by W. Scott Olsen
Prologue
Here
is a truth that crosses every border. Dinner is a time for stories.
There
is something magical about the meal. Or, to be more precise, there is something
magical about the occasion. We don’t often tell breakfast stories. We have to
get going. The stories we tell over lunch are brief, summaries at best. But
dinner stories can be long. They hold drama and nuance. They hold backstory and
foreshadowing. They have an arc that reveals something deeper than just what
happened.
Gather
a group of friends at an evening table and we share stories that nourish the
soul as well as the spleen.
The Chef
My
friend Eric Watson is a chef. Talented, imaginative and creative, he owns a
restaurant in Moorhead, Minnesota, called Rustica. What if, I asked Eric, we
gathered just one person, someone with an interesting job, and asked them to
tell stories? Could you come up with a menu to provoke those stories? Could you
come up with a menu that was based on or inspired by the work they do?
Eric
paused, but only for a moment. “Yes” he said. “I think I could.”
The
Guest
Warren Hintz. Emergency Room Physician. Sanford
Hospital. Fargo, North Dakota
The
Menu
Wood Roasted Manilla Clams
Preserved
Meyer Lemon, Garlic, Basil, Caper, Olive & Sweet Tomato
Ginger Miso Glazed Cauliflower
Edamame,
Tofu, Sweet Potato & Sticky Black Rice
Scallop Crudo with Toasted Coriander
Fresh
Orange, Shaved Fennel & Asparagus
Flash Seared Beef Tenderloin Medallion
Cumin
Scented Quinoa, Black Beans, & Carrot Tahini Puree
Caramelized Pear
Coconut
Milk, Ginger & Almond
Eric
and I sit at the bar at Rustica, going over the menu he wants to serve.
Is
there a connection between food and profession?
“That’s
what I’m shooting for,” Eric says. “We have an Emergency Room doctor. So I am
trying to keep it healthy. A lot of the ingredients on here—I just feel like
certain ingredients hit my stomach and make my stomach feel better. Healing
food. So like miso, or things that are umami driven, really savory. When I eat
salmon roe for example, it makes my body feel better. It’s personal to me. Everything
on here seems, to me, fresh, vibrant, healing. Something that’s good for the
body.
“I
tried to create a menu based around things that are going to cook really
quick,” he says. “When I think of the emergency room I think fast, speed, so I
wanted things that were quick. Like the beef medallions, for example. We can
flash sear them really quick and they’re done. The caramelized pear requires
very little cooking time. Everything on here requires very little, if any
cooking time.
“I
start light and work toward things that are heavier. The clams are super light,
super clean. Manilla clams are petite and tender. The cauliflower—I just wanted
to keep it healthy, so anything kind of along the vegan lines, health
conscious, plant-based. The pear? Just wanted to keep it as free of animal fats
as I could.”
I
smile, looking at the piece of paper that holds his notes, imagining the
evening.
“Should
we tell him?” I ask.
“This
is the Emergency Room,” he says. “I think it’s kind of fun to let him be
surprised.”
Dinner
Stories
Dinner
is at 5:00 p.m. on a warm clear April evening. Warren and I arrive at nearly
the same time. Grey hair and a closely trimmed grey beard, the man radiates
calm. He moves quietly. His voice is soft.
Eric
has reserved the best seat in the house, a table in the front window
overlooking the intersection of Main Avenue and 4th Street South. Cars
and trucks, the occasional motorcycle, people out for a stroll go by. Walkers
peer in the restaurant windows as they pass, all of them looking at the food on
the tables more than the faces of the diners. A happy, curious young woman
named Madi appears at our table and pours water, then takes our order for
drinks. She knows this is an occasion. Be right back, she promises.
Warren
and I smile, then start with beginnings.
“I
was working for an engineering consulting company in Bismarck,” he says.
“Remember
those aptitude tests we all used to take? They said I would be good at
engineering, so that’s what I went into. With nothing else to do I thought ok,
they’re smart, I’ll do that.
“Anyway,
I was sitting in my office three years into it, after graduation, and I
happened to look across the hallway to my bosses’ offices. They were both behind
their desks. I realized at that moment, even though there was probably a little
wanderlust happening before then, that these guys were forty-two years old and
I was twenty-six. I was doing the exact same thing they were doing. And I said,
do I really want to do this when I’m forty-two? Do I want to do this when I’m forty-five?
