As new third year med students in 1984, our class of 40 was jettisoned from the sterile familiarity of our first two years of med school. These two initial years consisted of intensive book study salted with weekly, carefully curated patient encounters. From this bookish environment, we were flung into the controlled chaos of Henry Gray Hospital,* a grim, grimy, labyrinthian behemoth that loomed over a busy superhighway, and was surrounded by troubled ghetto neighborhoods.
My classmates and I experienced a form of culture shock. We felt like raw recruits dropped into a battlefield with weapons we barely knew how to wield. Our gear consisted of stethoscopes, syringes, and the uncertain power of our fledgling medical brains. We fought urgently to understand complicated sets of lab values and patterns of illness and injury. We grappled for the first time with the sight, smell and feel of patients’ body fluids. We experienced crowding, heat and clamor as we interacted with the seemingly endless numbers of real, damaged, sweating humans. We both feared and venerated Henry Gray, this immense asylum for the sick, the wounded, the suffering and seeking. Bewildered, we underwent total immersion. It is the fastest way to learn.
I was assigned to the Surgical ER 11pm to 7am night shift. This was my first clinical rotation along with ten of my mates. The Surgical ER opened right out into the street, to minimize patient transfer time from an ambulance, a car, or afoot from the street to definitive and (hopefully) lifesaving care. This ER was routinely filled to bursting with perspiring, imperiled, often panicky patients and scurrying staff, docs, resident docs and students. So, the usual fare here was ruptured appendicitis, car accident victims, gastrointestinal bleeding, fractures, chest, head and belly trauma, complex lacerations, and overflow patients from the routinely swamped Internal Medicine ER. The surgical ER night shift’s perpetual aura of urgency and the dense atmospheric pressure of that long narrow suite of trauma bays gobsmacked me. I existed in a frenetic fog, forever striving, occasionally comprehending.
We new third years were mostly sent on simple directed medical errands and were allowed to watch as the real doctors assessed and treated the seemingly endless stream of unwell, battered, or otherwise anguished ailing. If time permitted, our elders would gift us with impromptu mini-sidebars to explain a physical finding, a lab result, or the rationale for a particular treatment. We devoured these tidbits, hoping to gain some footing in this complex new world.
The best at this rapid bedside teaching was the ER director, Dr. Carey Slivovitz. A medical and mental giant, he ran both the Internal Medicine and Surgical ERs and was often consulted by even the most experienced hospitalists for advice on complex inpatients. Dr. Slivovitz stood five foot five, was whippet thin, and had a generous ginger mustache whose ends he occasionally chewed when thinking or irritated. Routinely profane, endlessly energetic, he could be acerbic and short with students and residents yet was unfailingly kind and courtly with patients. The staff, residents and students enjoyed his quick wit and mordant sense of humor. Nonetheless, we students sought to escape his notice, since we routinely screwed up or displayed the shallowness of our knowledge. There was an element of hero worship in our avoidance. No one wanted to be found lacking by this chief of chiefs.
He demanded we all call him Carey, and when he explained the meaning of a physical finding, or clarified a complicated clinical picture, to me it was as if he suddenly parted the vast Red Sea of pathophysiology. For a moment all the vital intricacies of my patient’s condition, treatment and prognosis became comprehensible, clear. Yet once he turned away to analyze another case, the waves of my ignorance would come crashing back. Would I ever be able to correctly grasp a sick patient’s clinical presentation? Could I ever master the facts and complicated treatment algorithms that seemed second nature to more-fully trained doctors like our senior residents and attendings?
On a busy, full moon Saturday midnight, there was a gang shooting just outside Surgical’s huge glass doors. We all flinched and wheeled at the unexpected sound of gunfire. I saw two mid-twenties males in gang colors half carrying, half pulling a teenaged woman thru the doors. She had an arm around the shoulder of each of her guides. She was beautiful, dressed for a Saturday night out. She wore silky black fitted slacks, and a cropped fur jacket. Hanging open, the jacket revealed a shimmery white blouse. The blouse was saturated with carmine-red blood. She was shod in stiletto heels and her features were enhanced by carefully applied makeup. She took two assisted, faltering steps. Then she sagged, her head dropping to her chest, the luminous skin of her face turning in an instant from warm mahogany to the flat dull hue of concrete. Her legs bowed limply; her ankles turned inwards.
