Struggling to Stay Afloat, Save Lives in ER’s Chaos

On a bad day, working as a doctor in the emergency room is like swimming in rough water.

The big waves are trauma patients, brought by helicopter or screaming ambulance to the front of the line. We drop everything to help them live or die. The walk-ins and drive-ins with the flu, hangovers, twisted ankles and feverish kids are the smaller waves that keep coming and coming. You deal with all of them, trying not to get knocked down, holding your place as they roll in. Sometimes you swim out hard to pull yourself over a big, dangerous swell; sometimes you find yourself shocked and struggling, swamped by an innocent-looking one hiding viciousness.

On this Saturday, the ER at UCLA Medical Center was worse than usual. When I waded in at 8 a.m., the first trauma patients (there would be 10 more that day) had come, and already the wait was long for the walk-ins. They compared arrival times and got angrier. Some of them walked out--it’s called “LWBS,” left-without-being-seen, and it meant that for those patients, we had absolutely failed. They thought we’d abandoned them, and in truth we had. Not on purpose; we were fighting for dear life--literally--inside.

Finally, after a long day of apologies--”Thanks for your patience,” said again and again--I sat down beside Beth. She was 38, but her heart was 78, if you measure age by its function. She had a pacemaker, lupus, three kids, big brown eyes and a tattoo. Miracle of miracles, she was not angry. She gave me a little smile, and so I sat down, treading water and resting, safe with her for a moment. I had an hour to go in my shift, and nothing had knocked me down and no one had died. My wife, Lisa, was waiting at home for me, and I was pretty sure I was gonna make it through the rest of Saturday OK.

Beth was pleasant; I was tired and my guard was down. I never even suspected the emotional knockout that was coming, rising up out of the water while I was looking the other way.

She was there because her pacemaker kept popping out of its pocket. It was a clunky thing, slightly bigger than your father’s Zippo cigarette lighter, and it made a little square under the skin just above where her right breast met her armpit, next to the hummingbird tattoo. Beth had six miscarriages because of her lupus before she had her first child, Ben, in 1986.

After his birth, for some unknown reason, something attacked her heart and damaged the muscle. It ballooned in size, and as the nerves and tissue stretched, her heart almost stopped--something called complete heart block. This made it beat so slowly--40 to 50 times a minute--that she needed a pacemaker to make her heartbeat fast enough to keep her alive. She told me she was on her third now, one for each kid. I laughed. Things are funnier when you are really tired.

Patients come to the ER for real reasons, but often you have to ask just the right question to get the correct answer. Beth’s sign-in sheet said arm pain; she had that for years, since the skin near her armpit was cut and the metal box with wires going to the heart inserted. I usually ask if something happened today, something specific that scared them enough to come in. The question works most times, and it worked with Beth.

She had been carrying her 2-year-old in her right arm, in the checkout line at a Target store. As she went for her wallet, shifting the child, her bra strap popped the pacer out of its pocket, sliding under the skin, and for a moment she held her breath, terrified that the wires might dislodge and her heart stop. She didn’t want to die in front of her kid holding a package of tube socks, so she came in to have the pacer moved. It made sense to me. She’d been born in this hospital, had her children here, had the first pacer placed here. I said I’d arrange it.

I examined her, checked her ECG, her medical records and paged her cardiologist. I was sure the problem was not her heart, so we swapped her to a different room so a sicker patient could be cared for in hers. It took me most of the last half hour of the shift to get back, and by that time she was sitting on a bench in the main hallway, dressed and ready to go, brown purse in her lap. She knew what I was going to say before I sat down.

Her Medi-Cal had run out, her SSI was screwed up, and despite multiple letters from her nationally known heart doctor, she had no insurance of any kind. The hospital wanted to do her procedure for free, but it was going to take some time to set up, and the Target checkout line had been her last straw. She knew this before she came in but didn’t have anyplace else to go. Suddenly, big, fat tears welled up in her eyes, and before I knew it she had her head on my shoulder and was sobbing, silently jerking head turned toward the wall. Months of pain and fear brought her to me, and I was completely powerless to do anything. She was my last patient of the day and her frustration and helplessness were overwhelming to me. I wanted to cry too.

I made some phone calls and drew her a map to the county hospital where I sometimes work, with pride that Los Angeles citizens felt it important to take care of every person, regardless of wallet, last name, skin color or political party. I sent her there, ashamed that I couldn’t treat her because some people who had never examined her, who knew her only as a file, wouldn’t pay a cent--and that we doctors allowed it.

I watched her walk away down the hall and saw that she was careful to put the purse over her left arm, and then, like the last hissing kiss of a wave, she was gone. I felt the water recede, and I stepped out into the ambulance bay, happy to be safe again, on dry land.

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Mark Morocco is an emergency medicine doctor at UCLA Medical Center and at Los Angeles County/Olive View Medical Center. He is also the medical technical advisor for the television show “ER.”