“Lifting the curtain” on the emergency department

When the American Board of Medical Specialties voted in 1979 to make emergency medicine the nation’s 23rd recognized medical specialty, Patrick Crocker, D.O.’80, M.S., FACEP, says he found himself “in the right place at the right time – I fell into my dream job.” He completed an internship and residency in emergency medicine at Darnall Army Hospital, Fort Hood, TX, which launched his nearly 40-year career. 

Patrick Crocker, D.O.’80, M.S., FACEP

Retired in April 2017, Crocker has translated his many years of practice into a new book, Letters from the Pit: Stories of a Physician’s Odyssey in Emergency Medicine (BookBaby; lettersfromthepit on Facebook). 

Crocker’s career included serving as chief of several emergency medicine departments and founding the first children’s emergency department in central Texas, now Dell Children’s Medical Center in Austin; it saw 5,000 patients in its first year and now sees approximately 70,000 patients annually. He also was a governor-appointed member of the Texas Medical Board and served 25 years on the Austin-Travis County EMS Quality Assurance Board as well as on other medical entities. 

Letters from the Pit is a heartfelt and highly readable book that received numerous early enthusiastic reviews prior to its January release. 

“Patrick lifts the curtain for the reader to see a different and unexpected side of life in the emergency department that portrays life-and-death medical situations with lyrical meditations on the world of medicine and the world at large,” stated John McManus Jr., M.D., M.B.A., FACEP, council speaker of the American College of Emergency Physicians. “This little gem contains knowledge and lessons that can be applied not only in the medical field, but also in personal life.” 

After earning his master’s degree in human nutrition from the University of California-Berkeley, Crocker planned to write a series of letters to Jack, a college friend, about his experiences in medical school and beyond. While none was sent – “the rigor of training and practice all got in the way,” he says – his impending retirement rekindled his interest in assembling them in book form. He did so not only for Jack, with whom he keeps in touch, but also for his wife, Marcia, and other family members. 

“After a shift in the ER, you don’t really go home and tell your family what your day was like,” he says. “That isn’t fair to them, and often you don’t want to relive it.” 

Letters from the Pit recounts experiences that are tragic, funny, inspiring, challenging and all fascinating as Crocker seeks to adhere to the concept of primum non nocere, or “first, do no harm.” Below are excerpts. 

My First Delivery 

In the first chapter of the book, Crocker describes an obstetrics/gynecology rotation. 

Help, we need a doctor in seven!” someone shouts. My immediate response, of course, is to run to the phone and call one. A doctor, that is. I am serious here. I don’t know anything practical about birthing babies. I did see a video about a year ago, but I’ve never witnessed a birth in person. Just like reading about sex as a Boy Scout in a tree house. It isn’t much like the real thing, and neither is a video for delivering babies. Again, a piercing call from that relatively young voice for help… 

These are small rooms with regular beds where women suffer the first part of labor. Then when it is time to deliver, they are moved to the delivery room. Deliveries are supposed to happen in delivery rooms, not labor rooms. I guess nobody explained it to this patient because there she was, splay-legged on the bed with something bulging from her vagina. It kind of looked like a pale, yellow balloon about four inches across. I’ve never seen anything quite like this. I’m wondering silently if her guts are coming out. The nurse, not knowing whom she is dealing with, looks up expectantly and says, “Doctor, she is about to give birth.” Well, I’d pretty much figured that part out all by myself. I still want to call a doctor and stand in the background and watch one or two of these before I actually do one. At any rate, I am it this morning, and all I can do is try and deal with the situation until an RD arrives. RD stands for real doctor. In the firmest most authoritative voice I can muster (though probably not very reassuring), I say, “I’ll need the precip tray.” This is a tray all set up with what you need to do an emergency, or precipitous, delivery. I’d learned that much from the video, and in times of need, my memory usually doesn’t fail me. Of course, the nurse is one step ahead of me. She points out that the stainless-steel tray now positioned at my patient’s left leg was indeed the precip tray. So much for bluffing… 

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I get down close trying to figure out what to do next when, whoosh! Slimy water gushes onto my face. A bucketful. No joke. I am disoriented and surprised, and as nearsighted as I am, it takes a second to register that her bag of waters has ruptured, douching me in the face and covering my glasses. I can barely see through this coating of amniotic fluid. I am clearly in deep shit. Where in the hell is the frigging resident? 