The answer turned out to be no.
“So
then it was a matter of what are you going to do if you’re not going to do
this? I toyed with going into law school for a little while but there was a
movie that came out in the late 70s called And
Justice for All. Al Pacino. It was a great movie. It was really a spectacular
movie. But it was horrible in the message it was offering. The message, and one
of the lines I remember, was Al Pacino saying ‘There is no truth. Truth in law
is only what you can get people to believe.’ I realized I don’t believe that. I
couldn’t do that. So I started processing other things.”
Warren
takes a sip of his water and begins a smile.
“I
had a recollection of a girl I was dating during college and she had mentioned I
should go to medical school,” he says.
Then
he waits.
“Because?”
I ask.
“She
thought I’d look good in white.”
We
laugh.
“Why
not interrupt my whole life and my career path and everything else in the world
I had at that moment because I would look good in white?”
Madi
shows up with red wine for me, a gin and tonic for Warren. Her timing, I think,
is perfect. Warren and I take that first sip of our drinks and survey the room.
Other people are arriving and the room is filling with laughter. One couple, at
a table a bit distant from our own, is clearly on a date. Perhaps a first date.
Obvious, awkward eagerness.
“To
be serious,” Warren says, “it was during this same time that I would ride my
bicycle all over North Dakota and I was out riding one evening after dark. I
was right down by the Holiday Inn in Bismarck, just about to go underneath the
Memorial Bridge, and I heard this horrible screeching and scratching and crash.
A car crash. This was obviously before cell phones. I ran up to the middle of
the bridge. There was this car with four young girls in it. High school age.
And then the other car, the notorious drunk driver. And these young girls kept
saying, ‘Help me. Help me. Help us. Help us.’ There wasn’t anything I could do.
I didn’t know anything. There wasn’t a thing I could do other than just try and
reassure them, encourage them to stay calm. At least I knew enough that they
shouldn’t move around too much. Another person came up after that, backed up, went
somewhere and made the phone call to 9-1-1. I was able to stay there with them.
And it was that evening, night, next morning that I said I would never be in a
position where I don’t know what to do. So within two weeks I signed up for an
EMS course. Joined an ambulance squad. Went to medical school.
“I
am firm believer that everyone has a calling at some time in their life, he
says. And we always look at things we like to do and might want to do. That
night I found mine.”
Starters
Madi
shows up again. Right behind her, Eric appears, deep plates in each hand. He
sets them in front of us.
“Oh,
my heavens,” I say, then make introductions.
“We’re
starting out with a wood-fired, roasted clam,” Eric says, “with a sweet tomato
broth, olives, capers, basil, a little garlic, chicken stock, a touch of butter
and olive oil.”
I
understand plating as an art form, I think to myself, but I am always amazed by
the beauty of well-presented food on a plate.
“This
came to be,” Eric says, “with the idea of trying to pair it with an ER doctor,
at least the best I can. Just fast. Things that are flash cooked. I was just
thinking speed. I picture an ER doctor moving quick. Or at least thinking fast.
Nutritious. Good for the soul. Not a lot of saturated fat. But a lot of color. A
lot of vibrancy. That’s where I was starting and where I was heading.”
“This
smells grand,” Warren says.
Warren
smiles at me after he takes his first bite. Behind us, the sounds have changed
to forks and spoons and knives put to work. A dozen variations on the way to
say “hmm” that means “this is really good.”
“I
will confess,” I say, “I am afraid every time I get a meal like this. Shells
and such. Do I really know how to eat this? But I’m also old enough to know I
really don’t care.”
“Indeed,”
Warren says.
I
take my own first bite. Oh lord, I think.
“You’ve
seen a lot of water under the bridge,” I say. I already know he is the second
most senior physician in the ER. More than thirty years waiting for disaster.
“It’s
remarkably changed,” he says.
“The
technology has changed,” I say. “Has practice changed?”
