Once in a while I have an idea for a story that entails my doing a set of short profiles of individuals sharing some common characteristic. In the case of this story, I profiled four senior men of science, all medical professionals and researchers of one kind or another in Omaha, Neb. I really enjoyed the challenge of trying to capture the essence of these men and their work in relatively few words. The story originally appeared in the New Horizons, and I suspect you will be as impressed as I was by some of their groundbreaking and lifesaving activities and findings.
Men of Science
©by Leo Adam Biga
Originally published in the New Horizons
The Man Who Would Slow Aging
Denham Harman, professor emeritus and world-renowned researcher at the University of Nebraska Medical Center, humbly chalks up his work uncovering the mysteries of aging to a series of chance occurrences. Born in San Francisco and raised in Berkeley, Calif., he displayed an inquisitive mind early on, developing a passion for building model airplanes and setting his sights on studying aeronautical engineering. But then one day in the 1930s his father bumped into an oil executive at a Bay area tennis club where Harman’s brothers played and landed Denham a job as a lab assistant with Shell Development Co. “This was in the midst of the Depression — there were no jobs,” Harman said from the cubbyhole office he still works in every day at age 86. This chance encounter affording an opportunity he dare not refuse set him on a new course — “I got shifted, so to speak, and I was very lucky” — that within two decades found him posing a radical theory of aging now accepted by the scientific community.
While working for Shell he earned his undergraduate and doctoral degrees in chemistry from the University of California, Berkeley, which, just happened to be one of the top chemistry schools in the nation. After working on lubricating oils he was transferred to the reaction kinetics department where, he said, “just by chance our primary concern was free radical reactions, which in those days was a very unusual focus. There was not that much known.” His research helped Shell gain 35 patents, including one for the Shell No-Pest strip. Then, in 1945, his wife Helen unwittingly planted the seed for Harman’s breakthrough postulation when she showed him a magazine article –Tomorrow You May Be Younger — about aging research in Russia. It got him so hooked on the idea of aging as a biochemical process he made the rash decision, at 33, to halt his career as an industrial chemist to enter medical school. When Cal-Berkeley flatly turned him down, telling him, ironically, “You’re too old,” he went to Stanford. Why change careers in mid-stream? “I just thought here’s a field that’s real interesting and which I know nothing about,” he said. Besides, the question of aging still dogged him enough he sought a broader knowledge base with which to tackle the enigma.
During a 1950s stint at Donner Laboratory in Berkeley where, he said, “I didn’t have anything to do but think, I figured it was a great time to look at this problem. So, I asked myself the question man has asked for a long, long time and still asks: What causes aging? What causes that transition? Everyone goes through it. We’re all familiar with it. We more or less accept it. There’s a lot of theories that try to account for that but no one theory is accepted. I looked at the problem from the premise there’s a single basic cause. Mother Nature uses the same things over and over again and this is what you would expect. Also, it was obvious genetics and environment were involved. So, what could cause this to take place? I thought of everything I could think of, but it just didn’t jive. I began to think maybe I had wasted my time getting on about aging — that maybe I didn’t know enough.”
Then, in one of those moments when a burst of inspiration arrives only after much deliberation, it came to him. He recalls, “I was sitting at my desk reading at the Donner Lab when all of a sudden it flashed in my mind — free radicals. I don’t know where it came from, but there it was. I looked at that problem and everything fitted — the chemistry-biology fitted.” The trouble is, initially almost no one else agreed with what he dubbed “the free-radical theory of aging.” He was all alone, out on a limb and his many detractors “were trying to chop it off,” he said. By the time he joined the UNMC staff in 1958, he was engaged in animal tests to support his theory. What kept him at it in the face of doubtful colleagues was, he said, his view the aging process is “a very important problem — it’s the thing that kills us” — and his belief that the theory is correct. That’s the reason I’m still at this problem. It works. Otherwise, as a chemist, I wouldn’t waste my time if it didn’t.”
So, what are free radicals and how do they impact aging? Free radicals are molecules with an unpaired electron. These lone wolf electrons create havoc in cells, setting off damaging chain reactions that account, he said, for the effects we experience as aging. Free radical production is stimulated by oxygen, which provides the energy we need to survive, and by environmental sources, but over time free radical reactions increase to a threshold the body cannot tolerate and we die. Harman contends an increase in antioxidant — vitamin E, vitamin C, beta carotene — consumption decreases free radical reactions, thereby slowing the aging process. “You’re putting in a preservative, in effect, that counteracts the deleterious effects.” The benefits of antioxidants — from increased life expectancy and reduced incidence of disease — have been shown in studies of rodents and birds. His efforts to promote antioxidant use — he’s long followed a daily regimen himself — has succeeded. “Americans spend around $4 or $5 billion a year on supplements, most of which are antioxidants, and even though I can’t prove it,” he said, “I’m sure a lot of those people will live longer then they would otherwise.”
