Michael Epstein | Bookmarks: A doctor's tales from the emergency room

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An aging Episcopal priest enters the emergency room with a life-threatening episode of chest pain and decides to leave against a doctor's advice in order to attend a reunion of his community service group; a 10-year-old boy drowns and arrives dead in the emergency room but is resuscitated and leaves the hospital the next day in fine shape; bullet wounds, knife wounds, overwhelming infection, the alcoholic withdrawal of delirium tremens — such is the daily fare of "situations" in Paul Seward's fine memoir about his decades as an emergency room physician.

In "Patient Care: Death and Life in the Emergency Room" (Catapult, 2018), Seward achieves the two goals he set forth for himself in the preface. First, he shows the reader "what it feels like to work there" by relating stories about real patients, not as "events" but as "situations that as they happen, ask for a response from the people who are witnesses." Seward's responses are the core of this book and illustrate his second goal — emphasizing "caring for the person" as the key characteristic of a good physician.

Seward values the knowledge of anatomy, physiology, and pharmacology that a doctor needs and recognizes the complex technical skills that a doctor must have in the ER, but he focuses on the element that has a double meaning in the title of the book — caring. In each of the situations that he narrates, he shows that in addition to providing the medical care a patient needs, the good physician must also care deeply about the patient as a person. With great insight, he explains that this kind of caring, i.e. the love for the stranger, is not an intuitive or instinctive emotion; but once learned, this deep caring for every person who suddenly becomes a patient, characterizes the best physicians.

Seward describes 20 situations that he faced in the hospital, the challenges, the actions he took, the outcomes and the "take-home lessons" that he learned. As a retired intensive care physician, I found his descriptions to be well written, accurate, and engaging, but the reader doesn't have to be a healthcare professional to be enthralled by these stories. Seward writes clearly and explains complicated medical conditions with skill and a sense of humor, providing the lay reader with enough information for a clear understanding of the situation and his actions without drowning the reader in details.

The situations include both the everyday, quotidian events of life — the auto accident, the minor injuries (great chapter on nursemaid's elbow!) —as well as the dramatic, life-changing surprises that disrupt and, in some instances, destroy the life that one had been living until moments before entering the ER. He does not shy away from the ethical complexities inherent in some of these cases, clearly describing the key elements of each dilemma, especially the need for decision making when there is no clear right course of action and when the patient is unable to weigh in with a preference.

As an example, the book begins with a chapter in which a 22-year-old man, living in a nursing home in a vegetative state after severe head trauma in his late teens, presents to the ER with pneumonia, a condition that can usually be easily treated with antibiotics and respiratory support with a good outcome. But just because one can treat, is one obligated to treat? Seward explores this central question of biomedical ethics in a sensitive and caring manner. He also relates the ethically nuanced stories of a newborn baby with central nervous system abnormalities that are incompatible with life and of an elderly woman who has left clear "do not resuscitate" orders in her medical record with similar sensitivity.

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While I've not met Paul Seward, he and I are about the same age and he was finishing Harvard Medical School when I was applying for admission there. He completed a pediatric residency the year that I began mine, and we both have had extensive experience with caring for patients where a delay in decision making or a failure to successfully execute a therapeutic maneuver, would be devastating for our patient.

Because of this, I felt a special pleasure in reading this fine book. At times, memories of my own experiences came flooding back with the same sadness or elation that I had felt at the time. His tales of the exhaustion of residency, the importance of mentors, and the critical reliance on and collaboration with nurses were all spot on. His detailed explanation of the difficulty of placing a breathing tube in the windpipe of a patient with respiratory failure was especially vivid for me. As he states, "there are few sights in the universe that match the beauty of a pair of vocal cords," referring to the anatomic landmark that tells the doctor that he/she has successfully intubated the patient! I couldn't agree more!

More importantly, I agree with his primary theme, that a key characteristic of a good doctor is the learned skill and ability to care about the patient as a person, somebody with a life, a family, a job, some hobbies and a story that extends far before he or she appears in the emergency room or the doctor's office. It is this caring for the patient that one hopes to encounter in their own physician. Seward's final anecdote tells of a mother whose child had been admitted with meningitis. She later tells him that she knew her son was very sick, but she was "terrified because I didn't know who you would be."

Seward educates and entertains all of us with his new book. Non-health care professionals will emerge with a better understanding of how the ER works and perhaps how to better navigate that complex and unexpected setting. Doctors will emerge with a excellent examples of how to better care for and care about their future patients. For it is in this caring partnership between patients, their families, and their doctors that the highest quality care can be delivered and experienced.

This is an excellent book.

Michael F. Epstein is a retired physician who reads and writes in Brownsville, Vt. and Cambridge, Mass. He can be reached at mfepstein@gmail.com.


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