One Night, One Emergency Room

It’s a typical unpredictable night at Boston Medical Center’s emergency room: traumas rush in, drunk or high patients need (and refuse) detox, and a high-security prisoner has swallowed four sharpened metal pencil ends.

“If it can happen, we’ll get it,” says Andy Ulrich, a School of Medicine associate professor of emergency medicine and executive vice chairman of the emergency medicine department. “We never know what’s coming. Every day, every minute, every patient is different.”

The BMC emergency room is one of the busiest in New England, with physicians treating 130,000 patients a year. On an average day, 300 people stream through its three trauma and four emergency rooms, including a pediatric unit. Almost a third of all Boston EMS ambulances come here, according to Jennifer Mehigan, EMS director of media relations.

This busy urban environment attracts about 700 applications annually to the BMC emergency medicine residency program, Ulrich says. Only 12 are chosen for the four-year program.

Just before 6 p.m. on a recent weeknight, Ulrich begins his rounds with five residents and medical students in tow. Third-year resident Jason DeLong speaks indecipherable medical-ese as he reviews almost a dozen cases: hypertension, bad headache, right flank pain. Occasionally, a junior resident fields Ulrich’s questions on a case.

“Thank you,” Ulrich says jauntily. “I feel involved.”

Ulrich is one of four attending physicians who oversee residents and tend to patients on this shift. The 21-year BMC veteran could pass for a businessman, with his dress pants, tie, and quick talk. He’s as likely to joke with residents as to grill them on procedure.

“It doesn’t work well if people are concerned about hierarchy,” says Ulrich, who shrugs off the title “doctor.”

Although most beds are full, the ER is quiet. Residents settle at a bank of computers to scan lab results and X-rays. A signed photo of a patient with a possible broken hand is passed around, a boxer who once knocked out Mike Tyson.

Across the room, Mo Williams, a licensed alcohol and drug counselor, wakes a sleeping patient. “What you using?” Williams asks.

“Nothing,” the man says, barely above a whisper.

“You here alone?”

“Yes.”

Williams asks more questions until he reaches the key issue: “Do you need help with alcohol or drugs?” The man refuses and the counselor hands him a brochure for Project Assert, which helps patients access primary care and find drug and alcohol treatment.

“You gotta meet ’em where they’re at,” Williams says. Sober 15 years, he knows what it’s like to hit bottom and need help. Now, he says, he sees up to 30 people per shift.

Ulrich sits in front of a computer and scans patient files, asking DeLong about one case.

“He’s gone,” DeLong says.

“Gone, or physically gone?” Ulrich asks, checking to see if the patient is dead or released.

“Physically gone.”

Few patients die in the ER, Ulrich says. Trauma rooms are different; people often arrive short of breath, suffering from chest or abdominal pain, or badly injured in accidents.

A trauma call comes in: elderly woman in a car accident.

Ulrich walks swiftly, hand in pocket, to the bay where ambulances unload patients. Residents and nurses hover in an open trauma room, donning gloves as they wait for the woman to arrive. Peter Burke, a MED associate professor of surgery and chief of trauma services, appears.

Soon an EMT wheels the woman into the room on a stretcher, her neck in a brace. She shows no outward signs of injury. Her legs are shaking, from cold and fear, and her voice is barely audible when she answers the doctors’ questions.

“Hey sweetie,” the senior resident says. “How you doing?”

By now, 12 people are standing in the room. All play a role in the woman’s care. Clothing is cut off, a robe and blankets draped over her, blood drawn, information entered into a computer alongside her bed.

No one runs, screams, or throws objects. No family members stand in. There are no made-for-TV ER moments.

Residents and nurses conduct a head-to-toe examination, checking to see what hurts. A technician rolls in an X-ray machine to scan for broken bones. Within 10 minutes, the patient is wheeled to the CT scan room, where the machine provides a full view of internal injuries. All clear so far.

“In all ER work, imaging is a critical part,” Burke says. “You really don’t know what you will find. Every car crash is different.”

Outside the trauma room, security guards report hearing gunshots in the street; no one appears in the ER as a result. Snoring from a drunk man who took a nasty fall mingles with the beep-beep of monitors. Male nurses stop an intoxicated man from leaving his bed (for the third time).

The ER stirs: a high-security prisoner has swallowed four metal pencil ends and is headed in under armed guard.

Checking files, DeLong polishes off his third can of Coke Zero. “I’m an adrenaline seeker,” he says. DeLong came to MED because of its strong emergency medicine program. “There’s always something going on here,” he says.

Another trauma call comes in: a Portuguese-Creole woman is short of breath.

A horde converges in a trauma room to meet the woman, whose chest heaves as she struggles for breath through an oxygen mask. An interpreter hasn’t arrived yet, but the attending EMT says she was discharged from Beth Israel Deaconess days ago.

She could be suffering from a heart attack, pneumonia, or severe asthma, says William Davenport, another attending physician and a MED assistant professor of emergency medicine. “In emergency medicine, you don’t have to know what’s wrong,” he says, “you just have to know what to do.”

The floor is littered with blue latex gloves and strips of plastic torn from sealed packages. As an X-ray machine enters the room, all female staff exit.

“Ovaries out of the room,” jokes a male nurse.

The woman’s breathing becomes less labored after staff administer drugs to counter what’s believed to be a bad asthma attack.

Davenport says he loves his job at BMC, which he calls “the one place where we don’t do a wallet biopsy before we take you.”

Caring for the underserved and uninsured is one of BMC’s hallmarks. Roughly 70 percent of patients are low income, elderly, people with disabilities, or immigrants, according to hospital records. And 70 percent are from racial and ethnic minorities, with 30 percent non-native English speakers.

In comparison, Massachusetts General Hospital’s ER sees 90,000 patients a year, with 29 percent “nonwhite” and 11 percent non-native English speakers.

Minutes later, eight security guards rush through the ER, responding to a call that a patient is giving a nurse trouble. While they strap the man to his bed, another patient shouts random slurs from across the room.

Around 10:30 p.m., just before the end of Ulrich’s shift, the most unusual patient of the evening arrives: the high-security pencil-swallowing prisoner. He’s strapped to a stretcher, surrounded by four beefy black-clad armed guards.

Ulrich makes a wake-up call to a gastrointestinal doctor to come up with a plan for proper treatment. Meanwhile, the guards have unstrapped the prisoner, transferred him to an ER bed, and are standing by.

DeLong has no idea what the guy is in jail for or why he swallowed sharpened metal pencil ends. The answer to either question wouldn’t affect his treatment. Regardless, he seems unfazed.

“Prisoners, for the most part, are pretty docile,” he says, munching on a graham cracker. “They tend to be a nice bunch.”

Hours later, the GI specialist arrives with the equipment necessary to remove four sharp metal chunks from the man’s gut.

All in all, it’s a smooth case, Ulrich says. Doctor saves the day, patient feels better, and patient returns to prison after waking up from a long, sedative-induced nap.

This story originally ran February 8, 2010.

Leslie Friday can be reached at lfriday@bu.edu.