“Skills,”
he says. “Skills relative to procedures that you do to either save lives or make
things more comfortable for people. Whether it’s lines, IV lines, or
intubating, or something else, the skills have certainly followed the
technology. Better equipment. Better techniques. Procedures have changed. Patient
population has changed too, to some degree. Initially the patient population
was truly emergency medicine people. Then it started falling into urgent care,
walk-in clinic types of things. Now it’s all of that, plus. The only thing we
don’t do is preventative care. And only because the setting isn’t right for
preventative care. But whether it’s psychiatry, whether it’s chronic medical
care, whether it’s urgent care, whether it’s emergent care, it’s kind of the
full gamut of everything.”
“I
had not thought of emergency psychiatry coming to your room,” I say. “Other
places, yes. But not the ER.”
“Most
of that, unfortunately,” he says, then pauses, “is despair. It’s an incredible social,
cultural type of issue. Despair issues run the gamut of suicidal, whether it’s
just thinking about it or actual attempts, to alcohol and drug related issues,
overdose issues, intentional or otherwise. And just some health issues.
Certainly we know that physiologically and medically people get sick from their
stress. They get sick when they are in despair. Even if they are not using
things. Even if they are not suicidal. Just physiologically they would get
sick.”
Warren
and I sit quietly for a moment, take bites of our meal. I’m coming to
understand his pauses are a consideration of options. His life is based on
getting it right.
“It’s
curious,” he says, “that you ask what would bring people to the emergency
department for even routine things, like a cold, or a child who has a fever,
when there are walk-in clinics available. I used to ask myself that a lot. But
then I learned.
“I
think it’s been—I’m just going to guess on the timing of this—ten years ago? It
was in the middle of the night. About 2:30 in the morning. Even ten years ago
we weren’t overly busy overnight. Ten people, maybe twelve. Maybe even five?
From 10:00 p.m. until about 6:00 a.m. it was not a grand crowd. This one
particular morning, I was in our sleeping room, study room, whatever, and I got
a call there was a patient to see me. I came out to see him and here’s this eighty-seven-year
old little guy, nicely dressed, looking healthy, and his primary complaint was
fatigue. At 2:30 in the morning. And I wondered, I wondered what he was
thinking.
“So,
fatigue. I went through the whole gamut of what could cause a little old man to
have fatigue. He hadn’t fallen or been dizzy or anything. As I was interviewing
him, and then examining him, I was asking him—what do you mean by fatigue? Tell
me what you’re experiencing. What has changed recently?
“He
had more energy than I did! He was telling me that twice a week he would go
down to the Eagles club and dance until they closed at midnight. He was telling
me stories about little old ladies. ‘They just won’t let me alone,’ he says. ‘There’re
more old women than there are old men there, so I don’t have to worry about not
being able to dance,’ he said. ‘In fact, sometimes I just wish I could just sit
and chat for a little while.’
“And
I thought, so you dance all night, once or twice a week, and he says yes, I do.
And then he said he hikes miles a day! So I ask—has anything changed? He said,
not really. So I’m still processing, how does a little eighty-seven year old
man, nicely dressed, 2:30 in the morning, come into my department saying he’s
fatigued? I did some diabetes checks, some anemia checks, whatever else I could
come up with for fatigue. And I came back half an hour later and I said you
know, everything looks good. I don’t have an explanation for what you’re
experiencing. He said, it’s okay. I’m not necessarily fatigued. I’m just sad.
“And
I said, what are you sad about? He said, ‘Well, in the middle of the dance
night tonight, I got a phone call that my last best friend died. And I just wanted
somebody to talk to.’
“Since
then, I realized that everybody comes to see me, comes to see us, for a reason.
And whether that reason is something I understand, whether that reason is
something I agree with, whether it’s a reasonable reason or they just needed
somebody to talk to, at 2:30 in the morning, I’m there. I’m serving a function.
And so I kind of vowed that I will never ask again, in my mind let alone out
loud, if they should be there. Sometimes I do ask What are you here for? because I just don’t understand their whole
process, and that does clarify a lot of things. Sometimes it still just doesn’t
make sense, but at least most of the time it clears things up. But at least I vowed
I would never be angry or frustrated with somebody who’s there that I don’t
think needs to be there.”
“Have
you been able to keep that vow,” I ask?
“I
think for the most part yeah,” he says. “I have. I was so impressed with that
little old man.”