Personnel dashed to intercept the trio. The woman, now our patient, appeared to levitate via our multiple sets of hands into the nearest trauma bay. Once on the gurney, two nurses briskly scissored through her clothes, starting with her blood-saturated blouse, straight through bra, pants and panties. These were flayed right down the center, basically bisecting her outfit and laying her bare. She looked tiny, bloody and more naked than naked.
The team frenetically attempted resuscitation. The woman was asystolic: no heartbeat, no electrical signal on EKG. Rapidly, a tube was placed in her windpipe, lines were inserted into her collapsed veins, blood samples were withdrawn, and IV fluids were set to flow “wide open” until actual typed blood could be fetched.
“Double tap,” noted Hank, the intern who supervised and mentored me.
Between tasks, he pointed with a bloody gloved finger to two side-by-side holes barely visible thru the blood pooling on our patient’s chest. He then pointed to his own breastbone with two fingers. I frowned. I’d never heard the phrase before.
Later, Hank explained to me that a double tap- two bullet wounds spaced closely on the breastbone- indicated a targeted execution, rather than a ricochet or crossfire collateral damage. Hank was right. We eventually learned that our patient was the baby mama of a gang chieftain who led an ambush on rival gang members. Retribution.
CPR was ineffective, and no wonder! She had lost so much blood. The senior resident decided:
“I’m gonna crack her chest and do cardiac massage.”
He used a massive set of rib shears to cut through her breastbone, then inserted his hand into a chest cavity full of blood and squeezed her heart rhythmically.
“It feels empty. Empty.”
He shook his head as he felt her cardiac contours.
“She’s got a huge hole right through the left ventricle. She’s gone.”
The strongest pumping chamber of this woman’s heart had been torn asunder by the bullets. She had bled out through the hole in her heart and her circulation had irretrievably collapsed. There were groans all around. Dr. Slivovitz, as code leader and supervisor, “called it”. It was over.
The more experienced members of our team scattered, turning to urgent living patients, but I was transfixed. Rooted where I stood, I stared. The woman lay supine in the wreckage of her clothes and her anatomy. Her open chest gaped and the cut, raw edges of her breastbone were visible. Her eyes stared at nothing through half-closed lids. Her face, only splashed with drips, looked otherwise perfect. Her right arm hung half off the gurney. Her manicured nails were painted with an intricate pattern of gold and black.
I felt a poke in my ribs. Hank elbowed me gently as he removed his gloves.
“Hey, Paula, snap out of it.”
He looked around and indicated a large elderly woman on an overflow stretcher in the hall. She was audibly wheezing, as her worried adult daughter hung over her.
Hank nudged me again, a little harder, and pointed with his chin.
“Her. Go see her. This one doesn’t need us now. Go!”
I shook myself and trotted over. This patient was in true respiratory distress. She was laboriously wheezing as she inhaled and exhaled. She sat bolt upright, arms buttressed on knees as she pulled each breath with effort through her open mouth. A tiny tube for oxygen was draped over her ears and under her nose. It hung uselessly askew. The oxygen was blowing on her cheek. I glanced at her hospital bracelet.
“Ms. Kennedy, I’m your med student, Lyons. What started this breathing attack?”
Ms. Kennedy shook her head. She was too short of breath to speak.
“What happened?” I asked the daughter as I listened to her mother’s noisy chest.
“She has asthma, she ran out of her inhaler two days ago.”
Asthma! I knew something about this. I stripped off the ineffective nasal tubing. She was mouth-breathing, so I placed an oxygen mask on her face that covered both her mouth and nose. I dialed the oxygen tank up to from 2 liters/min to 3 liters/minute flow rate, as I had seen nurses and doctors do. Her lips looked blue-tinged. I placed a pulse oximeter on her finger. 79 percent blood oxygen saturation!! Normal was in the high 90’s. My patient was in respiratory failure. I called out for Hank, but he didn’t answer. I looked around in vain for a real doctor to help us. They were all fully engaged. Frightened, I turned the oxygen flow up to 10 liters/min, maximum, and prepared an asthma nebulizer treatment. Once it was assembled, I hooked the nebulizer apparatus to her oxygen mask so the medicated mist could flow into her lungs as she breathed. This all took several minutes.
My patient’s respiratory rate slowed, and the blue tint to her lips seemed to be receding. Ms. Kennedy’s pulse ox was up to 86 percent. Still terrible, but better. I looked around again; still no free interns, residents or attendings! Where had Hank gone? He was likely closeted in a room with another patient. I turned back to my patient and her daughter.
