Salon.com > J.B. Orenstein

Rack ‘em up

Fri, 12 Mar 2004 16:26:00 +0000

"I want big."

The first three words out of John Minoli's patients never vary. And Dr. Minoli, a Las Vegas plastic surgeon, doesn't expect otherwise. His clientele want one thing and one thing only: Big. Bigger. Biggest possible.

I took time off from my pediatric E.R. job to visit my old medical school roommate last March. John spent years in clinics in Los Angeles and New York polishing his innate surgical skills and artistry; now he had a nice, private practice group in the golden desert. While watching Sheena Easton belt out her catalog at a cozy spot in the Hilton he invited me to visit his outpatient surgi-center to watch him operate the next day. Thus, I found myself at the brilliant -- but, for a tourist in Vegas, odd -- desert hour of 7:30 a.m., hustling through a remote corner of town. By the time I arrived, Frank Sinatra was crooning in the background and John had halfway dissected his first breast of the day. (Both women operated on have given permission to have their surgery described in this story.)

"Sinatra? C'mon!" I protested.

An epidemic of fear hits the E.R.

Tue, 16 Oct 2001 19:02:00 +0000

Friday was a bad day in the E.R. Even before the creepy, ominous news came from New York -- and later Nevada -- about more anthrax, our hospital, a 700-bed megacenter, was full beyond capacity. There were more than a dozen patients in the E.R. "boarding" as inpatients, waiting for intensive-care beds. As recently as two years ago, that was unheard of, particularly on a nice balmy day in October.

But the president had spoken to the nation about the FBI's broad terrorism warning the night before, and while the speech and the overcrowding may have been entirely unrelated events, the coincidence was depressing. And as one last terrible portent, the waiting-to-be-seen boxes were full. Patients who had registered three or more hours ago were still waiting to be seen.

My first patient, an Asian woman in her 40s, had a measles-like rash, a high fever and a bad headache. There was no earthly reason for me to suspect smallpox. The rash was wrong. The natural progression of the disease didn't fit. Below her left shoulder, there was even a smallpox vaccine scar. But still, my stomach flipped and never settled down.

I called for the infectious disease specialist. "Sure does look like measles," he agreed.

A matter of life in death

Wed, 21 Mar 2001 19:38:00 +0000

A piercing shriek cut suddenly short, a car flipping sidelong against its natural direction. For an odd, hanging moment, nothing else happened. The sky overhead buzzed as a helicopter changed directions. On the ground, asphalt sparked in an infinity of rising dust and fallen glass crystals around a dusty brown car; a palette of reds splattered and dotted the windshield, and then began to drip.

The car tumbled to a halt in a precarious stance on the passenger side, all four tires airborne, after one-and-a-half turns on the highway. The truck had recoiled back into the mouth of the crossing. The next 30 seconds or so following the helicopter's departure were still. Police records indicate several calls registered to 911 nearly simultaneously.

That's how it ends or that's how it begins.

The intersection, at Route 1 and Rippon Boulevard, was long familiar to 911 operators. Route 1, three lanes in each direction on a slight elevation, bends gently to the south and east. Rippon Boulevard enters blindly. Route 1 traffic is hidden by a 20- or 30-foot hill at the intersection, a mound of dirt and tall reedy grasses. A left turn is a grope until the middle of a lane in which cars stream by at 50 miles per hour. It's a setup. A meat grinder.

Physicians’ Desk Reference, 55th edition

Fri, 19 Jan 2001 20:00:00 +0000

It was, some say, Elvis' favorite book. Judging from the stacks of copies at Borders and Barnes & Noble, it's a lot of other people's fave as well. The book, the Physicians' Desk Reference, or PDR -- the 55th edition of which has just become available -- is huge, dwarfing all other medical volumes on the shelf. It's blue. The cover's textured for that authoritative feel. But it's not what you think -- that is, if you think it presents the fruits of herculean, independent drug research, you're wrong. There is such a book, only nobody buys it (more on that later).