Second Course
Madi
arrives, smiling. “Can I take this first course out of the way?”
“It
was wonderful,” I say.
“I
think I devastated it,” Warren says. “Thank you.”
Eric
arrives right behind her.
“So
what do we have?” he says. “This is a pan seared cauliflower medallion with a
ginger miso glaze. We got a little tofu, a marinated tofu with a little splash
of tamari. Same thing with the edamame —it’s got a little splash of tamari as well.
And a sweet potato puree and a black sticky Tai rice.”
“Oh
my, Eric,” I say. “Where did this idea come from?”
“You
give me too much credit for ideas,” he says, laughing. “No, it’s just I like
the color scheme, I like the textures and flavors together, so yeah, that’s
really where it’s born from. Just kind of going all vegetarian, vegan on this
dish actually, so again just trying to keep it clean, healthy, small portions.”
We
invite him to linger but Eric says he cannot. Other customers. Other patients.
Warren
starts to talk about diagnostics and protocols. He tells me about ABC—airways,
breathing, circulation. But then he takes a bite, stops and points at his
plate, at the presentation of the food. All he says is “mmmm.”
“I
wish I had Eric’s imagination,” I say.
“That
sweet potato puree is just absolutely breathtaking,” Warren says.
We
are suddenly in that comfortable silence of good food. A shared, atmospheric
joy. Something shared even before language. Something ancient.
“I
marvel at creative people,” Warren says.
“Don’t
let anyone know,” I say, “but I actually like the tofu.”
“I’m
there with you, too,” Warren laughs.
“I’m
always amazed when people can bring out a flavor in cauliflower,” he says. “Something
that is so”—he pauses, then just smiles.
We
pay attention to the food, sip our drinks.
“Tell
me about diagnostics,” I say. “It seems to me, from the outsider’s perspective,
that you, your department, has to have the fastest diagnostic skills in the
world. The range of things you could be presented with is everything.”
“I
think that’s accurate,” he says. “You have to have at least a pretty clear
picture of what the possibilities are. We use the term differential diagnosis
relative to whatever complaint they have. So you came in with belly pain—what
are the possibilities? You came in with chest pain—what are the possibilities?
You came in unresponsive—what are the possibilities?”
“What
information do you have before you see a patient?” I ask.
“It
certainly varies,” he says. “A critical patient is really the only type of
patient I hear about before I generally go in to see them. For the most part,
all of the patients we see have a chief complaint or a primary complaint. And
maybe a little bit of details from the nursing staff.”
“So
usually you’re just looking at the chart hanging on the door as you go in?”
“Right.
Whereas critical patients, the staff are exceptional in letting us know there’s
somebody critical coming in in ten minutes, fifteen minutes, and this is what
we know. Sometimes it’s we know they’re not breathing well, some of it is blood
pressure is low, some of it’s that they’re unresponsive. And some of it they’re
not doing well. I hesitate to use the term routine patients, but their vital
signs may not be there when I walk into the room. But anyone that has something
that’s pretty dramatic, we’ll know.”
“So you’re already thinking as you walk down
the hall,” I say.
“Correct. And probably the first thing I think
about is ‘is this person sick or is this person ok?’”
“How do you…” I ask, then retreat. “Wait. Is a
broken arm sick? Is that what you mean?” I ask.
“No. Sick meaning are they, unless I do something
quick, going to deteriorate? Or are they already deteriorating? And that’s a relatively
quick assessment. You get just this general gestalt of what you’re seeing.
Pale. Sweaty. Heartrate of 230. Minimally responsive. Those things you can just
boom. You can have a big picture. Or at least a focused picture. And that’s
where the ABC comes in.
“And when I say okay,” he continues, “when they
look okay, or they look ill but their vital signs are okay, and everything else
is working okay, at least I have a little bit of time to process. I don’t have
to do anything immediately to manage something that’s life threatening.”
“How essential is the interview?” I ask. “You
have the machines to tell you what the body’s doing. How essential is the talk
to you?”
“It’s vital. Mostly because it gives you a clearer
picture of what direction to go. By the time you’re done with the interview and
an examination, things should be narrowed down pretty close to two or three
potential items. And then it’s just a matter of the process of doing the
investigation work that helps support those two or three items you’re thinking
about.
