Photo by Jim Coit

The E.R. door opens passage to a world where the possibilities of death or anguish seem multiplied.

Startled, you pull away from the hand that wakens you. Overhead your image balloons and stretches in the reflector of the operating light, merging into the gurney bed where you lie, into cabinets full of tongue depressors, swabs and blood-pressure cuffs, into the walls of your cubicle in the emergency room. Dimly you remember where you arc and what time of night it is.

“Every time he gets drunk, he starts shouting and his landlady makes up some excuse to send him here in an ambulance."

Photo by Jim Coit

The nurse gently touches you again. “Doctor, there are two patients out front and another one is checking in.” From another room comes incoherent shouting punctuated by a burbling, phlegmy cough. You enter to find a disheveled old man sprawled on a gurney. He is shouting dispassionately in some crazed alcoholic trance. The tiny room is already thick with the smells of his world: whiskey gulped alone in a downtown flophouse room, dirty clothes, cigarette butts, a whiff of vomit. His chart says he was sent in by ambulance for evaluation of cough. Cough?

You fade into half-slumber there at the desk, conserving your mental energy for the next case.

Photo by Jim Coit

The cough is many years old, the first clutching fingers of his tobacco habit compounded by years of sleeping on park benches. His lungs are free of the crackles of pneumonia; his brow is unfevered; there is no sudden turn for the worse. Why is he here, especially at this time of night? In the main room, the nurses laugh. “Mr. Smith comes in just about every other night," one says. “Every time he gets drunk, he starts shouting and his landlady makes up some excuse to send him here in an ambulance. MediCal pays for the ride, so it doesn’t cost her anything to have us baby-sit him.”

You walk in to watch his capable brown fingers darting across the lacerations of a wounded seaman.

Photo by Jim Coit

You want to call this woman and tell her to stop wasting your time and the taxpayers’ money, but nobody, least of all Mr. Smith, knows the telephone number or even the name of the hotel. Other patients arrive, and when you next think about the old man, the drivers have already whisked him back, their ambulance guided not by a street address in their log books but by the mysterious homing powers of old drunks. In their chronic trancelike state, old alkies seem to be, somehow must be, protected by unseen powers which lead them along inexorable lines of force to safe refuge in the sober, unforgiving night.

Photo by Jim Coit

A metallic grinding outside brings everyone in the main room up from their chairs. A dilapidated camper corners hard into the uphill curve of the street entrance, transmission, struts, and treadbare tires all protesting as if they were the emergency patients. Chinese fire drill, as passengers burst from all doors, knotting together at the rear door to lift a stocky, fortyish man into our waiting wheelchair. Plainly drunk, the man in the wheelchair adjusts his velvet smoking jacket with exaggerated dignity, attempts to stand, and falls back into the chair. A thin, agitated man explains that his roommate has taken too many sleeping pills, an impulsive suicide attempt after an argument. “He does this every time we have a fight, just to drive me up the wall. He’s had some liquor but I think he only took two or three pills. Right after he told me about the pills he started falling down and acting very strange. He’s never acted like this before. Is he going to be all right?”

“Young man, I am a bishexual,” his friend announces from the wheelchair, slurred but very loud, "and I would prefer it if you addressed me as Mary.” He seems to be looking for the venom that emergency-room doctors are reputed to reserve for homosexuals. You ignore the bait and his eyes promptly go dim again. He refuses to discuss his “little things with the pills,” including how many he took. Almost certainly he was acting when he began stumbling right after taking the pills, but without knowing what and how much he took, you have no idea whether his apparent grogginess means he is now heading for coma or merely a good night’s sleep.

“Mary, if you don’t tell us how many pills you took, we’ll have to try and get them back up,” you tell him one last time.

"I absholutely do not want to dishcuss it, young fellow. Now be a dear and leave us alone,” he replies as he settles back into his Gurney as if for a nap. You are obligated to treat him.