What the PDR does offer readers, in deadeningly dry prose, is the manufacturer's information packet for every drug licensed by the U.S. Food and Drug Administration. The drugs are listed in a nested alphabetical style: by pharmaceutical company and then by name, from Abbott Laboratories' Abbokinase, a clot-busting drug (available to institutions for about $2,300 a pop, but cost is just one of the urgently important items the PDR doesn't deliver), to Zeneca's Renagel, trade name for sevelamer hydrochloride.

Fighting for treatment

Tue, 24 Oct 2000 19:30:00 +0000

Could anything be worse than coming to see the doctor about a sore throat and finding out that what you have is not a sore throat at all but an aggressive, malignant tumor?

Yes.

What's worse, far worse, is finding out that you have a malignant tumor and not being admitted to the hospital then and there because the doctor is unwilling to play the elaborate intake game -- leaving you on your own to negotiate the Kafkaesque system to arrange diagnosis and treatment. Because even if you have a deadly cancer and great insurance coverage, the doctor must provide an airtight excuse to slip you in past the bean counters and case reviewers. Otherwise you can waste a couple of your last precious few months trying to force your way through a healthcare labyrinth that is blind and deaf to your suffering.

On a recent and relatively calm night in the emergency room, I picked up the chart of a 55-year-old woman complaining of a sore throat. According to the triage nurse's notes, the patient had just finished a course of the antibiotic Biaxin, but her throat remained swollen, which suggested a viral infection or a resistant strep.

Broken arrow

Thu, 03 Aug 2000 19:00:00 +0000

Warning: The content of this article deals with a painful male condition that just might prove too graphic for many readers. You are cautioned to proceed at your own risk.

Jennifer Gardner, a resident in pediatrics at Georgetown University, comes across as pretty tough. A tall, blond drink of water, Gardner's hometown of Haddonfield, N.J., is a place where she thought she had seen it all. But on this hot summer day, when she came across the case of Rod Johnson, she realized she hadn't. (No, it's not his real name.)

Rod had an interesting, almost unique complaint. Gardner charged in without once looking at the front sheet to see what his predicament was. "What's your problem?" she asked.

"I got a problem." He paused.

"Why don't you tell me your problem."

"I'll tell you the problem." He paused again. "You know ... um, how you, uh ... wake up sometimes with an, er ... an erection?"

"No, I don't know. I never woke up with an erection."

Rod had to spell it out for her. "Yeah, well sometimes you wake up with a bo -- a hard-on."

"Go on."

"Well, here's where it gets complicated. My alarm clock went off, and I already had this hard-on on. Then I, like, lunged over to turn off the alarm. It got caught."

Bringing back the dead

Wed, 12 Jul 2000 19:00:00 +0000

"Line 1, Jul."

I had just stepped into the E.R. when the secretary diverted my attention to the phone. It showed a single column of three red dots, two blinking.

I stabbed at the bottom dot and heard the voice of Tina, a nurse from the ambulance and helicopter communications center. "Three-year-old girl, drowning victim," she said with a hesitant, sucked-in breath. "CPR in progress."

A shared nightmare was about to unfold. "Shit. OK. ETA?"

"Five."

"OK." I hung up.

Coming in five minutes was a torrent of pain and grief whose name, for this story, would be Rebecca Rose. The summertime heat, between noon and 9 p.m., routinely invites a horror to emerge from the blue. An unattended child will go into a pool and drown. Once the rescue starts, the hard part of my job is not a matter of knowing what to do. I know what to do. The hard part is knowing when to stop.

The events run together seamlessly. A sunny-faced, moppet-haired toddler slips silently under the water and the dreamy summer day mutates into tragedy with the first, slightly raised calling of the child's name: Re-becca?? Re- BEC-CA?!! A scuffling scramble ensues. The missing child's name is called louder and louder until, with a wail, the facedown body is discovered in the pool. And then screams, sirens, the grunts of medics.

Mosh-pit mania

Tue, 13 Jun 2000 18:03:00 +0000

Start with 5,000 bodies. Five thousand steaming bodies. Five thousand steaming, bouncing teenage bodies. Packed into a space where, ordinarily, there would be no more than 3,000. There's an inordinate amount of surging and shoving, but no one minds because we're all so happy to be here -- it's the concert in the time to be 20 and surging and shoving in the pit.