Somehow, I can still remember a few simple steps from the video and successfully guide the baby’s head outward. Fortunately, the baby is in the common LOA, or left occiput anterior, position. Textbook. But now I am panicked. The baby looks like a monster. Or maybe a gremlin-like mobster wearing a nylon stocking mask. The mouth, eyes, and nose are visible, but a thick membrane covers the entire head and face. What am I to do? I can’t suction the baby’s mouth because there is no hole to get to it. I don’t even know if I should let this baby survive, it is so deformed. What will I tell the mother, or for that matter, the dean of the medical school? “I’m sorry, sir, my first baby was deformed, and I didn’t know what to do, so I let it die!” I figure my career in medicine is over… Maybe I can learn a trade; I’ve always kind of liked the idea of carpentry. I already imagine telling my parents and wife that, starting next week, I will be framing condos in Orlando. But thank goodness for Mother Nature. 

She has saved me and every other physician from making many a blunder. Another contraction comes, and if by magic, I have the shoulders out now and, lo and behold, the awful membrane peels away from the baby’s face, and it looks normal! My God, thank you. I will be a doctor yet. All the fuss was over the amniotic sac that, once in a great while, will cover a newborn’s face. Turns out this unusual event has a name, a witch’s veil. This wasn’t covered in the video. I give a slight tug, and out slides the baby… 

I must have looked a little better than I felt because smiling in the doorway is an older nurse who looks like she was around for Hippocrates’s delivery. She simply says, “Good job.” She has been there the entire time, watching me, protecting her patient, the baby, and protecting me. She won’t let a dangerous error occur. She doesn’t intervene as she sees things are going well. She understands that I need to learn to crawl before I can walk, walk before I run. She knows I will stumble along the way but the best way for me to learn is by doing just what I am doing. Hands-on care. Fall. Get up. Learn. Try again. She has been involved with probably thousands of trainees during her career. Nurses like her are priceless. 

Baby, mother, and young nurse go off to the nursery. The older nurse and I take a few minutes to reflect on the scene. I am still wiping amniotic fluid off my face. It is on the floor, the wall, and I am soaked. What a picture. Suddenly the tension is gone and behind closed doors the two of us laugh until we cry. I’ve found an ally, and the truth cannot be hidden. The real pecking order has been established. She watched out for me for the rest of the rotation and made sure everybody knew what a good job I had done with my first delivery. She saw to it that I got first dibs on any delivery I wanted. You see, Jack, if you can swallow your pride and accept help, which you do need, and understand medical care is a team sport, a good nurse can be your best friend. 

On the final morning of the rotation I hunt up my new nurse-friend to thank her and say goodbye. I find her at the nurse’s desk. I tell her that I’m grateful and that I start my pulmonology rotation after lunch. She says, “Oh, you will do fine, young man.” I turn to leave and hadn’t taken five steps when I hear her say, “I mean, you will do fine, Dr. Crocker.” I turn back for a last smile and go on my way. She knows I am not a doctor yet, and so do I. Soon, though. I won’t forget this little compliment, this courtesy, ever. 

I decide there is no need to walk to my new rotation. I will simply float. 

Her Last Doctor 

In this chapter, Crocker “helped a woman die today” – a pulmonary patient struggling for breath who didn’t want to be placed on a ventilator. 

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My mind drifts to how much more humanely we treat our pets. We love them, and they become part of our families. And when they reach a stage of life in which they are suffering, we take care of it for them. Yes, it’s a sad trip to the vet, with tearful goodbyes and a kiss on the head. And then the vet quickly and peacefully ends their suffering. Today, that’s my goal: making my patient’s passing less traumatic…this will not be assisted suicide, rather comfort care. At this moment, though, those definitions seem greatly blurred. 