Harman, whose research was long supported by a patroness, the late Mrs. Leon Millard, has in recent years seen funding dry up, a frustrating turn of events he ascribes to changing research priorities. Of more concern, he said, is the scant work being done on life prolongation and disease prevention using his theory’s tenets. “A great deal can be done, but we’re not doing it, and that’s disturbing.” As for himself, he continues writing articles, making presentations and giving interviews that lay out his ideas. Retirement doesn’t enter his mind. “I think you’re much better doing something,” he said. While he suspects his own life span may have been shortened due to recent health problems, he said time remains his main asset. “It’s what I have most of, but these are things you can’t predict.”
An Uncommon Man’s Search for Cancer’s Hereditary Links
As just one example of the uncommon life he’s led, Henry Lynch grew up a school drop-out and street fighter in a rough section of 1930s New York but persevered to become a medical doctor and noted cancer researcher. “I didn’t pick fights but, boy, the neighborhood I lived in it was a very common occurrence to meet bullies, and you had to defend yourself,” said Lynch, chair of the Department of Preventive Medicine and president of the Hereditary Cancer Institute at Creighton University. Even though he never attended high school — a result of his wartime service and working to support his family — he cultivated his naturally brilliant mind by reading “voraciously,” saying, “I did it on my own. I spent every free moment I had looking up things in the library. I had no doubt in my intellectual abilities.” Or in his physical prowess, which he put to use as a stevedore, farm hand and prizefighter.
Still a hulk of a man at 75, Lynch enlisted in the Navy as an under-age, but over-sized 16 year-old seaman in 1944. Serving as a gunner on freighters and transports, his tour of duty took him from the North Atlantic to the Mediterranean to the South Pacific. He boxed during his two-year hitch and once back stateside he resumed fighting as an amateur before turning pro. “I loved to fight,” he said, adding he boxed under assumed names in a 20-bout pro heavyweight career in order to retain amateur status in a hoped-for bid to play college football.
At first, it was as much his desire to play football at the University of Oklahoma under legendary coach Bud Wilkinson as it was his need to feed his hungry mind that led this then street-wise New York tough to enroll in college there in the late 1940s. By the time his failed tryout with the powerhouse Sooners ended his gridiron dreams, he was “consumed with studying.” He continued his studies at the University of Colorado and at Denver University and the University of Texas in Galveston. Trained in genetics, Lynch was serving an internal medicine residency at UNMC in 1961 when the course of his professional career changed. “I was called to see a family with multiple cases of colon cancer, but with no polyps. That was something I thought was quite unique. I studied that family. I went into great detail…not just studying the immediate relatives but extending it as far as I could to grandparents, aunts, uncles, cousins,” he said. “And I collected pathology extensively and wrote up all the clinical histories so I could put together and really understand how this could be a syndrome, and ultimately it emerged as one.” For his pioneering work, the syndrome was named after him. That first case history led him to track more families with colorectal and other cancers and it “influenced my whole decision to become a medical oncologist,” he said. It was also the start of a massive hereditary cancer data base he manages at Creighton, whose staff he joined in 1967.
Like any new idea, Lynch’s assertion some cancers have a hereditary basis was dismissed those early years. “People thought I was crazy. They kind of laughed or said I must be dealing with a chance situation or with an environmental factor,” he recalls, adding he often paid for fact-gathering trips out of his own pocket in lieu of grant support. His faith in his findings did not waver, he said, because “with a background in genetics I saw what we call a segregated model in the way cancers were moving through families and I knew it had to be hereditary. Finally, it wasn’t until the late 1960s that people began taking me seriously.” Today, Lynch is an acknowledged leader in his field, the author of 12 books and hundreds medical journal articles and a keynote speaker at medical conferences around the world. Despite his lofty status, he still goes out in the field recording case histories. He said getting good data “is not just a matter of the history, it’s winning confidence from the family members and gaining rapport. You’ve got to really care and they can tell right away whether you care or not. And I care. I really do. I care about them not just as research subjects but as human beings and they appreciate that.”
He and his colleagues not only track but identify pathological genes that cause disease and they apply preventive methodologies, including prophylactic surgeries, that remove or reduce the risk of cancer in patients. Genetic engineering, he said, will one day allow physicians to manipulate mutant genes. “If we can figure out the chemistry we might be able to design drugs that are the antithesis to what that gene is making, so we can block it and we can cure cancer and other diseases. That’s on the horizon. No question about it.” Where does Lynch draw the line in genetic intervention? “I don’t think we can foresee specific boundaries to this at this moment,” he said. “But if used prudently with the cardinal feature being the interest of our patients and following the orthodoxy of do-no-harm, then I think it’s fair to progress and to use all the tools God gave us to help humanity.”
Still actively engaged in work at an age when most of his peers are retired, Lynch can’t imagine quitting his passion. “Well, I will never retire. I just love my work. Besides, I don’t have any hobbies. I don’t know what I would do. My whole life is in this direction and I see a whole lot of problems there and some of them we can solve,” said Lynch, who has a wife, Jane, and three grown children. “It’s a joy knowing maybe I can help people.”
