Alumnus’s new book reveals the “human theater” of emergency medicine

One would be hard-pressed to imagine what Patrick Crocker, D.O.’80, M.S., FACEP, did not experience in his nearly 40 years in emergency medicine in Texas. Babies found in dumpsters. Patients who seemed beyond help who somehow rallied and recovered. Those who refused to stop smoking, abusing alcohol or drugs, eating a high-fat diet or doing any number of other unwise behaviors even as their lives and health disintegrated. Flaws in the health care system that fail and even harm patients.

Crocker shares these and many other true tales of emergency medicine in More Letters from the Pit: Stories of a Physician’s Odyssey in Emergency Medicine, a sequel to his Letters from the Pit, which published in 2019. More Letters debuted in August as the number-one new release in emergency medicine on Amazon and by Sept. 28 was ranked third among all emergency medicine books available via Kindle. Both books are structured as letters to his college friend Jack in a “first person, stream-of-consciousness narrative” about his career in a field where “there is little room for error when lives are at stake.”

“I really wasn’t planning to write a second book, but the response to the first one was so positive,” Crocker says. “My goal was the same – to write stories in a fashion that makes you feel like you were there watching.”

His highly visual and detailed writing style puts the reader in the rooms where it happened – the inexplicably listless four-year-old found to have a tick in her ear, the terrifying hulk of a patient crazed on a cocaine overdose, the pre-teen boy who was kicked by a horse but through sheer determination managed to scream for help before collapsing. Crocker is frank about the haunting guilt of patients who don’t survive, the joy for those who do and the frustration of treating patients who refuse to be upfront about their situation.

“One of the most frustrating things I’d encounter was patients who wouldn’t give me the straight truth the first time. I’m not here to judge you; just tell me what’s going on,” he says. “When I’d say, ‘What’s wrong?’ and they’d answer, ‘You tell me, you’re the doctor,’ you know you don’t have an ally.”

Tyler Cymet, D.O., FACP, FACOFP, chief of clinical education with the American Association of Colleges of Osteopathic Medicine, in his review of More Letters describes it as an “adrenaline- and emotion-soaked book” on “the bleeding edge on social issues encountered by health care providers.” In one chapter, Crocker describes a patient who, because he couldn’t afford medications for his hypertension, suffered a massive stroke and was bedridden with a feeding tube and catheter.

“Here’s a guy who for $10 a month, we could have paid for his medications,” he says. “Now taxpayers were going to have to pay a million dollars for all his care.”

Knox Todd, M.D., M.P.H., former professor and founding chair of the department of emergency medicine at the University of Texas MD Anderson Cancer Center, in his review says the book “opens a rich window into the human theater that is emergency medicine.” It reveals what Crocker calls “the things that can’t be unseen,” including experiences that cause many emergency medical providers to burn out, quit or worse.

“The pit is a nickname residents gave to the emergency room. Many of us felt our ER shifts were spent in a pit below the Black Hole of Calcutta, an eighteenth century dungeon that was especially deadly to its occupants. And, for certain, there were shifts that felt like that,” he wrote in the book’s preface. “My career as a whole, however, left me with a profound sense of fulfillment. I recall the deep satisfaction of being trusted by so many thousands of patients. Helping people in their time of need. Solving medical mysteries with only tiny pieces of information. Stretching my skills to save lives.”

Crocker expressed gratitude in More Letters for health providers who are stretched due to the coronavirus, which “began its rampage across the world” as the book was in final editing stages.

“Despite personal risk – and often without the required personal protective equipment – first responders, emergency room nurses, doctors and hospital medical staff worked courageously to save lives while risking their own,” he wrote. “A tremendous thank you to each and every one only scratches the surface of appreciation for their professional dedication. The entire world owes all of them a special debt of gratitude.”

From More Letters from the Pit:

“He’s Out of Control”

I’m working the crash area when we receive the alert that EMS, with police escort, are en route with a mid-thirties male who’s out of control. There’s no other information available from the paramedics, but over the radio you can hear yelling in the back of the unit. Figuring it’s simply another drunk causing a ruckus, I go back to work. He’ll be here soon enough, and I’ll worry about him then.

Several minutes later, they roll in. The patient is hardly talking now, lying on the gurney looking angry with Austin police officers on each side of him. Not an uncommon picture on a weekend night. Except for one detail.

