Five Patients

By now the waiting room was filled with troopers and policemen. The families of the injured men had not yet begun to arrive. Hospital personnel who had not been informed of the accident but had noticed the cluster of policemen stopped to inquire what was happening. At this time, no one really knew the nature of the accident and there was widespread confusion about it; most people thought a plane had crashed at Logan. An inquisitive crowd began to gather in the lobby. The EW administrators were busy trying to get identifying information on the patients and also attempting to keep the passageways from becoming clogged. "We got seven more coming," one of them said over and over.



A few minutes later, another ambulance pulled up and Ralph Orlando, a fifty-five-year-old father of four, was taken off. He had suffered a cardiac arrest on the way to the hospital and closed cardiac massage was being given by a nurse, the first person who happened to reach him as he was taken from the ambulance. Orlando was wheeled in at a dead run; the massage was taken over by a resident. The patient was taken to OR 1, where full re-suscitative procedures were begun.



The routine of cardiac resuscitation is now so standard that few people realize how recent it is. The basic principle of closed cardiac massage was first properly described in modern times in 1960. (It had been described in the nineteenth century but was not commonly practiced.) Prior to that time, a cardiac arrest was almost certainly fatal. The only treatment was thought to be open massage, in which the surgeon incised the chest and squeezed the heart directly with his fingers. Although frequently successful, open massage rarely produced long-term benefit; one study in 1951 indicated that of patients who underwent open massage, only 1 per cent survived to be discharged from the hospital. That figure still stands; open massage is now a last-ditch effort only.



Closed cardiac massage depends upon the anatomical fact that the heart is tightly packed in the chest between breastbone and backbone. Rhythmic pressure upon the breastbone will squeeze the heart enough to produce a pulse. Direct open massage is therefore not necessary, and the hazards of this surgery are avoided.



The purpose of cardiac massage is to maintain blood circulation which, in conjunction with artificial respiration, provides blood oxygenation for the brain. The brain is the organ most sensitive to lack of oxygen; under most circumstances brain damage will begin after three minutes of circulatory arrest. In contrast, the heart itself is much more durable and can resume beating after ten or more minutes. But by this time, unless resuscitation has already been begun, the brain will be irreversibly damaged.



In some situations, mere compression of the heart is enough to start it beating again, but the massage is generally accompanied by a variety of other maneuvers to correct metabolic changes from the arrest. This includes the injection of Adrenalin, calcium, and sodium bicarbonate. The experience of the last decade, utilizing these techniques, has demonstrated that cardiac arrest is reversible to an astonishing extent.



The procedure for Ralph Orlando was the standard one: closed massage and artificial ventilation, with simultaneous injection of substances to correct metabolic imbalance. This procedure failed to induce spontaneous contractions of the heart muscle. Electrical defibrillation was then begun.



No one had any idea how long it had been since Orlando had suffered his arrest; presumably whoever had ridden with him in the ambulance knew, but that person could not be found.



Initial electroshock therapy failed. Using a long needle, Adrenalin and calcium were now injected directly into the right heart ventricle, and further shocks were administered. It was now twelve minutes since his arrival.



While this was going on, the rest of the EW staff was organizing itself around the other patients. One resident was assigned to oversee the care of each injured man. In the operating room across from Orlando, John Conamente was also surrounded by people. He was simultaneously being examined by the orthopedic surgeons, having intravenous lines inserted in both arms, having blood samples drawn, being catheterized, and being questioned by the resident, who stood at his head and shouted in order to be heard over the noise of the people working around him. The resident conducted a typically stripped-down history and systems review, which under normal conditions might take ten or twenty minutes.



The resident asked, "What happened? Did it fall on you?" (At this time, most people still did not know the nature of the accident, except that something had fallen on a group of construction workers.)



"Yeah," John Conamente said.



"Where did it hit you?"



"My leg."



"Where else? Did it hit your shoulders?"



"Yeah."



"Did it hit your head?"



"No."



"Were you unconscious?"