No one ever had fun like this before, and it's not possible that more fun can ever be had again in the future because the music is the coolest ever and the scene is the coolest ever and therefore no place, no time, can exist that is better than right now. The band hasn't taken the stage yet, and beach balls bearing dot-com logos and Nerf Frisbees bounce through the space overhead. Over the speakers come the Violent Femmes: Add it up. A 1980 fossil (20 years old already!), but inside it creates the stirrings of a rhythm. A scrawny boy, spiky blond hair and naked to the waist, all that skin a clean slate still awaiting its first piercing and tattoos, has climbed on top of his friend's shoulders. He is facing a pixieish girl 6 or 7 feet away on her friend's shoulders. He wears a scrappy grin and his hands are held in front of him chest high. Like pinball flippers, his fingers gesture at his nipples, back and forth, back and forth. The girl, clearly the message's intended recipient, blushes and looks over at her girlfriend, also clambering aboard her boyfriend's platform of deltoids.

Who will care for the crazy?

Thu, 25 May 2000 19:27:00 +0000

Rachel came to our E.R. one afternoon shortly before Christmas. She had been found by a friend who came to visit her -- suspended by a rope around her neck.

The chart in my hand conjured up vivid images even before I entered her room. A portrait that pretty much matched her reality: not particularly pretty, her skin pallid, pasty; long, full, frizzled brown hair, indifferently gathered by a dark scrunchy. She wore dark grunge-style clothes: dark plaid shirt and jeans, a choker and metallic bangles. Couple of earrings, but not excessively pierced or tattooed. Uncommunicative. Vacant eyes. She told me too little for me to properly judge if she was inarticulate or merely silent.

It didn't much matter, thanks to a single word on the chart: Kaiser.

Nowhere have the ravages of bottom-line scrutiny of modern medical practices so thoroughly gutted the ability to provide care for patients than psychiatry. It is akin to post-AIDS Africa: direly afflicted, worse with each acid day. And if a single story can portray a ruinous state of psychiatry today, perhaps it is the story of Rachel (not her real name) because she received routine-or-better care.

Tales from the emergency room

Mon, 24 Apr 2000 16:00:00 +0000

When I introduce myself to people and reveal that I'm an E.R. doc, they get this excited little gleam in their eyes and ask one of two questions: "Is it tough?" or "How do you deal with the stress?"

I hate to disappoint the voyeuristically inclined, but the truth is, the tough, stressful part of the job has very little to do with plunging tubes down throats of unconscious people or yelling "Clear" and slamming defibrillator paddles. The hardest thing is to uncover the spiraling cascade of events, each one worse than the last, that sends a person to the E.R.

And that's why the healthiest-seeming patients are the ones I fear the most. For so often, they have the problems I'm simply not trained to fix.

Last month a colleague of mine working at an E.R. across town sent me a 15-year-old girl with a request to do an ultrasound to determine whether she was pregnant. I looked at her chart. Gulp. She had already been given a pregnancy test and the results were positive.

So why had my colleague deemed it necessary to order a wholly unnecessary test?

Stupid Patient of the Year

Fri, 03 Mar 2000 17:00:00 +0000

Television has the Emmys, film has the Academy Awards. If emergency medicine had an award, it would be for Stupid Patient of the Year. Why SPY? You can blame it on the Emergency Medical Treatment and Active Labor Act (EMTALA), which guarantees that anyone who comes to an emergency department of a hospital, for whatever reason, is entitled to see a doctor -- whether or not the person is actually sick.

The top award, for best picture, goes to the patient who expended the greatest effort to get to the E.R. in the face of the least degree of illness or injury. People certainly deserve some recognition for their inspiring creativity and determination to attain emergency care when they have no discernible pathology. As in any good awards show, I'm saving the big prizewinner for last.

Yet the subcategories are spicy and bountiful: most horrifying self-inflicted injury, nonlethal; most horrifying self-inflicted injury, lethal (oops, stepping on the Darwin award turf -- apologies); most disproportionate fear of poisoning; most overblown symptom; most worried by a worrisome health report; and most creative excuse to cadge a prescription for antibiotics.