This guy is positively enormous. Probably six feet, six inches tall and 300 pounds of sheer muscle. Not an ounce of fat on him. His shoulders are shockingly large, and his biceps are the size of my thighs. His waist can’t be more than thirty-four inches. He has the appearance of an overblown G.I. Joe action figure. Not someone you want to handle physically at all. So I’m glad to see he’s calmed down.

[Given the patient’s size, condition and eventual disorderly conduct, Crocker decides to apply the strong, heavily woven “Tuff-Man” restraints before beginning his examination. The patient’s rapid heart rate and 104-degree temperature raise concerns he’s ingested crack cocaine or methamphetamine.]

And then the big surprise comes. Right after the nurse sets up the monitors and steps out of the room, he becomes absolutely enraged. I ask him what’s wrong. His response, first with his right leg and then with his left, is to suddenly and easily snap the heavy restraints off of each leg. He turns his attention to his arms, and with one flex of his biceps and a shrug of his shoulder muscles, he snaps both free. Shit! I step back toward the open door.

The monitoring wires are ripped off and tossed into the corner. He looks like King Kong and stares at me for a moment. I’m certain he’s not mistaken me for Fay Wray or Jessica Lange, as I don’t see a milligram of kindness in his eyes, only pure fury. He jumps up and crouches on the bed, ripping his IV out as well. He grabs the IV pole, and I head out the door, closing it behind me and holding the door handle so he can’t easily open it. Fat chance I’ll have holding it with this beast pulling on it, but it’s all I have.

His next move really gets our attention. He takes the heavy IV pole and starts slamming it into the Plexiglas window, which I no longer consider unbreakable after witnessing his performance with the restraints. I hear our clerk overhead, paging for police to the ER STAT.

He bangs repeatedly on the window with the IV pole, and I can see it bow outward with each blow. I figure it won’t last long. The two officers who stayed to do their paperwork are at my side in seconds and help hold the door closed. Then the two from triage arrive and quickly assess the situation.

[After forbidding the officers from using Tasers or stun guns, Crocker has his nurse prepare a fresh IV and a dose of a drug that will temporarily paralyze the patient.]

The officers line up in twos like an entry team you see on TV. Eight of them first, with me and my nurse to follow. And then comes another surprise.

Instead of a simple immediate entry, the officers crack the door open, and three of them at once direct pepper spray right onto the patient’s face. We hadn’t discussed that part. But I’m desperate to get control of this situation as my patient may be dying. The officers slam the door closed. King Kong throws his body again and again at the door. It too bows outward with each impact. I see two of the officers drop their hands to their holsters, ready to draw weapons. Jeez, what a mess.

Fortunately, my patient is too disoriented to remember he must twist the door handle to open the door. After a minute or two he drops, writhing on the floor, rubbing his face, coughing, and having difficulty breathing. That was a lot of pepper spray and results in worsening his delirium.

And then we charge in, and everyone piles on him. One or two officers on each arm, one on each leg, one on his chest, and one pinning his head sideways to the floor. Our nurses are the best, and this guy’s veins are the size of pencils. She pushes the paralytic drug in, and, within thirty seconds, he’s as limp as a rag. And not breathing. Terrific.

The officers look relieved and relax as though the emergency has ended. I yell at them, “We need to pick him up and put him on the gurney! He’s not breathing, and I need to get his airway controlled!” And like a scene from Gulliver’s Travels, the little people lift our giant off the floor and position him onto the gurney. I easily get the breathing tube down into his lungs and the ventilator attached.

[Ultimately, the staff are able to send the patient to the intensive care unit.]

During the rest of my shift, I think about all the other ways this case could have gone. Had the police officers not been so Johnny-on-the-spot and only two had been present, my patient would have likely been shot and killed. Had they not refrained from using three Tasers at once, he also might have died. And all the other possible bad outcomes, including injury to our ER staff, that were avoided.

I know there isn’t enough appreciation for the work that first responders do in our communities. Police, Fire, EMS, and the ER staff all sometimes risk their own lives to save another. And rarely is anyone offered thanks.

Those thank yous would be appreciated. But none of us really expects them. We’re just doing our jobs.

As I leave the hospital for the night, I realize I’m looking forward to my next discussion with the hospital administrators who are intent on having our police officers replaced with unarmed security guards. A fool’s errand, if I’ve ever heard one. I wish one of them had been there tonight. Or maybe had helped hold that door closed to keep King Kong in his cage. They might just change their minds.

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