COLUMN ONE : ‘Today, I Saved a Stranger’ : For emergency room doctors, not even the long hours, frantic pace and potential for violence can dim the adrenaline rush that comes from saving a patient’s life.

The patient was drunk and he wanted sleeping pills, but the doctor refused him a prescription. So he returned to the small emergency room in rural North Carolina late one night with a revolver tucked into his belt. He was stalking Dr. Perry McLimore, aiming for revenge.

Out of the corner of his eye, the doctor spotted the man and his gun. He ducked, grabbing a flimsy curtain for cover, but the bullet grazed his left shoulder. Then, out of nowhere, two state troopers emerged; they had been in the emergency room on police business. Clutching his bloody shoulder, McLimore watched in amazement as the cops, in his words, “took care of the problem.” Translation: They blew his assailant away.

That, however, is not the end of this tale, which took place six years ago. The ending is that, after being shot by a drunk gunman who was then killed before his eyes, McLimore did not take the rest of the night off. He did what any self-respecting emergency physician would do.

He finished his shift.

“Well,” the 36-year-old doctor explains matter-of-factly, “I couldn’t find anybody on such short notice and I really wasn’t hurt that bad. The wound itself was nothing and I was supposed to stay until 7 that morning.”

They are a rough-and-ready crew, these emergency room doctors. The cowboys of medicine, they often are called. Their credo is to expect the unexpected and to take all comers, be they prostitutes or bank presidents, without complaint. They stake their honor on being able to handle any crisis that stumbles through the door, on making life and death decisions immediately, without looking back.

Other doctors--radiologists, cardiologists, surgeons and pediatricians--exist in a world that is clean, predictable and safe. Emergency physicians live a precarious life, always teetering on the brink of some unknown. And most say that that is the way they like it.

But on occasion, as McLimore and others have discovered, the unknown can be dangerous. Last month, a disgruntled patient opened fire in the emergency room at County-USC Medical Center in Los Angeles, one of the nation’s busiest public hospitals. Three doctors were wounded, one of them critically. And the question on many lips afterward was: Why would any doctor, after years of expensive schooling to prepare for a career in one of the nation’s most prestigious and high-paying professions, want this job?

“That’s been the hot topic lately,” said Dr. Kathleen Myers, who is completing her third year of residency in emergency medicine at UCLA. “I’ve had lots of phone calls from friends and family, asking the same question.”

The answer almost always touches on the same themes: The adrenaline rush that comes from bringing a patient who is clinically dead back to life. The no-time-to-sit-down-let-alone-eat-lunch pace. The intellectual jazz of correctly matching an odd set of symptoms with disease. The esprit de corps, especially on the overnight shift, when one no else in his or her right mind would choose to go to work. The satisfaction of knowing you can juggle six or seven patients at once and never drop the ball.

There is a moment in the life of every emergency physician when the magnitude of that power and responsibility suddenly hits home. Because despite all the backup from nurses and paramedics, when a critically ill or injured person arrives in the emergency room, it is the doctor who orchestrates the race against the clock.

For Dr. Robert Hockberger, now chief of emergency medicine at Harbor-UCLA Medical Center in Torrance, that moment came when he was a 28-year-old senior resident in charge of the emergency room at a busy hospital in Chicago.

At 4:30 a.m., three trauma victims, all with gunshot and stab wounds, were wheeled in. All 18 beds were full, several with seriously ill patients. Hockberger took a look around. My God, he thought to himself. I don’t have enough staff.

And then, the doctor says, the realization hit: “All of a sudden it dawned on me for the first time in all of my training, that there were people who might live or die based on the decisions that I made.”

He collared a seasoned nurse and put her in charge of one of his patients. And for the next 45 minutes, he shuttled back and forth between the junior residents and medical students, supervising their work and working the phones to bring in reinforcements until all the patients had been stabilized.

“At the end of that time, I was dripping sweat and my heart must have been going 120 beats per minute,” Hockberger said. “But it also felt great. I was euphoric. I felt so high that I had been able to make it through that 45 minutes, that most of the patients looked better and that none of them had died.