"No."



"Does your left arm hurt?"



"Yes."



"Your other arm?"



"No."



"Your right leg hurt?"



"Yes."



"You have pain anywhere else?"



"No."



"Your chest hurt?"



"No."



"Breathe okay?"



"Yes."



"Pain in your belly?"



"No."



"Pain in your back?"



"No."



"You ever been in the hospital before?"



"No."



"You ever had an operation before?"



"No."



"Any heart trouble?"



"No."



"Any trouble with your kidneys?"



"No."



"You allergic to anything?"



"No."



"Can you see me all right?"



"Yes."



The resident held up his hand, fingers spread wide. "How many fingers?"



"Five. I'm thirsty. Can I have a drink?"



"Yes, but not now."



By now the orthopedists had concluded their examination. Conamente had fractures of his left arm and right leg.



Out in the hallway, another group was working on Thomas Savio, who complained of difficulty in breathing, pain in his chest, and pain in his lower abdomen. He had a large bruise over his right hip. There was a possibility of pelvic and rib fractures. A laceration on his forehead, while bleeding profusely, was superficial. He was wheeled off for X rays.





Meanwhile, in OR 1, attempts at resuscitation were discontinued on Ralph Orlando. Half an hour had passed since his arrival in the hospital. The resuscitation team filed out to help with the other patients, and the door to the room was closed, leaving behind two nurses to remove the intravenous lines and catheters and drape the body in a sheet.



Out in the lobby, John Lamonte, one of the workers, sat in a wheelchair and described what had happened. He was the least injured of all the men, though he had fallen from a height of thirty-five feet. "We were on a scaffolding," he said, "building an airplane hangar. There were three scaffoldings, all about thirty-five or forty feet up. One of them blew down in the wind. It came down real slow, like a dream. There were about twelve people on it, and some underneath." As he spoke, he gathered a crowd of listeners.



Across the room, one of the administrators was telephoning the City Hospital for a woman, to inquire about her brother-in-law. He had been taken there and not to the General. The woman bit her fingernails and watched the expression of the man telephoning. Finally he hung up and said, "He's fine. Just some lacerations on his hands and face. He's fine."



"Thank God," the woman said.



"If you want to get over there, there are cabs in front."



The woman shook her head. "My husband's here," she said, pointing down to the treatment rooms.



Ralph Orlando was then wheeled out on a stretcher. A woman who had just arrived in the EW for treatment of a rash on her elbows stared at the body. "Is he dead?" she asked. "Is he dead?"



Someone said yes, he was dead.



"Why do they cover up the face that way?" she asked, staring.



In another corner of the room, a woman who had been sitting stolidly with a young child got up and took her child out of the lobby while the body was wheeled out.



The emergency ward then received word that there would be no more people coming, that it would get no more than the six it already had. By now equilibrium was returning to the ward. People were no longer running and there was a sense that things were in control. The state troopers had for the most part gone, but the relatives were still arriving.



Mrs. Orlando, a stout woman accompanied by two teen-age children, was one of the many who immediately tried to leave the lobby and get back to the treatment rooms. All relatives were being prevented from doing this, because the area around the patients was already badly crowded with hospital personnel. Mrs. Orlando was insistent, however, and the more resistance she met, the more insistent she became. The EW administrators tried to coax her out of the lobby and into a more private waiting room. She demanded to see her husband immediately. She was then told that he was dead.



She seemed to shrink, her body curling down on itself, and then she screamed. Her daughter began to sob; her son tearfully swung at members of the staff, his arms arcing blindly. After a moment of this, he began to pound and kick the wall and then, following the example of his sister, he tried to comfort his mother. Mrs. Orlando was crying, "No, no, I won't let you say that." She allowed herself to be led into another room. There was a short silence, and then she cried loudly. Her sobs were heard in the lobby for the next hour.



An MIT undergraduate, working in the emergency ward on a computer study project, watched it all. "I don't know how anybody can stand to work here," he said.