The King of Calcium
When Creighton University endocrinology expert Robert Heaney discusses the benefits of good nutrition in fighting the onset or progression of disease, he has a knack for making what could be a dry recitation of facts into an engaging discussion. For example, listen to his explanation of why our calorie-rich modern diets are actually nutritionally poor in comparison with our forbearers: Hunter-gatherers, he said, enjoyed an amazingly varied diet by foraging off the land and its bounty of nutritionally-rich nuts, roots, leaves and berries, whereas since the agricultural revolution our diets have been dominated by cultivated seed plant-derived foods — cereals, breads, legumes, wheat, rice, corn, millet — that provide high energy but low nutrition. “One of the issues modern nutrition is confronting,” he said, “is the role it may play in the chronic diseases that affect human kind today — cancer, degenerative cardiovascular disease and dementia. Does nutrition play a role there? Nobody knows. But there’s some evidence it does.”
Muddying the works, said Heaney, an Omaha native and Creighton grad who, with wife Barbara, has seven grown children, is the often spurious nutrition claims promoted by quacks and charlatans. “A lot of this stuff is just made up by people who don’t know anything about what they’re talking about,” he said. “I’m not going to sit here like a crank and say, It’s all nutrition — if you just ate right you wouldn’t have any problems. That’s not true. But I am convinced there is a role nutrition does play. The field I’ve worked in, osteoporosis, is an example.” He said the high incidence of osteoporosis today is likely due to diets low in calcium and vitamin D, two essentials for keeping bones healthy and strong into old age. “If your calcium intake is low,” said Heaney, the author of the book Calcium and Common Sense, “you are constantly withdrawing calcium from your bone bank in order to meet the needs your body has today. The problem is that as that goes on day-after-day, year-after-year, 24-7, that revs up bone remodeling and leads to structural weaknesses. So…much of the damage associated with osteoporosis is due to this high level of remodeling, which makes the bone more fragile.” While some progress is being made in assessing who is at risk for osteoporosis, he said identification is complicated by the fact “we’re immersed in a society in which everybody has low calcium intake but not everybody gets osteoporosis because some are more sensitive to low calcium and others are more resistant.” He said factors that impact the equation are starting to be “worked out. For example, African-Americans have a bony apparatus that tends to protect them against low calcium intake whereas whites will tear down their skeleton much more readily.”
Research by Heaney and others clearly makes the case for calcium and vitamin D in reducing bone fracture rates in older patients. He said where he used to be asked by science writers if calcium is vital or not, “I don’t get those questions anymore. There’s a high awareness of the importance of calcium and I suspect that’s due to the media. What the general public doesn’t know is how much calcium they need and what amounts are contained in the foods they eat.”
According to Heaney, calcium is also a marker for a nutrition-poor diet. “We did a study at Creighton of 300 or 400 volunteers that found those who had low calcium intakes — meaning less than 70 percent of the recommended daily intake — tended to get less than 70 percent of the recommended intake of four other key nutrients. So, a low calcium intake tends to translate to having a poor overall diet low in lots of other nutrients.” He said the preferred way to get patients to increase calcium is through diet. “The best way to get the nutrients we need is from eating other organisms. We don’t know enough to put it all into pills. So, we stress food. If I can get you to eat calcium-rich foods then I know I’ll have a much better chance of your getting all the nutrients you need because dairy foods are such good sources of so many of these nutrients. We recommend fortified foods as a second or third line of defense and only recommend supplements as a last resort.” He is quick to note calcium is not the only nutrient crucial in osteoporosis and nutrition is not the only factor impacting the disease.
Even at 75 Heaney is still at the top of his game, evidence of which came with his being honored as the 2003 recipient of the E.V. McCollum Award from the American Society for Clinical Nutrition for his creative work as a clinical investigator in generating and testing new concepts in nutrition. For him, research is a never-ending exploration, journey and challenge. “It’s all those things. It’s always a question of why and how. Those are the interesting questions,” he said, adding he’s had a curiosity for how things work since he was a kid taking clocks apart. He said he “doesn’t waste a lot of time pondering” retirement, adding he’s too busy anyway between his research, writing and speaking commitments. Besides, the grant funds he secures for CU’s osteoporosis research center are what keep it open. “The day I stop, the work stops. That’s why I’m happy to keep doing it.”
High Flying, Straight Shooting Doc
University of Nebraska Medical Center otolaryngology physician-professor and retired Air Force veteran Anthony Yonkers has applied his healing arts in a wide variety of settings. He’s served as flight surgeon aboard jets, provided medical advice to Stratcom leaders running nuclear scenarios in its underground command post, taught medical students and resident physicians in training, conducted research into new head-neck procedures and performed countless operations that improved patients’ lives. The Muskegon, Mich. native and University of Michigan grad came to Omaha in 1968 as an active duty Air Force major assigned to Erhling Bergquist Hospital at Offutt Air Force Base. As an ex-serviceman, Yonkers is widely respected in his role as an attending clinician at Omaha’s V.A. Medical Center.