“And that was the first time that I felt that I honestly could do it. I might not always be able to diagnose exactly what was going on, I might not pick out the right medication, but I could keep almost anybody alive.”

Apart from such emotional rewards, emergency physicians are well paid, with a median annual salary of nearly $143,000 in 1992. One recent study showed that the typical emergency physician earns $13,000 a year more than doctors in other non-surgical specialties. A 1991 survey found that experienced emergency physicians earned as much as general surgeons and more than internists, pediatricians, neurologists and psychiatrists.

The erratic schedule also has its advantages. The 10- and 12-hour shifts are intense, but on the whole emergency physicians work fewer hours than other doctors. And as one emergency physician says: “At the end of your shift, you’re free as a bird.” No frantic trips to the hospital to deliver a baby in the middle of the night. No emergency appendectomies on your day off. No need to carry the dreaded beeper.

This makes for a corps of doctors with enough free time to lead well-rounded lives; many emergency physicians say they were attracted to the field because they could pursue other interests or devote more time to their families. Stories of emergency physicians who lead other lives as scuba divers, artists and race car drivers abound; in Long Beach, there is one who works as a stand-up comic on the side.

At the same time, there are considerable drawbacks to the job, even beyond the very real potential of violence. Frequent night shifts can ruin a doctors’s social life, not to mention his circadian rhythms. Emergency physicians are also more likely to be exposed to infectious diseases, such as hepatitis and AIDS, than are many of their colleagues.

The work can be depressing. Emergency rooms have a way of laying bare the ills of society. When drug abuse and violence are on the rise, emergency doctors are the first to know. When there is a measles epidemic because families are too poor to afford vaccinations, it turns up in the emergency room.

When homeless people have nowhere else to go, they come to the emergency room to curl up and get some sleep. When retired people lose their health insurance, the emergency room is the court of last resort.

No place in medicine is more democratic. Most other doctors draw what they call “psychic income” from long-term relationships with patients whose cultural and socioeconomic status often mirrors that of the doctor’s own. Emergency physicians may spend no more than 10 minutes with the people they treat. As often as not, the patient whose life is saved in an emergency room will never even learn his doctor’s name.

Every once in a while, though, there is a poignant exception.

Dr. Charlotte Yeh runs emergency rooms at two busy Boston-area hospitals. For her, the exception came in the form of a teen-age girl who, 11 years ago, arrived at the Newton-Wellesley Hospital emergency room after taking a massive dose of antidepressant medication. She was suffering from uncontrollable seizures; her heart was beating with wild irregularity. A medical history soon revealed that she had attempted suicide several times before.

Yeh worked for two hours, struggling to prevent the girl from succumbing to the overdose. At times, the doctor was besieged by doubts. “Why am I working so hard?” she thought. “I’m not God. If she really wants to kill herself, why shouldn’t I let her go?”

But the girl lived, and several months later she visited Yeh to say she was hoping to turn her life around. Then, a few months ago, Yeh received a phone call at work. The woman on the other end of the line said she wanted to come see the doctor in the emergency room. She arrived with her husband and an infant cradled in her arms, a far different person from the suicidal teen-ager whose life Yeh had saved.

“I just want to thank you,” the new mother told the doctor, “because you gave me this.”

There is a roller-coaster quality to emergency medicine; for all the lives saved, death is a frequent visitor and is all the more traumatic because it claims those who just moments before had been healthy. There isn’t a doctor in the emergency business who hasn’t been the bearer of awful news. And nothing is worse than the death of a child.

Stories of burnout are legion, as are debates over whether the emotional toll of emergency medicine prompts doctors to leave it.

A 1992 study published in the Annals of Emergency Medicine concluded that “a disproportionate number (of emergency physicians) reported high levels of stress and depression.” The study also found that 12% of the 763 doctors surveyed planned on leaving emergency medicine within a year; that 58% planned on leaving within 10 years, and that those who reported high levels of stress were more likely to quit.