“Things are not so much different here than
they are anywhere else in the country,” he says, “in Boston, in inner-city New
York. The quantity of trauma, quantity of violent trauma, is certainly
different. But the general flow, the general what you do, the patient
population, all of those things are pretty uniform all across the country. Right,
wrong or otherwise, medicine has evolved into a clinic practice that is maintenance
of things which have already been identified as problems. Walk-in clinics,
urgent care clinics, and emergency departments are I have something new. Or, something old is now broken. My blood
pressure is now, suddenly, too high. It’s difficult the way medicine is setup
now. You can’t call up your doctor and say your blood pressure is now 210, you
have a little bit of a headache, you’re having some problems with vision, and
expect that he will drop two other patients in the next half hour to see you
and try to manage that. So we see you. We have all the tools to manage that.
And especially if it ends up getting worse.”
“Tell
me about a particularly difficult diagnosis,” I say. “Is there a patient or
whatever that particularly confounded you? Or one that you just nailed?”
Third Course
We
are interrupted when Eric arrives again.
“Eric,”
I say, “these are all beautiful dishes. Oh, that smells so good.”
“Probably
one of my favorite ones,” he says. “We have a little scallop crudo, just
keeping it raw and fresh. Quickly marinated and served immediately. That way
the citrus doesn’t start to cook it. In this case, a nice, fresh, sea scallop. Came
in fresh. We drizzled a mixture of orange juice and fresh lemon juice over the
top. We got toasted ground coriander seed sprinkled over there, we got fennel,
shaved fennel, red onion on the bottom with some shaved asparagus. That’s it. And
fresh orange on top.”
We
all look at each other, and I suddenly wonder if chefs and physicians don’t
often get the same looks. Gratitude for the ineffable. We stop talking. Eating is
its own pleasure.
“I think the most memorable patients,” Warren begins,
finally, then pauses again. “It’s interesting because when you think of the
world memorable you think of something that touched your heart, that maybe has
a bright spot in the back or in the forefront of your mind. These are memorable
in the opposite direction. They certainly have impacted my heart. They
certainly have impacted my perception of life. But I’m not fond of remembering
them. Those are abused children.”
We pause.
“It always amazes me,” he says, then pauses
again.
“As an aside,” he says, “this is exceptional. Holy
Moly! I just had my first bite and I go Oh Man… This has touched me. This is
exceptional. Man, I like fennel, but I am not sure I’ve ever had fennel that’s
this good.”
We pause again. Talking about pain in the midst
of joy. The restaurant crowd. Laughter and love at the other tables. The happy
noises. Somehow good food gives permission.
“The thing about child abuse,” he says. “I’m
always amazed. I can certainly come up with sad. Anger. But every time I would
see a child that’s been abused, either physically or sexually, and thank
goodness it’s not often, I’m always amazed anybody could do that to a child.
“The other thing I’m always amazed at is the
demeanor of the assailant.”
“Do you see them?” I ask, amazed. “Is it the
parents who bring them in?”
“Sometimes the parents,” he says. “Sometimes
the boyfriend of the mom. Sometimes a relative. Most of the time it’s somebody
they know. And all the time I’ve experienced it, it is somebody they know.”
“And that somebody is standing in the room with
you as you’re…,” I say.
“Yeah,” he says.
“Have you punched anybody?” I ask.
“No,” he says.
“You
can almost always tell who the perpetrator is,” he says. “Because they’re
removed. They seem concerned…”
“Concerned
about evidence of their own guilt?” I interrupt. “Or concerned about the child?”
“Concerned
about the child, he says. At least you get that impression. But there’s almost
a sense of laisse faire intermixed
among some of the other things. This is serious, and initially you think they
don’t understand the seriousness, the seriousness of the injury, the
seriousness of whatever is going on. And even if they’re engaged enough, that disconnect
always comes through someplace.”
“How
often does the child point a finger at someone and say that’s where my injury
came from?” I ask. “Ever?”
Warren
looks at his plate for what seems like a very long time.
“I’ve
had very few abused children who are in a position to point the finger. The
ones I see are toddlers, at best.”
“What
about trauma,” I ask. “Not just car wreck trauma. But knives, bullets, beat-ups?