While never an Air Force pilot, he learned to fly in the Offutt AeroClub and even got to take the stick of T-38 trainers on flights he accompanied. These days, he pilots his own single-engine Mooney to medical conferences, family get-togethers and relief efforts undertaken by the Order of St. Lazarus, a humanitarian organization he is active in that provides medical care to leper colonies around the world. He and his wife Mary have four grown children.
When Yonkers neared the end of his Air Force active duty in the late ‘60s, he was set to go back to Michigan when a position opened in the new Department of Otolaryngology at UNMC, where he’d volunteered. “I was only going to stay a year or two to see how this brand new department worked out…and lo and behold I’m still here 35 years later,” said Yonkers, who continued as a reservist, rising to the rank of brigadier general, until 1998. “It’s been kind of exciting to see the department develop as we’ve added more staff and areas of concentration,” including a center treating patients with head and neck cancers, a prosthetic division building radiation shielding devices to help save tissue and molding false ears and noses and a sleep institute addressing patients’ chronic sleep disorders.
Yonkers and his UNMC colleagues participate in studies looking at everything from sinus infections to breathing disturbances to cleft lip and palette repairs to the treatment of papillomas of the voice box. He said new insights into treating medical conditions often arise from clinical experiences that prompt questions that in turn spur quests for answers through “studies of what best proven methods or accepted techniques work best in a given set of circumstances.”
For Yonkers, one of the most pleasing aspects of his work comes in his role as a teacher. “It’s fun in that you’re seeing young people develop. You’re taking a medical student with maybe one year of general surgery training and in four years you’re turning him or her into a specialist that can go anywhere in the country and hold their own. That makes you feel good.” He said practicing medicine gives him great satisfaction. “It’s a fascinating area. It’s an opportunity to work with people and to do something to alleviate their discomfort and to make their lives better. It’s very satisfying.” At 65, his passion for his work remains undiminished. “That’s the reason I’m still here and not retired,” he said. While he knows there may come a time when it’s prudent to lay down his scalpel, he believes older docs like himself offer what cannot be taught or replaced. “Through the years you build a feel or sixth sense for things and it takes awhile to accumulate those assets and nuances. That kind of knowledge is hard to measure and is lost in a forced retirement.”
- It’s Not Just Your Gene Pool (lewrockwell.com)
- Study: Anti-Aging Supplements Best Taken in Middle Age (livescience.com)
- Why Prostate Cancer May Not Run in Families (newsweek.com:80)
- Mayo researchers develop new laboratory cell lines to study treatment for ATC (eurekalert.org)
- Experts find gene variants for stomach cancer (reuters.com)
- Alternative Treatment for Osteoporosis (brighthub.com)
- Calcium and the Law of Unintended Consequences (theness.com)
|The camera rolls as emergency room trauma team goes into action.|
To be honest, I was hoping for something dramatic to happen in the ER that agreed to accommodate for a few nights my hanging around, asking medical staff and paramedics and patients questions and taking voluminous notes. Nothing much did. That is to say, a stream of patients came through presenting all manner of problems, but nothing over the top sensational occurred. I think I still managed a good story out of the assignment. You be the judge. The article appeared in The Reader (www.thereader.com) as a kind of companion piece to another story I did based on ride alongs with paramedics. You can find the paramedics story on this blog as well. It’s titled “Merciful Armies of the Night.”
ER, An Emergency Room Journal
©by Leo Adam Biga
Originally published in The Reader (www.thereader.com)
Hours of Boredom and Minutes of Terror
Hollywood portrayals of hospital emergency rooms depict white hot action zones where medical drama and staff intrigue continue nonstop. What’s a real ER like? Recent visits to the NHS University Hospital ER found a medical treatment center, social laboratory, educational classroom and last refuge all in one. An intersection where the gallery of humanity meets and various trends surface. A mission, a haven, a hell. Or, as one ER nurse put it, “We deal with the heart of Omaha here.”
Like many staff, nurse Susie Needham feels the ER is THE place to be on the frontlines of medical care due to its fluid nature, one she summed up as “hours of boredom and minutes of terror.” Unlike television’s ER, long tedious stretches can grind by before a single trauma arrives. Then again, a run of critical or extreme cases can suddenly pile-up, kicking a slow shift into high gear. As Needham put it, “From moment to moment, it can change.
Most people that work here are attracted to the fast changing pace and the variety of different patients we see. It’s never the same. You have to know a lot about a lot of different things, and that’s what keeps you on your toes. It makes it interesting.” On a Friday night in April Needham, a pretty freckled blonde with an impish smile, tended a diverse mix, including a bronchial pediatric patient with difficulty breathing, an adult drug abuser suffering withdrawal pangs and a drunk woman ostensibly there for stomach pain but whose battered body and frayed psyche told a more sinister story.