Their findings are echoed by Dr. Van Miller, who has worked for 12 years at St. Francis Medical Center in Lynwood, which runs the busiest private emergency room in Los Angeles County.

“Now that I’m 44 and happily married and expecting my first child, I find the hours kind of upsetting,” Miller said recently. “It’s not a sound way to live your life. I doubt if I’ll finish my career in the emergency room.”

Malpractice is also an issue. Emergency physicians say they are more likely to be sued than doctors in some other specialties, so their malpractice premiums are higher--although not as high as those paid by doctors specializing in anesthesiology and obstetrics, considered high-risk disciplines. Emergency doctors say their patients may be more inclined to sue because there is no long-term doctor-patient relationship.

And then there is the matter of respect. Emergency physicians are engaged in a constant battle for it--from their colleagues in other specialties as well as from their patients.

“People don’t believe we’re good doctors,” said Dr. Lee Payne, a Texas doctor who turned down a prestigious fellowship in oncology to pursue a career in emergency medicine. “People will often ask: ‘Where’s your real practice?’ And you say, ‘This is my real practice. This is what I do.’ ”

Historically, there was good reason for this sentiment. For years, America’s emergency rooms were staffed with doctors who didn’t seem to fit anywhere else, castoffs from other disciplines, young doctors moonlighting to bring in a little extra cash or physicians with such quirky personalities they couldn’t make it in private practice.

Even the American College of Emergency Physicians acknowledges in its literature that “as recently as the 1960s, emergency care in the United States was, at best, inconsistent.”

Dr. Marshall Morgan, the head of emergency medicine at UCLA, is a bit more blunt: “The people who practiced were basically rejects.”

That began to change after the wars in Korea and Vietnam, when military doctors brought the techniques they had learned in the combat zone back home. As public attention focused on accidents as a leading cause of death, a movement evolved to professionalize emergency medicine.

The nation’s first residency training program in emergency medicine was established in 1970; today, 98 such programs exist. Emergency medicine was recognized as a medical specialty in 1979; of the 25,000 practicing emergency physicians in this country, 11,570 are certified specialists. Thus, a medical oxymoron was created: a specialty composed of generalists.

Still, old prejudices die hard.

Says Hockberger, the doctor from Harbor-UCLA: “The surgeons feel they can run trauma better than we can. The cardiologists feel they can read EKGs better than we can. The pediatricians feel they can take care of kids better than we can.”

But nothing is beyond the turf of an emergency physician; the breadth of knowledge, if not the depth, required for the job is extraordinary.

Miller, of Lynwood’s St. Francis Medical Center, carries a stack of index cards in the pocket of his white lab coat, notes he made as a medical student nearly two decades ago. The cards contain information on treating everything from seizures to meningitis to pediatric diarrhea. Miller laughs when he reads them now; he hasn’t needed to consult them in years.

Still, he says, “I’m unable to part with them. They’re more like rosary beads now. I pull them out and finger them when I’m really nervous.”

Emergency rooms are full of nervous energy, although the drama is not always found where one might expect it. Car crashes, heart attacks and shootings may make for exciting TV, but the tension of emergency medicine often comes in subtler moments: a CAT scan that discloses a patient has a blood clot on the brain, a child whose seizures can’t be controlled, a volatile patient who seems just about to go over the edge.

Yeh, the Boston doctor, tells the story of a patient, clearly agitated, who came to the emergency room, demanding that the doctor come with him to his car. She asked what he wanted, and he said he had something to show her. She asked what it was and he said it was a knife.

“I’ll tell you what,” Yeh calmly said to him. “You look like you’re kind of worried about this knife. Why don’t you just go out to the car and get it and bring it in to me?”

Sure enough, the man went to his car and brought back the knife and, without a word, gave it to the doctor. She asked him what he intended to do with it. He looked at her and replied: “A man’s got to protect himself.”

As she called for psychiatric help, Yeh realized for the first time the danger that she had put herself in. But by then, the critical moment had passed. She hadn’t gotten stabbed--and neither had anybody else. And she thought what every emergency physician wants to think: “Today, I saved some stranger’s life.”