A nurse gives him ipecac to vomit, but he won’t drink any water afterward. Without the water he can’t wash up whatever pills remain in his stomach, perhaps earning himself a day of coma and a respirator.

“Now, Mary, you have to drink this,” you say as you raise a urinalysis beaker full of water, touching the rim to his lower lip. "Whatever you don’t drink you ’re going to wear,” you add, tipping the beaker. His protests become a string of bubbles as the water level rises over his pursed lips. When water begins to trickle down his chest, he shudders and starts to drink. Six glasses later he vomits up two sleeping pills. After the nausea passes, he stops feigning grogginess and soon he walks out into the night, followed by his scolding lover.

In the 3:00 a.m. glare of fluorescent lighting, the too-bright colors of the main room start to fray the exposed nerve endings in the backs of your eyeballs. While you fill out charts, you reflect that if only patients with real emergencies came to emergency rooms, every E.R. in San Diego woyld stand empty. For every heart attack or appendicitis, there are a dozen chronic coughs, sham overdoses, week-long back aches — problems that could wait for treatment at the outpatient clinic, or sometimes aren’t even problems at all. This isn’t the way it was supposed to be. The E.R. is supposed to be action, excitement, life-or-death. The opportunity to help people in trouble, evaluate their problems quickly, and make life-saving decisions gave the emergency room a special immediacy and fascination all the way through medical school. After years of studying textbooks and medical journals, managing hospital patients with chronic medical problems who only come in for “a little tuning,” young doctors often question the relevance of their lives; they feel cut off from the mainstream of society. But the emergency room door opens on an ordinary street, full of homes, businesses, cars, garbage cans, husbands (and wives) late for work, policemen making busts, hookers turning tricks, children dodging traffic — all the ingredients which in varying proportions make up all the streets of this land. The E. R. is the hospital’s interface with that street, and to those on the inside it promises excitement as well as terror. Somehow the reality falls short of that promise.

Night duty in the E.R. intensifies your sense of futility and failed promise. Few patients come in, mostly drifters, whores, a few slashed Marines, other denizens of the dark hours. Some are only looking for shelter; others have met with strange, random violence. The air seems charged with omens: perhaps the night vapors rolling in from the street make connections with older, deeper substrata of human experience; perhaps the poisons of fatigue running through your veins directly affect the brain, gently lulling the frontal lobes, loosening their repression of older thoughts (and perceptions from our reptilian past. Ghostly stillness for hours, then suddenly the room is bustling with patients and activity, arriving together as if on cue — at 3:00 a.m. this takes on almost supernatural significance. Emergency-room personnel look to outside influences to explain these feelings. For example, the belief that E.R. admissions are influenced by the full moon is so widespread that university computers, whirring softly in climate-controlled subterranean vaults, have carefully probed the timing and nature of E.R. visits, looking for patterns tied to the moon, the stars, the arc and period of planets' passage. The computers found no pattern at all; still, secretly, every E.R. doctor believes.

By now Carlos, the surgery resident, has been awakened, too. You walk in to watch his capable brown fingers darting across the lacerations of a wounded seaman. Born in Mexico, Carlos understands omens and their impact on people with great penetration. Once he told you about the small Mexican village where he was stationed as an intern. “They believe in the mal ojo. the evil eye, very strongly there,” he whispered one night. “Once 1 saw one man threaten another with mal ojo on the main street of town. Do you know what the other fellow did? He brought down a machete on the man’s head, right on the spot. He split the fellow’s head and torso down the middle, down to the third rib. Can you imagine the fear it would take to make a man that strong, and that hasty?” Carlos is in tune with the emergency room as very few are.

The seaman is in police custody, still high and feeling no pain, laughing and proud of taking on six rednecks in a bar. He cannot stop talking while suture glides through anesthetized skin, patiently closing the lacerations on his arms, his scalp, over his right eye. “Boy, will you look at these goddam cuts! They’re really pretty bad, aren’t they, doc? I bet these are about the worst cuts you’ve seen all night! ” But in his eyes you read a different message, written in the fear that makes his laughter a little too loud and just a little nervous: “If these were serious injuries, then I must be very strong and hard to kill to have survived so easily. Are these cuts the immunization? Am I immune from death now? Please tell me I am.”