For the most part, ERs treat a procession of fevers, coughs, sprains, aches, cuts, bruises, breaks. Purely routine stuff. Unless it’s happening to you, of course. Since one person’s trivial complaint may be another’s dire crisis, everyone is treated the same. No condition is refused. Nothing is taken for granted. Trained to assess and treat serious problems, medical staff try first ruling out any life-threatening cause before looking at non-critical or non-medical issuses. Most ER medical staff possess extensive critical care backgrounds, but it seems all ERs (the step-child of acute medical care) are not equal.
On busy nights (Sundays are worst) patients stack up and long waits ensue. Triage nurses sort cases on an as-needed basis, with the severest seen promptly and the mildest set aside for a kind of walk-up window service, Fast Track. But again, unlike TV, where patients sweep through the ER unchecked, the real world entails staff documentation-communication for all patient admissions, treatments, releases. In terms of volume, University Hospital recorded 27,018 ER visits last year, a slight rise from 1998. Traumas typically account for about 3.25 percent of all cases.
Not long past dusk on St. Patrick’s Day things were unwinding surprisingly slowly in the ER considering this was a designated trauma night (meaning area rescue services were to feed trauma patients there) on a Friday holiday known for alcohol-related injuries. Earlier in the day, staff treated a 43-year-old Omaha man knocked unconscious in a bar fight. Michael Kimball was brought in comatose. Massive swelling in his brain forced doctors to remove his skull to relieve the pressure. (Editor’s Note: Kimball never regained consciousness and, two weeks later, was pronounced dead. Police cited insufficient evidence to file charges in the case.).
Hours later, during a protracted lull, staff lingered about “the hub,” the ER nerve center, bantering in the irreverent MASH humor used for stress relief. Attending physician Dr. Paul Tran made a colleague, Dr. Rick Walker, envious by describing his sound sleep the night before, a rarity after the rush of a nine-hour trauma shift. When not hanging at the hub or crashing in the staff lounge, docs, nurses, techs and residents use computers and charts to monitor the condition of patients in surrounding non-critical care rooms and trauma bays (a total of 16 beds), to track the progress of lab workups, x-rays or other procedures and to file paperwork. A large grease board hanging high on the wall is smudged with running patient status reports. This checks and balances system aims to avoid patient-bed-meds. mixups
The staff perked up that night at the static-filled emergency band radio (always droning on in the background) report of a CODE 3 (critical medical) case en route, with an ETA of five minutes. Staff are uncanny at hearing the calls headed their way and ignoring the others. The paramedic’s sketchy details described an elderly man who fell and hit his head outside a Bag ‘N’ Save. The man, whom paramedics found minus vital signs, had been shocked back to life. With the clock ticking, Dr. Tran, a slight Vietnamese native with a gentle bedside manner, conferred with colleagues on whether to summon the trauma team, a kind of in-house medical SWAT squad on call to treat the most severe critical care cases, or to handle things themselves.
It Never Gets Better
Dr. Walker, a beefy man whose pockets are invariably overstuffed with paperback novels and stethoscopes, has spent his entire medical career in emergency medicine. He said part of the appeal for him and others is the extreme nature of the work. “I think it’s very challenging, and that’s a large aspect of it. It’s also a big adrenalin rush, and as I’ve assessed my life and career I’ve come to the conclusion I’m an adrenalin junkie, and I think that’s probably what did it for me.”
He said being exposed to the tragedy that accompanies trauma extracts a certain toll:
“You see bad stuff happening here, and it’s stuff that, you know, can make you cry, like kids dying. It’s tough and it can really get to you emotionally, and so what you have to do is build up a wall because otherwise you’d be breaking down every time you saw something like that and you could not function. That wall tends to stay up most of the time and the last few years it’s become an issue in my personal life.” Nurse Jackie Engdahl said it takes a special breed to work there, “Oh, definitely, Type A personalities make good ER nurses. You have to be very aggressive…very assertive because of what you deal with. You deal with not only ill and injured people, but intoxicated people and drug-induced and psychotic people. You gotta love a good challenge and you gotta be strong enough to whip into shape when the going gets tough.”
For trauma nurse coordinator Kathy Warren, it’s a matter of staying focused no matter how horrendous the reality before her. “Some of these cases are just horrible looking when they come in. You just have to totally ignore that and focus in on the task, so whether you’re starting the IV or helping the docs with procedures, you detach yourself and just click into gear. You can’t get nervous. You have a job to do,” she said. Warren, whose job entails her dealing with family members, said staying composed is hard when working with parents who’ve just lost a child. “Sometimes I have to step back for a few minutes and take a deep breath. When I get home after a case like that, everybody knows its been a bad day as soon as I walk in.”