As promised, her lung doctor comes to see her. He is a top-notch doctor I have worked with for years and he has been down this road many times. He spends some time with her and holds her hand. It is actually very touching to see him like this, in a role I have never witnessed him performing. I think he is doing a great job with her and move closer to the bedside. 

He confirms everything they have discussed previously. He reiterates that the end is very near and that her only desire is to be made comfortable. And we all agree that this will be the approach for the next couple of hours. If she improves, she will go to a bed upstairs and to hospice care tomorrow. If she doesn’t, she will die here in the ER, with me watching over her. I have learned that she is all alone in the world. She has no kin and no close friends. I will be her last friend…

When I return, it is obvious that not only are the treatments not working, she looks a bit worse. She also seems a bit sleepy. I believe carbon dioxide is building up in her blood, high levels of which will have this sedating effect. Ultimately, the carbon dioxide level will get so elevated, it will be fatal. I know now I will be her last doctor, as she will never make it to that hospice bed. She asks for a little more morphine, and I say yes. 

I stay at the bedside patting her hand, trying to give some final comfort. I give her the last small dose of morphine, and she says she feels better, even comfortable. She now asks me to please pull the curtain closed. I do, and then I sit back down next to her. I can’t let her die alone behind a curtain. 

She is lying back on the bed, with her head elevated. Her eyes are closed, but she is still awake. She says she is ready to rest. We both know this is her euphemism for dying. She asks me to stay till she falls asleep. I tell her I’m not leaving, and in minutes, she is asleep. 

I am thankful that the ER has been slow today and that I have been able to spend more time with her than I would with almost any other patient. After all, I am all she has. I can’t help but feel sad. Her breathing stops in another five minutes. The heart monitor continues to beep with each heartbeat for about fifteen minutes, and then flatlines. She is gone… 

I know my patient was grateful for my help and for those small doses of morphine. I hope when my time comes, I get the same treatment. I know I have done the right thing, but I am saddened nonetheless. I understood her wishes and followed them. 

What I cannot understand is the reaction I get from staff members. It seems they wanted me to put her on a ventilator and send her to ICU. Yes, that would have been the easier route, but that would have failed my patient and dishonored her wishes. More care is not necessarily better care. 

Rites of Spring 

In this chapter, Crocker shares the tragic drowning of a child. 

Suddenly, the ambulance crew bursts in. Paramedics are compressing a small, delicate chest, with bag ventilation in progress. It’s odd the things that cross my mind. I notice he is still in his brightly colored swimsuit. Sandy blond hair covers his perfect head. A really cute kid. He reminds me of a Norman Rockwell painting on an old Saturday Evening Post. Close-up of his smiling face, shirtless in bib overalls, a barn behind him, and chewing a stem of green grass playfully poking out of a broad smile. But now his eyes stare vacantly. Pupils are dilated, with only a hint of reaction to light. 

We go to work. A quick endotracheal tube is placed so we can get him better ventilated. I see some slightly bloody froth coming from his trachea during the procedure. It’s not a good sign. It means he has aspirated the pool water into his lungs. I’m already a bit morose. The nurses scramble for an IV site and a partner works to place an intraosseous line, one that’s directly inserted in the bone marrow used when veins collapse and we can’t start a regular IV. It will deliver medication and fluids. These tasks are accomplished quickly here. Our nurses are very good. They are pediatric specialty nurses, and we are in a pediatric trauma center. If our patient has any chance at all, it is here… 

Three minutes later, he is still flatlining. We have peripheral lines now, and I order another dose of epinephrine. Within another minute or so, his heart begins to beat. The team allows itself a little enthusiasm as we get a weak pulse. We start dopamine, and his blood pressure improves. His once cold, white skin begins to take on some color. 