Do you see a fair amount of that? I saw something today about an increase in
the homicide rate.”
“I
think there was a three percent increase in the homicide rate,” he says. “No,
he says, it was a thirty percent increase. Which means we’ve had six.”
“So
we’re not a violent town, in terms of your office,” I ask.
“No,
we are,” he says. “There’s no question. But we’re still the knife club. Not the
knife and gun club. Lots of stabbings. Lots of knife violence.”
Madi
shows up again, to check on our drinks. I can tell she wants to know what’s
going on.
“How
does this look from your perspective?” I ask her. “Is any of this on the menu?”
“No,”
she says. “I don’t even know what any of it is. I don’t even know what Chef is
bringing out because he’s been preparing it all. I haven’t got a clue. But I
heard that you guys are writing a book?”
“Yes,”
I say.
“And
the courses are meant to go along with the story?”
“He’s
an Emergency room doctor,” I say, pointing at Warren. “Eric has to come up with
a menu to match his profession.”
“Oh
boy, that’s a tough one,” Madi says, then continues. “I’m going to be studying
nursing.”
“That’s
good for you,” Warren says, genuinely.
“I’m
excited to get into it,” she says. “I’m going to start this fall.”
“Is
medicine still attractive to eighteen-year olds?” I ask when she walks away.
“It
seems like it,” he says.
I
look around the restaurant. Every seat is filled. Food arrives and conversation
stops to allow eyes and noses their own vocabulary. The first date couple is
gone, their seats replaced by two middle aged couples. I silently wish them all
well.
We
go back to knife and gun club talk.
“We
do have firearm injuries,” he says. “But the majority of those are
self-inflicted.”
“What
about somebody just beating up somebody else?” I ask.
“We
see a lot of that. It’s been that way for a while. Ten, fifteen years.”
“Stupid
bar fights?” I ask.
“Stupid
bar fights. Domestics. For the last ten years, twelve years, I work strictly
days. I gave up shift work.”
“The
benefits of age,” I say.
“Or
the agonies of age,” he says. “I couldn’t do shift work anymore. So I don’t see
as much of the violence as people who work the evenings and especially the
overnights. Nothing good happens after midnight.”
“What’s
the most common complaint during the day shift,” I ask.
“Chest
pain,” he says.
“How
many of them are ER necessary?” I ask.
He
pauses, takes a bite and says “I go back, he says, to everybody who comes to
see me believes it’s necessary in some way or another.”
The
evening light outside our window has shifted into the golden hour. There is saxophone
jazz in the background. Crowd noise.
“I
have a strong—that’s a reasonable adjective—concept of the value of life,” he
says. “The last twenty, twenty-five years, I’ve gotten even more understanding
of the value of anybody and everybody, whether they’re a chronic drunk or
whether they’re a psychotic on stimulants, whether they’re somebody who comes
to see us too often. Whether it’s somebody who has chest pain that is obviously
not life threatening. I think the simple answer is that I truly just appreciate
the value of every living being.”
“Did
that come from you’re your time in ER” I ask. “Before medicine? From family? I
ask. Religion?”
“Certainly
it is family,” he says. “My mom and dad had a strong influence on me. They had
an intense sense of the worth of people. They came from little or nothing, but
gave to people who needed it. I’m also the product of a world war two veteran and
they have a tendency of touching people’s hearts. My dad was in the infantry in
the South Pacific. I don’t have stories that he would share—about anything. Except
being sick with malaria and yellow fever. His platoon was devastated, twice,
and he survived. A man I admired all my life. He certainly had his struggles
with depression, though fortunately not substance abuse. He was in a
psychiatric ward a couple times in his life. And it certainly gave me an incredible
understanding of those people who are struggling. And most people are. Whether
they’re coming in for a heart attack, belly pain, or a bad headache. At that
moment they’re struggling with life.”
Fourth Course
Eric
presents the next dish.
That
last one, we say, has to go on the menu.
“It
might go on a special,” he says, smiling.
We
stopped the conversation for that one, we say. It was terrific.
“So
here we go,” he says. “Fourth course, I believe. Flash seared beef tenderloin medallion
on top of a carrot tahini puree. Some brown rice quinoa with black beans. A
little dust of toasted ground cumin seed. And then just the natural pan sauce
drizzled over that.