Added Susie Needham, “People think you get callous or something, but you don’t. Some of the things we see are heart-wrenching and no matter how many times you’ve seen them it still really bothers you. It never gets better.”
Things finally began heating up again on St. Patty’s Day once the Code 3 patient was wheeled in on a gurney by paramedics and lifted onto a bed in the T2 trauma bay. The heavy-set man of about 65 lay there in a coma, a breathing tube inserted in his throat and an IV snaked into one arm, his big hairy belly billowing up and down as a bevy of ER medical staff hovered over him to keep him alive. “I need, STAT, six units of platelets…” a nurse called out. “Tell respiratory to bring a vent, please,” called another.
Then, when someone barked, “I need another set of hands up here,” a tangle of arms belonging to eight nurses, techs and docs converged to perform, seemingly at once, multiple tasks, from hooking up a ventilator to running a blood pressure line to starting a new IV to drawing blood to attaching EKG electrodes. “Sir, there’s going to be a tube going down the back of your throat,” one of them said more out of habit than out of any expectation of a response. Lying there, totally exposed and vulnerable, his life completely in the hands of these angels of mercy, the man, referred to then only as John Doe due to a lack of ID, was an anonymous soul brought back from the very brink.
Time is of the Essence
Time is critical in trauma or near trauma scenarios like these. That night’s charge nurse, Scott Miller, said it involves quick, precise coordination and communication. “Everybody swarms in to get the job done as fast as possible. In a case like this you have Dr. Tran coordinating and everybody trying to feed information to him as to what they’re finding at the same time as they carry out his orders.”
When the whole trauma team is activated, a whole slew of specialists — from surgeons to anesthesiologists to radiologists to lab techs — converge on the spot, making teamwork even more essential. According to Kathy Warren, “You have a lot of people and everyone has a different role and, hopefully, they know their role so they’re not getting in your way and you’re not having to tell them everything. It usually works pretty well, and it’s amazing the amount of things that can be done for a patient in a short amount of time when you absolutely have to. But that’s what a trauma center is supposed to be able to do.”
Emergency care often starts with the rapid response of rescue squads on the scene. Paramedic Tom Quinlan was among those responding to the 911 call that found Doe lying unconscious. “He was not breathing. He didn’t have a pulse. So we started our CODE 99 (for clinically dead cases) protocol, which is intubate him, start an IV and do CPR. We ended up shocking him a couple of times. We finally got a pulse back and he continued to breathe for us on the way to the hospital,” he said.
Added Dr. Tran, “Time is of the essence here. After so many minutes, it doesn’t do any good, so it’s all speed and skill. The man probably experienced sudden death when his heart went into fibrillation, meaning it didn’t pump any blood and, so, the brain promptly became unconscious and he fell down and hit his head and only by actions of the paramedics did he come back. He was extremely lucky to have had everything done in that time, otherwise he would be dead by now.”
Dr. Tran said the fall resulted in “about a five-centimeter hematoma on the back of the head.” Since Doe was found unresponsive and bore a scar on his chest indicating a history of heart surgery, the question on Dr. Tran’s mind was whether the patient’s vegetative state was due to the fall or to some new cardiac event. Not wanting to overlook a potential cerebral cause, he called in part of the trauma team after all. As Scott Miller, explained, “We’re assuming now he had some sort of heart event that caused him to fall and hit his head. We will be doing a CAT Scan to make sure there’s not something else going on, like a big bleed in his head. We don’t think that’s the case, but you can’t always tell for sure.” Later, it was confirmed a cardiac event did trigger the trauma.
As for the long-term prognosis, Dr. Tran said, “I’m not sure of the condition of his brain function later on.” By then, Doe was identified and his family contacted by nursing resource coordinator Regina Christensen, who met with family members. Part of hers dutie entails fielding inquiries from news hounds looking for material. She noted with incredulity some sound disappointed when a case is upgraded from critical to stable condition.
When treating a trauma, there is no room for bruised feelings. The required care must be delivered NOW. Hashing out differences can come later. One of the reasons nurse Jackie Engdahl likes working in the ER is the maturity of the people working there. “When I worked in other hospital areas there were very clashing personalities and people always bickering back and forth. But here, it’s not that way. You say whatever you want to say to someone and then it’s over and done with. There’s never hard feelings.” And, she said, where some physicians resent or reject nurse input this ER’s docs welcome it. “The doctors here work really well with the nurses. The doctors trust our judgment and they really listen to us. They allow us to do a lot of things, which is nice.” What about departmental romances? “There used to be between the nurses and paramedics,” nurse Janie Vipond said. “It just depends on the group you have at any given time. But, yeah, it happens.”
I Felt I Was in Good Hands
Amid the controlled chaos of an unfolding ER trauma, staff attend to myriad details, not to mention other patients. For the trauma patient whose life hangs in the balance, it can be a surreal experience of wailing sirens, flashing lights, antiseptic smells, probing instruments, strange faces and endless questions. There is fear, confusion, agony. There is even a strange sense of peace. Beverly Harter, a 62 year-old wife, mother and grandmother, has been there. How she got there is a story in itself.