“How do you feel?”
“Better,” my patient huffed softly.
Before I could even fully register my relief, my patient smiled at me; then her eyes rolled up in her head, and she collapsed against me.
“Help!” I yelled. What the hell was happening to Ms. Kennedy?
Now we had plenty of help and attention. I was shoved out of the way as the code team swarmed my patient.
“10 liters/minute! What idiot put her on 10 liters/minute?” The charge nurse barked.
The team converged on my crashing patient, starting a dopamine drip (a drug to support her plummeting blood pressure), ventilating her with bag and mask, putting in bigger IV lines, and preparing to intubate Ms. Kennedy.
“It was me,” I said in a mouse voice, “Was that wro…?”
A hand hooked around my elbow in the middle of my question and pulled me away from the fray. It was Hank. Hank explained:
“Ms. Kennedy doesn’t have asthma, she has emphysema. Her lungs gradually got so bad that her brain now only tells her to breath when carbon dioxide, toxins, have built up to a god-awful level that would kill you or me. You gave her all that oxygen, too much, and it washed out the carbon dioxide and all the other crap, and her brain stopped telling her to breathe. You knocked out her respiratory drive.”
I was devastated. I had just killed my patient with OXYGEN. I had turned a universally life-giving element into something deadly. Whatever made me think I was capable of being a doctor?? I looked at Ms. Kennedy as real doctors labored over her. Then I looked at her daughter, standing aghast near the bedside, both hands covering her mouth.
Hank took pity.
“Look, Paula. She’s been living on a knife’s edge for years. You made a mistake. We all make them.”
I shook my head, staving off tears, and bolted from the ER.
In the outside hallway, I passed by the male doctor’s locker room and entered the nurse’s changing room (no female doctor locker rooms in those days). I ran to the back and sat heavily on a bench in front of the showers. I put my elbows on my knees and buried my face in my hands.
A minute or two later, I felt, rather than saw, a presence leaning over me.
“Hey, Paula! What’re you doing in here?”
I looked up. To my horror, it was Dr. Carey Slivovitz, characteristically scoffing at protocol, standing at ease in the ladies’ shower room. His tie was tucked between the buttons of his white shirt, to keep it out of blood and fluid when he leaned over the bedside during an exam. Hands on hips, he peered at me quizzically, chewing the left end of his mustache. I was speechless. Was he here to expel me? I wouldn’t have been surprised.
“You okay? What’s the matter?” He asked me ingenuously.
Helplessly, I let it all spill out, at volume.
“I just killed a patient with oxygen, OXYGEN! It isn’t even a drug! Her daughter watched her die! AND I just saw a perfectly alive girl almost my age die on her feet, and we tore apart her body and it was all for nothing, we couldn’t save her! Oh my GOD! I KILLED a patient. WITH OXYGEN!”
He mused for a moment, then sat down on the bench beside me.
“Feels terrible, doesn’t it?” he began.
I nodded vigorously and quickly brushed my hand over my eyes.
“I know,” Dr. Slivovitz pronounced. He sighed. We were both silent for a moment. Then he smacked his hands briskly on his thighs.
“But, turns out we’re lucky. Ms. Kennedy isn’t dead. She’s not in great shape, but she wasn’t in great shape to begin with. She’s alive in the ICU. They’ll take good care of her. You can check in on her after your shift. And oxygen IS a drug. You know that now, and you know you can overdose someone on it. You learned something important and that’s a good thing.”
He continued, “And the woman that was shot. We can’t control gangbangers that shoot, and we can’t save every patient, no matter how much we wish we could. You just gotta accept it or you’ll go crazy.”
“And finally,” he declared as he stood up, “Even if Ms. Kennedy dies, I’ll still have killed WAY more patients than you, and I’m the director of this ER.”
He took a step towards the door, then turned back to me.He jerked his thumb in the direction of the Surgical ER.
“C’mon, get back out here. I need you to help me with a spinal tap.”
He strode confidently out into the hall, apparently never doubting that I would follow. I stood, wiped my eyes with the backs of my sweaty hands. Ignoring the hammering of my heart against my chest, I hurried to catch up with him.
THE END
Paula Lyons, MD 1/31/25
Editor, Thomas Corby
*Names and places have been changed and muddled in hopes of preserving confidentiality.