“I
started with the carrot and tahini,” he says. “I’ve liked that flavor for a
while. Then things fall into line with that. The black beans. The quinoa and
then the cumin. Beef tenderloin. Small cut. Low fat.”
Here,
I think, is the center of the meal. At least for me. It looks so pretty on the
plate, we hesitate to cut. But then we do.
“Tell
me a story,” I ask Warren. “Walk me through a typical case?”
“This
one wasn’t a difficult diagnosis,” he says. “It was a difficult situation. And
I hesitate just a little bit because it’s to some degree well-known.
“Emotionally
it was difficult,” he says. “Mechanically it was difficult, too. I was the
physician for a woman who was in an auto accident. And one of my partners was
the physician for her child. Her child died. And so, mechanically the
difficulty was how do I do what I needed to do, to make sure that this woman is
okay? And how do I provide whatever she might need from a trauma standpoint,
and still allow the time for her to hold and grieve for her child?”
He
continues talking, but seems to wait between every phrase.
“And…so,
from a process standpoint, I chose to…. She was doing okay, and I was watching
certain parameters…so even though with trauma patients we like to have things
in order, ready to go for whatever investigating things we need to have done,
within the first ten or fifteen minutes of them arriving…it took me an hour to
identify the things I definitely needed to do, and in order to get them done…I
chose to take that time.”
I
want to know more, I think. But I also do not want to open a wound.
“Do
you ever learn to give bad news?” I ask.
“I
think so,” he says. “Early in my career,” he says, “and I have no idea why I
thought this, but I thought I had to give an explanation of the process. And
then give the bad news. Fortunately, that didn’t last very long, a year or two,
maybe three years. But I began to realize they really don’t care about the
process. It’s nice for them to hear the process before you give them the bad
news because then they know. Once you give them the bad news it doesn’t make
any difference what the process was and what actually happened. Some people
ask, but very rarely.”
“So
any more,” he says. “Obviously I introduce myself, I find out who are family
members and who are friends, and who is the person I direct my comments to. And
I usually just say I’m sorry, there wasn’t anything we could do.”
“How
many times a week do you do that?” I ask.
“Every
other week, maybe,” he says.
I
would have thought it would be more often. Aging population and then add
motorcycles.
“The
ninety-year old,” he says, “is more difficult. You have to know, in a
relatively brief amount of time, their whole medical history. You need to know
what they’ve dragged along with them on this particular day. So even if they
are not on death’s door, but they have something that’s potentially life-threatening,
the information if vital. Fifty-year olds, sixty-year olds, seventy-year olds,
even maybe eighty-year olds, with a heart attack, there is no question about
what you do. Call a cardiologist. They go to the cath lab. They get stents.
Whatever else they do. But a ninety-five-year old with dementia, diabetes,
kidneys that aren’t working perfectly well. They come in with a heart attack. Now
what do you do? The angiogram even by itself can damage the kidneys even more.
Would the person really understand what’s going on?”
Dessert
Madi
clears our plates and sets new silverware for dessert.
“How
many different sets of silverware did we go through,” I ask.
“You
guys are getting special treatment,” she says.
“My
wife really likes these,” Warren says, “so I’ve been storing them in my pocket.”
“Oh,
I know,” she says. “We’ve been counting.”
When
she walks away, Warren continues. “We see a fair amount of people who…There’s a
husband/wife team in Princeton who coined this term Deaths of Despair. They’re
looking at demographics. Profound increases in suicide. Certain groups in that
category. Late teens to early twenties. And the other group that’s really
increased in incidence is the middle-aged white male. So, suicide. Drug
overdose. And indirect deaths due to substances. Alcohol or drugs or whatever
the case may be.”
“Not
Corvettes and motorcycles,” I say.
“Not
Corvettes and motorcycles.”
“That
was the category they looked at,” he continues. “And in my mind the term Deaths
of Despair is an incredible term. And it speaks specifically to what we see day
in and day out.”
Eric
arrives. Caramelized pears, sliced standing upright on the plate. A balancing
act to carry across the restaurant.
“So
final course here,” he says. “Ohh!” A pear tips, but he recovers.