On May 16, 1999 the Logan, Iowa resident was attending a graduation party at the nearby trailer home of a daughter. Various family members and friends were present. The weather was threatening that afternoon. When the sky turned ominous and a tornado warning sounded, the 12 partiers fled the trailer for their cars in an effort to outrun the storm. But it was too late. With a twister bearing down, they left their vehicles to take refuge in a roadside ditch. Huddled on the ground, exposed to the savage winds, the group was deluged by parts of farm machinery ripped asunder in the cyclone and propelled like shrapnel. The metal shards rained down on them, tearing skin, cracking bone, crushing organs.
When it was over, Beverly’s daughter was dead and two grandkids, both injured, left motherless. Her son endured a broken clavicle. A family friend died. As for Beverly, she suffered a punctured diaphragm, a perforated bowel and two crushed vertebra. Her house was leveled. Ironically, the trailer escaped unscathed. Transported by a local rescue unit to Missouri Valley, Beverly was then taken by ambulance to the nearest trauma center, the University Hospital ER.
Beverly, who remained conscious during much of her ordeal, did not have to be told she was badly hurt. “I knew I’d suffered spinal cord damage because my legs were on fire, and they stayed on fire.” she said. She also knew her daughter “was gone” and other loved ones injured. As for her Omaha ER odyssey, she recalls “bright lights,” a sense of “time standing still” and “a lot of people doing a lot of things and asking a lot of questions. I was really hurting and kind of fading in and out from the sedation, but I was able to answer a lot of questions. They explained to me what they were doing at all times, and that was reassuring.”
Indeed, despite her pain and grief, she recalls feeling calm. “You just have a sense that everybody’s taking care of you and that they’re all working together doing their jobs. I felt I was in good hands.” She also felt the staff’s compassion. “They were extremely sensitive and caring and protective about what happened to me and my family. They knew the devastation and loss we had. I was just overcome by their concern for our well-being,” said Harter, who today is confined to a wheelchair.
Kathy Warren said she used to doubt whether the time she spent with families who suffered a loss made a difference until her own father died in the hospital and she found comfort in the support her colleagues gave her. “I realized how important it is to have somebody treat you with kindness and to let you grieve however you want to and to explain things to you. Ever since then I’ve really pushed staff here to sit down with families and to talk to them. It’s not an easy thing to do as a medical person. Some people are better than others. But people don’t expect us to be super men and women. To save everybody. They just need us to be there.”
Not all exchanges are so pleasant. Patient complaints over long waits get expressed along the sarcastic lines of, “I’m sure glad I wasn’t dying.” Before things get nasty, staff try defusing the matter. “The basic strategy is to make them see you as being on their side,” said Dr. Bob Muelleman. “On the other hand, you want to be very much in control of the situation. If it’s just a matter of them yelling and cussing at you, well, that pretty much comes with the territory. Once in a while there’s kind of a thrashing or flailing out. If you think there’s the potential of them really getting violent you can call in security or police, but normally you can handle it on your own.”
When care complaints cannot be appeased, they are passed-on, in writing, or addressed on-site by managers like Regina Christensen. “It can be anything from somebody upset that their mother’s IV is out to something as complicated as a gang-related situation where the patient himself or his family is threatening staff. It’s just an array of things,” she said.
The Truth is Stranger Than Fiction
Meanwhile, back on St. Patrick’s, a drunk middle-aged woman involved in a domestic dispute came in with an aching gut. However, the night’s triage nurse, Susie Needham, recognized bruises and marks as signs of physical violence and sexual assault. After questioning the woman, a horrific tale of prolonged torture and bondage emerged that prompted ER staff to follow procedure and report their suspicions to police. Acting on the medical staff’s input two officers, who earlier arrested the woman’s boyfriend on misdemeanor assault charges, returned to open a rape investigation.
According to Needham, “If people come in here with traumatic injuries that don’t really fit their stories, we call the police.” Often, she said, such patients prove to be victims or perpetrators of a crime. Surrounded by staff and police in a room concealed by drawn curtains, the woman cried out, “I can’t take it anymore. I don’t want to take it anymore.”
After examining the woman a visibly shaken Dr. Tran said, “It’s one of the most remarkable cases of domestic violence I’ve ever seen. She has multiple problems. Number one is domestic violence and sexual assault. Number two is chronic alcoholism. Number three is a low platelet count. Number four is what appears to be an upper GI bleed.” As part of hospital policy in such cases, staff called in a domestic violence-sexual assault counselor to apprise the woman of her rights and refer her to appropriate community resources. But, as ER staffers say they’ve seen far too many other victims do, the woman rejected police-medical entreaties to undergo a forensic exam, something required for a criminal inquiry, and declined pressing rape charges. She was admitted and treated for medical problems.