For the patients, too, the emergency room is charged with hidden meaning, death anxiety blearing the starkly modem furniture, the brightly colored walls, counter tops, waiting rooms. Gradually the walls become coated with a thin grimy film before your very eyes, the visible residue of fears we all carry but only confront when illness strikes us, raising the specter of our own mortality. Whether speaking to us through a chance laceration that lays bare the secret workings of muscle and tendon, or perhaps a sudden tightness across the chest that mocks our daily assumption of the right to breathe, the specter's message is clear: you are only flesh and blood and someday you will die.

To those already touched by the specter, the E.R. door opens passage to a world where the possibilities of death or anguish seem multiplied. Every needle, every strange machine, every whispered conference in the corridor carries special menace to the sick and frightened patient. Knowing the strength and the newness of these fears, you reassure and explain every procedure as carefully as you can, but the fear remains.

Curiously, when affected by illness, the mind frequently reacts in the simplest way imaginable: denial. A few days ago you remember seeing an ancient widow, wizened, neatly dressed, alone in the world, who was finally brought to the E.R. by concerned neighbors. Her problem was obvious to everyone but her: a minor foot infection had festered for months until her entire leg was swollen, the skin taut and shining from instep to groin. Until now she had refused to see a doctor and still insisted that her foot was getting better by itself. To her the purulence draining from her sores was only “a little bit of water”; your concern was incomprehensible. Since she had denied her illness for so long, her worst fears of losing her independence had to become reality — you admitted her to the hospital to have her sores opened and surgically drained. Her process of denial exists to some extent in all of us.

Now Carlos finishes sewing up the sailor, tiredly explaining both to him and the arresting officer what further treatment is needed as he fills out the forms for the sheriff’s office. After they leave, he sits at the main desk, staring into a cup of 4:00 a.m. black coffee, fluorescent light dancing over its dark ripples. "I was just thinking of one of my roommates at the medical school in Guadalajara,” he says almost to himself. “He was a quiet, strange boy, used to lock himself up in his room to study all the time. Do you know who he is? He’s the doctor who fed cyanide to all those people in Jonestown. ’’Carlos is always gentle and a little sad, as if burdened by such a personal vision of what medicine can do when it goes terribly wrong. Abruptly, he reaches overhead to turn off the chattering police radio with a vicious swat.

Dr. Grant’s police radio is a local joke, the brainchild of one of the emergency room’s attending physicians. Dr. Grant’s desire for immediacy and action carried him much further than most E.R. doctors; he actually quit medicine and joined the police department for two years. Now back with the hospital, he still carries a finely honed vision of the physician as man of action. One day he hauled a huge steamer trunk into the E. R., gleefully pulling out his own personal Resusc-Annie, a plastic female dummy filled with electronic monitoring devices, which set off warning lights if you attempt to resuscitate her incorrectly. One by one, he called in each physician to brush them up on cardiopulmonary resuscitation — mouth to plastic lips, lean in like this over plastic heart — until each one got it right. Although he is an invaluable force for emergency preparedness, some of his ideas border on the comical.

For example, the radio. It is tuned to pick up the paramedics’ two-way radios as they communicate with their base station at Mercy Hospital. Theoretically, he brought in the radio to let us know in advance if Mercy chooses to shunt an unusually difficult paramedic case to our hospitals. In practice, the medically interesting cases are always triaged to Mercy, and with time. Dr. Grant has become more and more absorbed in his radio, listening hungrily as case after case slips past our doors. When he is not in the emergency room, the radio eventually gets turned off.