“Caramelized
pear,” he says. “With a little sugar in the raw to help it caramelize. We got
natural pan drippings around the outside and a sauce in the middle. We got
coconut milk and almonds over the top.”
“Any
reason why you chose this as the finish?” I ask.
“Because
I love pears,” he laughs.
“Honestly,”
he says, “I just love the presentation. I like the way they slice and present.
It just seemed like a nice grand finale.”
He
has a meeting at 7 p.m., he says. We all shake hands, say thank you, try to
express admiration and astonishment, and then he dashes off.
The
pears are very good.
“If
I get annoyed at anything,” Warren says, after a moment, “it’s chaos.”
“How
so?” I ask.
“Chaos
is out of control,” he says.
“But
when the ambulance pulls up and the door goes up, that’s what you’ve got,” I
say. “That’s who you are. You’re the emergency room.”
“But
it doesn’t need to be,” he says, “if everybody who’s there does what they’re
supposed to do. That’s where training comes in. That’s where protocols come in.
Even in the most dramatic cases, it doesn’t need to be chaos.”
I
ask about mass casualty drills. Airplane crashes. Train derailments. Chemical
explosions in town. Suddenly hundreds of people heading for the emergency room.
The hospital does participate with the police and fire department in regular
training. But in-hospital care, he says, is much different than pre-hospital
care. “The EMTs,” he says, “they have a whole specific role they need to do and
they’re very good at it.”
“Is
there a most chaos-filled, most dramatic story?”
He
pauses for a long time.
“This
particular instance was a young lady, early thirties probably, and she came in
without the ability to breathe. Because of something that was going on in her
throat.
“Fortunately,
this doesn’t happen very often,” he says. “Most of the time airway management
is reasonably routine. You might have a hiccup or two, but even with the hiccup
you’re usually successful.”
“There
was already a tube in?” I ask.
“No,”
he says.
“Ok,”
I say. “She brought herself in?”
“She came by ambulance,” he says. “But as she was doing somewhat okay, the paramedics are usually pretty judicial. I mean if they need to, they do. But if they don’t need to within the next ten minutes, they wait for us. It’s just that much easier. Because you’re in, to some degree, a controlled environment. You have everything you need and all the people around you. The respiratory therapists, everybody else that’s there. For the paramedics, you’re in somebody’s home. The light’s not good. Or they’re in the ambulance, bouncing down the road. So if they can wait for a better, more controlled environment, they usually do. And she was holding her own for a while. But it was obvious that wasn’t going to last for very long.
“And
this was one of those airway managements that was more than a hiccup. Multiple
tries by myself, even with anesthesia, even by our ear/nose/throat doctors,
were unsuccessful. We were able to ventilate her a little bit, without the
airway, but obviously that wasn’t going to last for very long. So we wound up
doing a surgical airway in the operating room. And even that was more difficult
than usual. It turned out that she had the airway about the size of a child.
Maybe a ten-year old’s. Maybe eight.”
“Just
a condition?” I ask.
“Exactly.”
“And
it was not only the size,” he says, “but it was floppy. So instead of this hose
that stays open, when she was not breathing it would collapse. Multiple tries
but we finally got enough of a temporary air way she could be moved to the
operating room for a definitive airway.”
“And
nothing in her history,” I say.
“No.”
“You
could have done some real damage if you continued to try to stuff an adult
sized tube down her throat,” I say.
“Some
of it was, you couldn’t even see,” he says. “Just the anatomy she had in her hypopharynx
you couldn’t see enough even to attempt. Multiple attempts by multiple people. You
just couldn’t see. Even fiber optic scopes were unsuccessful.”
Warren
takes a bite of his dessert. “That was probably the most harrowing and chaotic
thing I ever did.”
Madi
clears the plates. So much more to ask and say.
Behind
us, the restaurant has grown quieter.
Many people have left, heading out to other rooms, other places, for
deeper comfort or rest. Some people
linger over their knives and glasses, this place what they need.
But
the evening is not late. Madi and the other servers ready the tables for new
customers. Eric is gone, but another
chef readies the kitchen for whatever orders may come.
Warren
surveys the room. “Remarkable,” he says,
quietly.
No comments:
Post a Comment