12-hour shifts per month, O'Brien usually works about 10, a concession to his other duties. This wasn't always the case; he says it was only in recent months that he managed to cut his weekly workload to a "manageable" 60 hours, give (but never take) a few.
"I guess I'm kind of a Type A+ personality," he says. "But I have been trying to spend more time with my kids, taking them to gymnastics and baseball. I even have a cabin on Norris Lake.
"And I'm playing golf again--something I feel should be relaxing," he adds with a dubious grin.
It's early afternoon when the trauma unit goes on standby for the second time; one of the nurses' station scanners emits a long series of arcade blips and siren bleats before a static-riddled female voice cuts through the din and announces a Scott County auto wreck that has injured at least two people.
The call sets in motion a vital arm of UTED's medical outreach--Lifestar, the helicopter ambulance service that affords seriously injured patients in remote areas quick access to the hospital's expertise and 24-hour care.
A handful of paramedics and flight nurses crawl inside one of the two tan-and-orange rotatory leviathans parked behind a green fence just a few yards outside the ED waiting room entrance. Moments later, the whirlybird's massive blades, spanning perhaps 35 feet, begin beating the air relentlessly, stirring a gale-force wind that claws at hats and lashes at small trees on the nearby hillside. The hulking chopper rises haltingly at first, then surges and disappears in the milky sky.
Back inside, assistant head nurse Sheila Duncan is listening to dispatched updates on the Scott County victims. Their car was T-boned (emergency slang for a perpendicular two-car collision), she says, and the 78-year-old driver is unconscious with a distended abdomen and maybe a pair of collapsed lungs. "Not good," she mutters when she hears the woman's age.
An attractive 40-ish woman with a snowy complexion and a pert stack of dark auburn curls, Duncan spends most of her work week in the emergency department. In truth, "work week" might not be the proper term, because the schedule for ED nurses is a brutal, schizophrenic affair; Duncan's work cycle calls for seven consecutive days of 4:30 a.m. wake-ups and 12-hour shifts, then seven days of rest. "That week off is like a vacation," she says. "The week you're on, all you do is work and sleep, work and sleep, with a little time for a hot bath at night."
When asked why she chose the emergency department over other, less tumultuous areas of the hospital, the 18-year nursing veteran responds off-handedly that "you experience everything--gunshot wounds, DOAs, dealing with families," citing perhaps all the reasons why most people would not want to join the ED. Then she adds, in an altogether more vulnerable tone, "I guess I take it personally in a way, because I've been on the other end."
Then she's in trauma four, bent over the plump grandmother, tenderly clasping the hand of a woman who had looked unbearably sad and lonely only moments before. Next door, the nursing home patient is sleeping, a blanket pulled up to his chin. In trauma seven, Do-rag has moved one lank arm down to his side, but his face is still set in that unflinching stoney glare.
The reports from Scott County only seem to get grimmer with each squawking scanner bulletin, but life in the ED is too diffuse, too quintessentially of-the-moment for the attention of all its denizens to be absorbed by any single crisis or event, especially not one that is still several whole minutes away. Even with the specter of some potentially moribund episode looming, the ED is a windmill of divergent sounds and activities; machines beeping and blinking, speakers humming, monitors going off in two or three rooms at once, conversations between family members, cops, docs, nurses, residents...
There are three permanent attending physicians staffing the ED during peak hours. O'Brien says some of the other physicians shuttling in and out of the ED's ever-changing cast are doctors from other departments, paged for their particular specialty. Others are residents serving four-week tours of duty as part of their training, while still others are simply visiting, running errands, flirting, killing off a coffee break.
All of them, however, recognize the rumbling crescendo of an approaching chopper. At exactly 2:50 p.m., Lifestar I comes lurching over the top of UTMC, landing slowly in front of the hangar with its nose pointed skyward and its great white underbelly descending like some monstrous airborne whale. Huge blades once again whip the surrounding brush into a churning frenzy, beating billowy folds in the white lab coats of the doctors waiting below.
The older woman is rolled out first, her head an unwieldy mass of tape and gauze, her neck locked in a thick orange brace. Her 40-year-old daughter is brought in close on her heels, wrapped and strapped in a similar fashion. But her injuries are apparently less serious than those of her mother, and she is rushed to room eight, the second largest of the trauma centers. "My name is Danielle, and I'm going to be with you all the time," says a woman in a blue apron and scrubs, one of six medical personnel in the room. "I know this is kind of scary, but it's routine stuff. You're about to feel a little stick..."
In number five, her mother is beset by more than a dozen people. To the benighted, they might look like malevolent blue wraiths, cloaked in ghouls' robes and masks and wielding all manner of brutish implements over the frail naked body of an elderly woman wrenched in silent agony. The trauma five doors close.
Do-rag watches the whole scene play out from his vantage in room seven without so much as blinking an eye.
By 4 p.m., the steady flow of traffic into the ED has mysteriously abated, and the staff enjoys a moment of rare tranquillity; neither of the Scott County accident victims suffered anything worse than a few broken ribs, the nursing home patient in trauma three is resting comfortably under the watchful eyes of three family members, and the little old lady with the chest pains has slipped into a blissful slumber, her x-rays finished and her pain mercifully stopped.
On a stretcher next to trauma five, the would-be suicide victim, just back from x-rays, is attended by three residents. "You've got a lot more birthdays ahead of you," one of them says gently.
"Thankfully, most of the stuff we see is stuff that's going to get better," says pediatric emergency physician Russel Rhea. "That helps you tolerate the few that don't."
If O'Brien is a self-professed Type A, Rhea with his soft voice and brown curly hair seems as if his P rating might fall somewhere in the nether regions of the alphabet. He says he relishes the often exhilarating turbulence of his work in the ED, but his real reasons for choosing the department have tiny peach cheeks and flaxen blonde hair.
Having briefly run a small private practice in Nashville, Rhea says the shift work of the ED affords him more time with his family, a department now staffed by two daughters, ages three and one.
"When I was in practice, I didn't see much of my first daughter," says Rhea, who is impressively quick on the draw with his weighty stack of Polaroid snapshots. "Now, when my shift is over, I hand off to someone else and go home."
For Rhea, the time he spends with his own children is therapeutic, salve for the emotional wounds wrought when he must sometimes watch someone else's little ones die. But he also says gruesome trauma cases and frenetic life-and-death struggles are so commonplace in the emergency department that most of his war stories tend to blur, one blood-stained episode fading into another.
O'Brien agrees, and adds that it's the quieter, subtler moments, far removed from squealing heart monitors and hastily set IVs, that
make life in the ED worthwhile, and often memorable, for the doctors who are called to it.
"One of the better things I ever saw at a hospital was when some other doctors and I gave an elderly woman who was terminally ill some time to die alone with her husband," O'Brien says. "There was no rush-rush-rush like you see on TV shows, none of the pumping on chests or any of the other things we're known for. They said good-bye. It's a truly rare moment when you get a chance to do something like that."
Meanwhile, in trauma seven, a pretty red-headed nurse is chatting up Do-rag, straightening his bedclothes, fluffing his pillows and patting his bony shoulder, and for the first time in more than four hours, this hard-looking man with the flame-red kerchief on his head and the world-sized chip on his shoulder breaks down and smiles as broadly as his gaunt face will allow.