In the unaccustomed radio silence you fade into half-slumber there at the desk, conserving your mental energy for the next case, brain cells cycling now in slow, lazy waves while your thoughts flow randomly, puddling in an idea the way thick syrup fills in the holes in a stack of waffles (how long till breakfast?). The radio, silent now on its shelf, enlarges in your mind as its meaning unfolds: emblem of the watchful jealousy that exists not only between your hospital and Mercy, but among all the hospitals in San Diego. The city is dotted with hospitals, far too many for the number of people who fall sick in a given period. Financial survival dictates a gigantic Monopoly game where each hospital takes paying patients from the others when it can and unloads non-paying patients to other facilities whenever possible. Virtually all U.S. citizens are covered by MediCal, private insurance, or their own meager savings, so the game takes on racial overtones as Mexican aliens become the bad property to be unloaded first.

Every day in the emergency room you see an endless stream of "dumps," patients who were refused treatment by some other facility and sent to your hospital for non-medical reasons. Sometimes the deceptions used by the referring physicians are so blatant that they transcend outrage and become amusing to everyone but the shunted patient. You think about a lady you saw earlier this evening, a dump from a private clinic in the beach area. The chart read, “Referred for impending diabetic coma.” Yet when you entered the room you found an immensely fat, cheerful woman in her fifties, alert, witty, and much further away from coma than you have been in days. The referring physician sent her on a series of buses to reach you; momentarily, you envisioned this voluble woman, probably sitting on a bench seat near the front, chatting with the driver while she crocheted. Sitting there on the bus, did she know that down in the bottom of her crochet bag were documents from a physician saying that she was in a coma?

Her labs from the clinic and your repeat values in the emergency room showed blood sugars that were moderately high, in the expected range for an untreated adult-onset diabetic. You asked her what the other doctor had told her about her diabetes.

“Well, I had been a little sleepy the day before, but then again, I’ve just settled down, you see. I ’ve been on the road the last few months, just seeing the country a little bit since my husband passed away.’’

“I’m sorry about your husband, ma’am. Tell me, why would settling down make you sleepy?’’

“Well, I think it’s the job. I started work as a Kelly girl yesterday and, oh my, it’s been a long time since I worked as a secretary. Of course all the weight I’ve put on makes it hard even to reach the typewriter keys any more.

"Anyway, I went to see this nice doctor a couple of times for a check-up and today he told me the tiredness was my diabetes and I should come here right away. I do hope it’s nothing serious. I really feel very good.”

You called the referring physician to make sure there was no mix-up in communications. He repeated the whole bogus story again, with mistakes about the nature of diabetes that a first-year medical student wouldn’t make. Drumming your fingers, you finally asked the $64,000 question: “Well, now that she appears to be out of danger, sir, what are your plans for follow-up?”

“Since her medical problems are so complex,” he paused, then cleared his throat, “and of course her funding isn’t in order, I thought perhaps you boys could carry the ball from here.”

You thought to yourself: What’s so complex about putting this poor fat lady on a diet, then giving her insulin if she still needs it after losing a few pounds? Won’t you take MediCal? But what you said was: “Very well, sir. Thank you for the referral. ” If you don’t give in, the woman will bounce back and forth even longer before she finally gets proper medical help. Another dump.

The other E.R. doctors were listening gleefully to your side of the conversation. Suggestions for a diagnosis for the chart were numerous, based on standard medical polysyllables: “Hypofundemiai’ “Finance-openia,” “Transferred for wallet biopsy” were fired in quick succession. Finally you wrote, “Transferred for routine care of adult-onset diabetes,” and closed the chart.

Her story was annoying but harmless, yet other faces also form in your mind. Rafael Mejia, a made-up name but a real person, was a construction worker whose son shot him in the belly during a family argument. He was rushed to a community hospital where a frustrated E.R. doctor was unable to get a surgeon to operate on an uninsured Mexican-American. You saw him arrive here by ambulance from the other hospital and sent him straight to the operating room. Minutes after his arrival, gloved hands entered his belly and carefully excised pieces of kidney, colon, small intestine, and the entire spleen. He lived, but the delay increased his blood loss and chance of internal infection. Other faces march across your vision: brown, black, white, stretching far into the past. Few deaths can be blamed on dumping, but the cost in suffering to each patient frustrates both patient and doctor.

