The Place Where They Have To Take You In

Days and nights on the front line at Minnesota's busiest emergency room.

You also get to do some top-notch medical work. "Good stabs" (the staff uses the phrase without any irony, as firefighters might talk of "a good four-alarm") challenge skill and imagination; they can crack a chest in here if needed, breaking ribs to reach in and plug a hole in the heart with a few staples or a finger. "I remember when I saw them use a Foley catheter [a kind of inflatable balloon] on the heart for the first time," Dawn says. "The guy didn't live, but it was neat. When you look at it as a person, it's sad. But when you look at it as 'here's the lungs, here's the heart, here's how it all works'--that's fascinating."

When a patient dies in the stab room they don't break the news over the phone. There's a family room reserved for those occasions, a tiny, windowless place with an African-themed wall hanging and a pastel landscape. If they want, relatives are taken into the stab room; nurses and doctors will go with them and touch the body, so the relatives feel comfortable doing it too. Security is not far behind, because people often "act out their grief" by going after the equipment or the staff. Some family members have ended up back in Specials, with four-point restraints and tranquilizer shots.

Apart from dealing with the families, they don't talk about death much in the ER. It is, Mary Ellen explains, just one of many events you deal with by the appropriate set of procedures. "There was a student from the U here once," she chuckles, "trying to do her master's thesis on emergency nurses' response to death. She had to give up, because she didn't get any."

"Some people deal with it by telling sick jokes," Lynnell says. "I drive 22 miles to Lakeville, and by the time I get home I'm usually through with it. Stuff with kids bothers everyone; with a SIDS death, usually the whole department is upset for days. But you don't really want to talk to anyone about that." Hennepin County offers debriefing sessions for medical and law-enforcement personnel who have been involved in high-profile traumatic cases. Attendance from the ER is notoriously light.

"You develop this teflon around you," Mavis, another veteran nurse, muses over coffee. "Stuff doesn't stick. It can't. Because if it did, pretty soon you'd be stuck all over, if you know what I mean." She pauses. "It's just there all the time. You're driving to work, and you think 'are my closets in order?'"

Diane chimes in: "Or, like your mother told you, make sure you have clean underwear. I tell my family every day how much they mean to me." She pops her food out of the microwave. "Remember that creamery fire you and I worked? At 11:30 at night? What you told the guy?" Mavis shakes her head.

"He had burns over 98 percent of his body, and he couldn't speak. But you could tell he could hear, and he was trying to talk. And you just said three things: That his family was coming over, that he was going to die, and that the pain was going to stop. And he calmed down. I'll never forget that."

Dr. Ernie Ruiz, the ER's godfather, works these days out of a small office in the parking ramp, a block away from his department. He has lots of projects in the works--fighting to establish an emergency-medicine specialty at the University of Minnesota, training rural doctors in the basics of crisis care. The only time his enthusiasm wanes for a moment is when I ask about the point that comes up almost every time politicians and administrators discuss emergency medicine--how expensive it is, especially when people come for the kind of "primary care" that could be provided at a clinic.

"I'm a very poor businessman," Ruiz says apologetically, "and I know virtually nothing about the cost of medicine and the managed-care milieu. I always felt that our job is to do the best we can by our patients, regardless of the cost. That's one of the reason why I'm not chief of emergency medicine anymore." He quit the ER two years ago and was replaced by Dr. Joe Clinton, one of the physicians he trained. The assistant chief is Steve Sterner, and he's the doctor I'm assigned to follow one day.

Sterner is a thin man with a hawklike nose, a crown of hair, and an unflappable disposition. He's barely started the shift when the ambulance beeper goes off; six minutes out, right side weakness. "Ugh," go the residents. "Stroke."

But there's no stab announcement when the paramedics bring the old man in on a stretcher. He's had this problem for a while, one of them explains; a doctor at the neighborhood clinic has been monitoring him. "So what's new this morning?" Sterner asks. "Nothing so much new as that it got to the point where the family couldn't handle it anymore. The incontinence is new, I guess, and he's more confused than he used to be."

Sterner nods and hands the case to the resident. "This is a typical case of what we see with all the managed care now," he says, walking away. "People have chronic, long-term problems, and there's a care plan set up with a high priority on conserving resources. But the patient, or the family, may not be happy with that. So a visit to the emergency room is a way of creating a crisis point when they feel they're not getting anywhere. Because they know that at least we'll see them. Then it's out of their hands and into ours.

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