It’s the best we can do, but I fear it is not enough. Most likely, we started too late in the game for a good result. I wonder if I have done the right thing. What will his future be? How long was his brain starved of oxygen? Our guiding dictum is primum non nocere. First, do no harm. Is attempting resuscitation on a patient with fixed and dilated pupils harm? Maybe. But I can’t watch a child die without trying. Decisions that were black and white when I was younger now seem gray. Is this wisdom from years of practice? Or simple indecision. I don’t know… 

The intensivist (a critical-care specialist) and I discuss possible hypothermia, a process of cooling the body to preserve brain function. I am in favor. Hypothermia sometimes works wonders, protecting the brain from its own inflammatory response and biochemical transmitters that become activated to complete brain death. The intensivist objects. Research supporting hypothermia mostly is based on adults after cardiac arrests stemming from heart disease, not drowning. I argue the brain can’t tell the difference. I realize hypothermia is not harmless and has its own complications. But I want to go for broke, as it seems there is not much more to lose. The outcome is he will decide when they get to the pediatric ICU. Primum non nocere. First, do no harm. And with that, this little boy is wheeled out of the ER – and out of our lives. But not from our memory. 

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Everyone is thinking of his or her own children. Are they safe? Are they swimming at a neighbor’s house or a public pool? Kids who may have misbehaved today and were promised a spanking later will get a reprieve. Or they will simply get a hug they don’t understand. If it’s a boy over six, it will be an embarrassingly long hug. He won’t understand until he has a child of his own… 

Sadly, my patient’s story ends as I had feared. A cerebral perfusion study the next day shows zero blood flow to this precious young brain. Simply put, his brain is dead. I don’t know what happened after that. Perhaps he was an organ donor and gave the gift of life to others. I hope so… 

Life in the ER can sometimes be grim. Some shifts come filled with broken bodies, death, and destruction. Other days are better. We see humanity at its worst and at its best. Most of us love what we do — the chance to save a life. We simply can’t leave such a challenging place, no matter how sad it gets. 

Hardly a week passes, and like clockwork, we get our second drowning. 

My New Dress Code 

Crocker shares his hatred of the white coat and the gradual loosening of his professional attire. 

After a few months at my new job, I lost the tie. Nobody says a word. Cool. Ties are just ridiculous, anyway. Soon thereafter, the white coat goes. I hate the damn thing. Still, not a peep. Weeks go by. 

Even though the nurses all wear scrubs in the ER, the doctors don’t. I decide to join the nurses and start working in scrubs. It’s great. Loose, a little baggy, informal, and very comfortable. It is like going to work in your pajamas. And they are cleaned every day. I love the change. Nobody says a word. More weeks go by. 

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I have administrative days during which I do not see patients. I do paperwork and go from meeting to meeting. It’s another sweltering summer in Central Texas so, bye-bye shoes. I’m putting on Birkenstocks. What’s the worst thing that can happen? Get chastised, told to go home, and put on shoes? But…nobody says a word. I am feeling very happy at work. I love it. 

Late August finally comes, and we are in the peak of the Texas heat. I decide things have gone so well, I will go for broke. I get ready for work, sporting a T-shirt, shorts, and sandals. My wife asks if I am really going to work in the hospital dressed like this. It gives me pause, and I rethink my position. I decide, yeah, I am. Maybe this time, I’ll be told to go home and put a shirt and pants on, but at least for a while, I will be completely comfortable. Dressed just like a freshman at Berkeley once again, I feel at home in these clothes. Off I go to work. 

My trusty and beloved assistants, Rhonda and Heather, simply smile and laugh. They support me no matter what I do. I’ve been accepted into this mini-family. I have a great day of comfort, and nobody says a word. I may have found my dress code. The future looks bright. 

Meet the new me. No more shirt and tie. I will make my laid-back look expected of me. “Oh, that’s just Dr. Crocker and his way,” they’ll say. Nobody will tease, nobody will complain, whether I’m chief of emergency medicine, chief of staff, or a hospital board member. This is even better than going to work in pajamas. 

They say, “The clothes make the man.” I’ve got it made.