The patient’s suffering takes an odd toll on his physician. Each patient has his greater or lesser pain, then he usually either dies or gets better; but the effects on the physician are long-lasting and far more subtle. You care about people or you wouldn’t be in medicine; you care about them and you take a little of each patient’s pain into yourself. With every laying-on of hands, the exchange of pain energy for healing energy crackles at your fingertips, suffering faces etched forever in the synapses of your brain. You learn to distance yourself from the suffering all around or you bum out, consumed by the needs of others. Mostly you distance yourself through humor, starting with those first days in anatomy when jokes helped you gradually accept the idea of cutting into meat that was once a person. In those days the jokes were rough and physical; as a mature professional your defenses are purely verbal, crystallized in the slang of medicine which is ironic and brutal: senile patients are “gomers” (acronym for Get Out of My Emergency Room), burn patients are “crispy critters,” comatose patients are “gorks” or “gorked out,” the neurosurgical intensive care unit (where many patients die) is the “flight deck.” These words depersonalize your relationship with severely ill patients at a time when personal feelings will cost you too much sanity.

You think of Mr. Kulovics (it is not his true name), one of your first patients as a medical student. He was comatose, suffering from a terminal disease; you knew him only through the love of others. Many fellow parishioners came to visit this man who was once a bastion of his church, devoid now of understanding, reduced to less than a saintly relic of his former self. Day and night he chanted only “Oy, oy, oy” while being fed, while needles were inserted into his veins, while his wife stood, head bent, holding his contorted hand through the bed railing. Just once you heard him speak. While starting an IV line, you saw his eyes clear momentarily, coma fogs rolling back to sea, revealing a serene coastline where mighty cities once stood. He seemed to want to speak: you leaned close, and he whispered, soft but very distinctly, “God is love.” Then the glimmer of intelligence faded from his eyes. The resident and interns laughed at your story, and each morning they asked whether Mr. Kulovics had seen God today, amid general laughter, until the morning when he finally found Him, or whatever waited for him on that distant sea. To this day you still know there was no trace of disrespect in his doctors' hearts; the laughter only made his decline and passage easier for those who tended him in his last days.

A series of dull thuds snaps you back to the here and now. A security guard is trying to escort a disheveled young man stumbling down the hall from the main hospital, ricocheting from one wall to another. Tall and muscular, the younger man is too heavy for the guard to control. “I found this guy outside the hospital, reeling like he was drunk,” the guard tells you. “He says he drove himself over in his own car, but I think he’s getting worse every minute. Says his name is Joe.”

You ask Joe what happened as you and the nurses muscle him onto a Gurney. Running a hand through curly blond hair, he smiles a sweet, stoned, crooked smile. “I dunno, man, I dunno. I was, like, staying over at a friend’s, you know. Her folks were out of town. We were just drinking beers in front of the TV. Her old man had some kind of pills in the bathroom. I took some, just to see if it was a good high. But shit do I feel strange now.”

“What kind of pills were they? How many did you take?”

“I dunno. They ’re just some kind of pills her dad takes. I figured they were tranks or somethin’. Don’ even know how many I took. I’m real sleepy.”

“Where’s your girlfriend? Maybe she can tell us.”

“Shit, she left a long time ago. We had a fight an' I took the pills after she went over to her girlfriend’s.”

Already you have a bad feeling about this case. Whether this was truly accidental or an impulsive suicide attempt, Joe is not trying to impress anyone with how far gone he is (unlike Mary earlier). You don’t know what he's taken, although about half a dozen nasty possibilities come to mind, and he is getting sleepier by the minute. You ask how to get hold of his girlfriend.