“What do you do?” a frustrated Needham asked. “That’s tough,” Dr. Tran said, “because once enough time passes, the evidence is lost. We can’t do anything. You have to respect the patient’s wishes. Patient autonomy is everything. Why did she refuse? Oh, fear, love rejection, sensitivity. Who knows? Unfortunately, it’s common.”
Bizarre, believe-it-or-not episodes are also common in the ER. Take the time an obnoxious drunk showed up with a fierce but inexplicable pain in his belly. After sleeping it off, he staggered up from his cot and only then did the ER doc notice a speck of blood, on the sheets, which upon closer inspection turned out to be from a tiny hole, splayed by burn marks, in the man’s back. Apparently, he had been shot but was too drunk to recall it. Sure enough, an x-ray revealed a bullet lodged in the abdomen.
Or, take the time a stabbing victim arrived cut entirely from stem to stern, his entire rib cage exposed, yet conscious enough to describe the whole bloody fillet job some whore performed on him. Or, the time a man fell at home on a fireplace iron and walked in the ER with a small wound on his neck which, upon further exam, proved to be a deep puncture penetrating his cervical spine. For Dr. Muelleman, who treated all these cases while working in a Kansas City, Mo. ER, such incidents fall under the heading of “the truth is stranger than fiction.”
Perhaps the most frustrating cases are those involving entirely preventable injuries, especially those incurred while victims engaged in some high-risk, reckless behavior, like a young man Dr. Muelleman treated in Omaha who crashed his car while out joy riding and ended up paralyzed from the neck down. “I don’t call them accidents anymore,” he said, “because an accident suggests an act of God. I call them injuries because when people put themselves in these circumstances something is going to happen that didn’t have to happen.”
As ERs are traditionally the 24-7 stop-gap or catch-all of American medical care, the entire spectrum of need shows up there. In most public hospitals, no one is turned away, regardless of insurance status or ability to pay. “The emergency department is the safety net for many people seeking care who really have no other place to go, said Dr. Paul Tran. “Admittedly, there’s going to be abuse of the resources because this is reserved for emergency cases, but who’s definition of emergency is it? A toothache at 2 a.m. may be an emergency to you, but it may not be to someone else. We are here to take care of people from all walks of life and with conditions as minor as a toothache or as serious as a heart attack. And from that standpoint, it is very satisfying to provide people the last resort they need and to get the instantaneous gratification of turning them around.”
Given its open door policy, “the ER is where you really see the cross-section of humanity and so, if there are social ills, you seem them in the ER,” Dr. Muelleman said. “Some of the ills we deal with are domestic violence, drug and alcohol issues, child abuse, lack of immunization and lack of access to health insurance. Another segment the ER picks up on are the acute psychiatric and homeless populations.” He said in an era of managed care, ERs play an increasingly large social service and public health role. “
So, if we’re dealing with intoxicated people we try to get them in a shelter or detox center. If it’s an abuse case we bring in social workers, police and protective agency professionals. If we’re dealing with domestic violence, we make sure patients understand the resources available to them.” Nurse Scott Miller is “troubled” by how many kids he treats who “are not well cared for” at home and “very frustrated by the large number of people with legitimate psychiatric problems who can’t get seen” due to a lack of psychiatric beds locally. He said, “I’ve spent many hours fighting on the phone, calling medical staff at home, to get people admitted in the hospital when they don’t really have a medical problem. But when no psychiatric place will take them, we can’t just send them home.”
Dr. Muelleman said where ERs have always tried educating patients about prevention safeguards and optional resources, “Some have gone to the extent of smoking cessation and substance abuse counseling. I’m just reviewing a grant for a hospital to screen Type II Diabetes, which is not something you’d traditionally think of as an ER doing. There is a real move toward ERs getting involved with public health, even things like bike helmet giveaways. Some have even gone as far as to give pneumonia and flu shots. Even here, during seat belt awareness week, we do educational stuff to let people know about the importance of seat belts.”
As a survey of ER web sites will attest, there is debate in the medical community over the all-encompassing role of the ER. On this subject, Dr. Muelleman takes a pragmatic position. “You can’t select why people use the ER. Once they’re here, you can’t ask, Why are you here again?, although you may be tempted to. I mean, I support the notion public health policy in America should be changed to help take care of people’s health needs in a more comprehensive fashion than just having them go to the emergency room, but given that’s not the case, the mantra in the ER continues to be — anybody, anytime, anything. That’s exactly what it is. Should we change medicine so that doesn’t happen? Well, yes, we should, but in the meantime we’ve got to do what we can to help people.”
- Some ERs post wait times by text, billboard (msnbc.msn.com)
- Newly Insured are Likely to Congregate in Emergency Rooms (prweb.com)
- Timesunion.com: If it’s an emergency, they’re on the clock (timesunion.com)
- Text Your Way To a Short Emergency Room Wait [Medicine] (gizmodo.com)
- Lengthy waits in local ERs (windsorstar.com)