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?
This was a board-certified E.R. doctor, an otherwise perfectly competent practitioner whom I had worked with for several years. While many doctors do have substance dependency problems, this guy was not on drugs. I called the doctor and he confessed: He was scared of facing the girl's mother.
The mom had made clear to him, in no uncertain terms, that her daughter was a good girl; her daughter didn't do that. We E.R. doctors like to think we're tough, that we can handle just about any hostile or obnoxious personality type. But he had caved.
He acknowledged that, yes, there were certain conditions that might result in a virgin's having a positive pregnancy test, but these were uniformly nasty: ovarian, pituitary or some other kind of hormonally active tumors. Rather than rule any of these out, he sent her over to the mother ship -- to me -- for an ultrasound.
Upon cross-examination as to the girl's presenting symptoms, he confessed that the mom had brought her to the urgent care center because she was vomiting and tired all the time. In other words, she was acting pregnant.
Just to be perfectly clear about it, this was the stupidest referral for a medical test in the annals of medicine. If she had been bleeding or complaining of crampy abdominal pain, and was in danger of miscarrying, she would, indeed, have needed an ultrasound. The procedure could have also found out if the girl was in any danger of having a tubal, or ectopic, pregnancy. But to do it to make sure that a pregnant girl is pregnant -- well, that's lunacy.
Once they arrived, I understood. This shameless act of cowardice by a doctor who knew better was fully excused by the fact that the mother was as big as a mastodon and wore the demeanor of an irritable boar. She bullied her way past the triage nurse and planted herself in the middle of the E.R., loudly demanding the whereabouts of Dr. Orenstein. Her daughters (a younger sibling was also in tow) cowered in terror behind her.
My initial plan -- to extricate myself by telling her that her daughter was with child and to check in with the OB-GYN clinic -- was not going to do. So, in what was arguably one of the most wasteful moves in my career, I sent the daughter for the ultrasound. I figured it would give me time to formulate a Plan B, not to mention devise retribution against my colleague for sending me this mess.
By the time she arrived at our hospital, the girl was thoroughly distraught. At least the sonogram would give her time away from her mother. With her I sent our social worker, a wonderfully sensitive, empathetic human being who could cajole a confession out of John Gotti. But she was powerless to get the girl to own up.
My shift is only 12 hours long. I checked my watch. If I could somehow stall the girl in the ultrasound room for another, oh, nine hours, then I could palm her off onto someone else. As I deliberated how I would actually go about doing this, the girl was wheeled back with her sister, accompanied by the only report possible from the sonographer: normal, intrauterine pregnancy.
Plus, three words from the girl: Don't tell Mom.
Now it was my turn to do something eminently dumb. The only problem was, I didn't know which dumb option to pick: Respect the girl's wishes and leave her to figure out how to deal with her pregnancy, or sweet-talk her into letting me tell Mom and thereby preclude any chance of her ever getting an abortion -- which, according to the social worker, was what the girl wanted and what the mother would never approve.
Fortunately, the social worker provided me with a third way out. I would call in the authorities on the case. The girl had the right, as an emancipated minor, to make her own reproductive decisions. If, however, the boyfriend turned out to be older than 18, she was also a rape victim and we had the onus to report it. If not, we might not have to call in the child welfare workers.
I played bad cop, the social worker played good cop, but we were both cops: Tell us the truth and we won't say a word to your mother. Coercion. The social worker had her pegged better than I did. She bet the girl would sooner face her mother's wrath than give up the boyfriend. I bet she would jump at the chance to get an abortion by giving up the father and eluding her mother.
She clammed up about the baby's father and broke the truth to her mother. Mom exploded into torrents of maternal despair. She wailed, shrieked, sobbed, threatened, beat at her mammoth breast and finally swore on her grandmother's grave that her daughter would never leave her sight again. She would personally raise her grandchild until her own daughter became a fit mother.
When the social worker and I explained that she didn't have the right to make that decision for her daughter, she dared us to do anything about it. Talk about scary. Here was a 275-pound hailstorm of fury daring us to interfere in her family dynamics, and all we had for protection was a scrawny security guard 50 yards away.
The social worker held her ground, firmly repeating that if the girl's boyfriend was older than 18, she was legally in the purview of child protective authorities. Barely audible, the girl miserably admitted to a 15-year-old boyfriend who had returned to their country in Central America. The sister nodded briskly at the revelation, as if unburdening herself of a long-held secret. The social worker and I still gamely played out our hand, but it was over. The girl had the right to choose what she would do with her womb, but she was no match for her betrayed, towering mom.
The social worker went to the authorities anyway -- to nominally check on the girl's story but also to give her a fighting chance. The girl wanted an abortion, and at eight weeks pregnant, she had only four weeks left before she would be too far along.
The investigators very quickly found out what, I believe, the social worker had already guessed: The "boyfriend" was no pimple-bound adolescent but her own father. We were not, it turned out, the first ones to coerce her to give up some hidden part of herself.
It explained a lot: not only why she couldn't reveal the true father, even at the risk of incurring her mother's wrath, but also why her mother had so ferociously denied her pregnancy. On some level, she must have known.
With that information, the case was brought before a local magistrate. The child protection workers recognized the girl's desire for an abortion but also listened to the mother's case. She obviously cared for her daughter a great deal, was adamantly opposed to an abortion on religious and personal grounds and would be a willing and loving godmother for the baby. The judge, in full possession of the facts, and presumably in full possession of his faculties, ruled that a mother knows what's best for her daughter. (Or maybe he, too, was afraid of the mother.)
The girl was now at 10 or 11 weeks and within a week would be beyond hope of an abortion. Her appointed attorney filed an appeal and the social worker testified on the girl's behalf.
In a rare act of courage, I offered to appear in court as well. E.R. doctors spend an average of eight to 12 minutes with a patient and then move on to the next case. We jump in and out of people's lives; we don't jump back in. The demands of negotiating an acute injury or sudden illness create a thick, tough skin, but come at us the wrong way and we're only as tough as eggshell. The same eight to 12 minutes spent consoling a family or sharing in their mourning is beyond the ability of most of us. It takes a certain cowardice to intervene in someone's life -- offering lifelong consequences good or ill -- and then not face the family.
I never needed to appear. A few days after the filing, the deed was done. The court of appeals judge expedited a review and quickly sided with the girl. I imagined her being whisked away, alone, to a secret clinic for an intimate procedure, and then it was over.
Dad vanished; the girl disappeared into the custody of a foster family. Reduced to a husk by losses she'd never comprehend, the imposing mother went home to raise her remaining daughter.
So sometimes it's the patients who have nothing wrong with them who are the worst off of all. Given the terrible pathology lurking behind it, the girl needed her pregnancy terminated, and the family that allowed the sin needed help. But there were far better places to go to have the situation treated. The E.R. has no cure for a broken family, but in this case, as in so many others, it was where the family ended up. Our door was open and in they came.