“She went over to her friend’s. 1 forget her name .... It’s, uh . . . Mary .... She, uh . . . .” His lids close.

You've got a stethoscope on his chest already. Heart sounds fine, respiration, pulse, and blood pressure are ail right, too. By slapping his back and shoulders you wake him enough to get a phone number for her friend. On the phone, a sleepy voice answers, “Hello.”

"This is the emergency room. I need to talk to Joe’s girlfriend. It’s urgent.” Hand held over the mouthpiece, you ask the nurses to install a cardiac monitor. Soon a second sleepy voice answers.

“Sorry to wake you, ma’am. I’m a doctor in the emergency room. Your friend Joe has taken some pills and is nearly unconscious. We need to know what he took. He said they were your father's pills. Do you know what he took?”

“Did he get into my dad’s stuff?” she cried. “Shit, they’re gonna kill me! I don’t know what the pills are; they’re just Dad’s medicines.”

You ask her to go home and check the medicine cabinet, them call you back. Joe is just barely arousable now, even when you knuckle his ribs. On the cardiac monitor his EKG pattern looks normal. Breathing is still deep and regular. The biggest danger is that he took some type of barbiturate. The combined effect of barbs and alcohol can tum off the breathing center in the brain. If that happens, you ’ll have to put a tube in his lungs fast and breathe him artificially, before his brain cells die of lack of oxygen. Properly placing the tube is difficult, but in an adult at normal body temperature you will have no more than three or four minutes to get him breathing again before the damage is irreversible.

Joe’s girlfriend calls you back in a few minutes. The bottles are still open on the bathroom floor. When she spells the names out you recognize them instantly: flurazapam and amitriptyline, trade names.

Dalmane and Elavil. Bad, but could have been a lot worse. Dalmane is a sleeping pill with negligible effects on breathing. Elavil is an antidepressant. In overdoses, its most worrisome effect is distortion of the heart’s electrical activity. When the heartbeat is altered badly enough, the heart can no longer pump blood and the body dies of oxygen starvation while the heart chambers quiver ineffectively. Fortunately, these heart effects are unlikely, and the cardiac-monitor will give early warning if trouble develops, hopefully in time to get the heart pumping again. This man needs a bed in the cardiac care unit, where each heartbeat can be electronically monitored until the drugs are safely out of his system. You call the C.C.U. resident.

Soon the C.C.U. resident drifts down to the emergency room, stubbly, wearing wrinkled surgical greens, looking worse than most of your patients.

“Bad night?” you ask.

“Bad night,” he confirms.

You explain the story, he listens to Joe’s heart, and agrees to watch him for the night. Soon Joe is taken to the unit, suffering no more than the effects of the sleeping pills, snoring blissfully as the nurses wheel him down the hall. The clerk hands you a telephone. Joe's mother, already alerted by his girlfriend. Of course she is extremely worried. “Yes, ma'am, we think he just didn't realize what he was taking. Mostly the pills just make him sleepy. There is a tiny chance of some irregularity in his heartbeat, so he’ll stay in a special unit tonight where they can keep an eye on him every minute.

Of course, if he does have some heart problems, it’ll be touchy for a while, but we’re expecting him to do fine. Should be out of danger in a matter of hours. ” After a few more reassurances you give her the number of the C.C. U. for further quest ions. then hang up.

It’s after five now. Carlos and the other doctors are asleep; the night nurses are reading magazines and getting ready to go off shift. The patient rooms are empty, silent as the streets outside. You walk out the emergency room entrance, wanting to look at something besides hospital walls.

The sky is already gray, paling to the east. Pre-dawn hush envelops the street; no breeze ruffles the tree limbs; not even a few tentative notes of birdsong yet. Before long, alarm clocks will start going off all over the city, ringing in another day of heart attacks, bleeding ulcers, car wrecks, all the side effects of civilization. Right now, for a few moments, it’s just you, the street, and the sky.