Dr. Martin Nathan, a surgical resident who had also seen it, said to him, "There are good ways to find out, and there are bad ways to find out. That was a bad way."



"Are there any good ways?" the student asked.



"Yes," the resident said. "There are."



A few minutes later, a nurse went into the private room with sedation for Mrs. Orlando and her family. Soon thereafter, the emergency ward received confirmation that the remaining casualties had been treated at other hospitals. The five in the emergency ward were being cared for; three would go to surgery in the next hour. The extra personnel began to leave, in twos and threes, and things slowly returned to normal. One hour and ten minutes had passed since the first patient arrived.



At 6 p.m., a forty-six-year-old insurance salesman arrived after vomiting up blood; twenty minutes after that, a man came in with his sixty-one-year-old mother, who had suddenly lost her ability to speak and seemed to have trouble keeping her balance; then came a nineteen-year-old graduate student who had broken a glass while washing dishes and cut her ankle. At 7 p.m. a thirteen-year-old boy arrived who had been side-swiped by a car and had suffered a scalp laceration. At seven thirty, a child who had fallen out of bed and cut his forehead; at eight, a fifty-year-old man suffering from a heart attack; moments later, an unresponsive twenty-year-old girl who had swallowed a bottle of sleeping pills, brought in by her roommates; a two-year-old child who cried and tugged at his ear; a nineteen-year-old boy with appendicitis; a thirty-six-year-old woman who had driven her car into a telephone pole and was unconscious; a fifty-nine-year-old alcoholic who said he had been beaten by two sailors and had facial lacerations; a man who was thought to be in a diabetic coma; a linotype operator who had burned his left hand; an elderly man who had fallen and broken his hip; a forty-eight-year-old man with abdominal pain and rectal bleeding.



At midnight, a woman arrived complaining of squeezing chest pain; at 2 a.m., a sixty-two-year-old man with known cancer arrived with a high fever; at two thirty, a schoolteacher who had had abdominal surgery two months before was admitted with symptoms of small-bowel obstruction.



The last resident got to bed shortly before 5 a.m., lying fully dressed on a stretcher in one of the treatment rooms. On his door was tacked a sheet of paper which said "Wake me at 6:30."



"However great the kindness and the efficiency," wrote George Orwell, "in every hospital death there will be some cruel, squalid detail, something perhaps too small to be told but leaving terribly painful memories behind, arising out of the haste, the crowding, the impersonality of a place where every day people are dying among strangers."



That is a reasonable description of Ralph Orlando's death, and the unfortunate way his family learned of it. Yet one cannot imagine those events taking place anywhere in the hospital except in the emergency ward. The EW is the place where the haste, the crowding, and the impersonality are seen in their most exaggerated form. And in many ways, the EW is the place where one can see most clearly the work that the hospital performs, in all its positive and negative aspects; the EW is a kind of microcosm for the hospital as a whole. Its growth in recent years has been phenomenal. Its patient load has been increasing steadily at a rate of 10 per cent per year for nearly a decade. It now treats more than 65,000 patients a year. Half of all hospital admissions come through the emergency ward, and many aspects of hospital life are now arranged around that fact: for example, elective admissions in medicine and surgery may have to wait as long as twelve weeks for a free bed, because emergency cases receive priority. If an elective patient has, for example, surgically treatable cancer, the delay may be difficult for everyone to accept.



Yet the trend is clear. The hospital is oriented toward curative treatment of established disease at an advanced or critical stage. Increasingly, the hospital population tends to consist of patients with more and more acute illnesses, until even cancer must accept a somewhat secondary position. And there is no indication that the hospital has fallen into this role passively; on the contrary, this appears to be the logical outcome of many aspects of its evolution.



Massachusetts General Hospital now consists of twenty-one buildings along the banks of the Charles River. Included within this complex are the first structure, the Bulfinch Building, and the most recent, the Gray Building and Jackson Towers, still under construction. All together, the hospital has more than 1,000 beds, and is one of the largest hospitals in the United States.