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ER

“Take a knife and cut this pain from my heart.” —Bruce Springsteen, “The Promised Land”

The Emergency Room or ER of any hospital is where people go to for any acute pain they have, real or imagined — heart attacks, strokes, asthma, abdominal catastrophes, fractures, and even psychotic attacks. In big government hospitals, the ER can be an overcrowded place of controlled chaos, noise and screams, blood and filth — perhaps an infernal place recalling Dante’s warning: “Abandon hope, all ye who enter here.”

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Every medical student has to go through a rotation at the hospital ER. At the Philippine General Hospital (PGH), surgical residents in training rotate for three months or more at the ER; it is considered a hardship post. They confront a multitude of motor vehicle crash victims, mauled patients in various stages of drunken stupor, stab and gunshot wounds with medico-legal implications and possible future courtroom appearances for the surgeon — and the usual hordes of agitated relatives.The air in the ER is perpetually shrouded in tension, like a black cloud so thick it can be cut with a knife. At the ER, humanity is at its worst, and also at its best; it is Shakespeare’s great stage of fools.

The American author Michael Crichton, himself a medical doctor and creator of the hit TV series “ER” which made George Clooney a star, calls the ER the microcosm of the hospital as a whole, oriented toward curative treatment of established disease at an advanced or critical stage, “ … the place where one can see most clearly the work that the hospital performs, in all its positive and negative aspects.”

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Surgeons have their unforgettable ER stories. Mine was about a young construction worker who fell from the second story of a building and impaled himself on an iron bar. The bar was cut to enable transport to the PGH. He arrived in the ER looking normal except for the iron bar protruding fore and aft from his chest. I eventually made a large incision across his chest, and found out that the bar had missed the heart by mere centimeters. He went home three days later, none the worse for wear.

Then there are the stories behind violent human behavior, of drunken husbands and wayward youngsters, of aggrieved neighbors and erstwhile friends, of petty gang wars, of the manifold display of human weaknesses, of death itself. “However great the kindness and the efficiency,” George Orwell wrote, “in every hospital death there will be some cruel squalid detail … 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.”

The ER is the first area of the hospital many patients encounter — and first impressions will be etched indelibly in the patient’s memory during the hospital stay and even beyond discharge.

There is one concept in the ER that the public hardly understands: the triage system. A throwback from the days of Napoleon Bonaparte when his army marched across Europe, it simply seeks out the most seriously injured, salvageable from those who are otherwise stable and the dead—in short, a priority system. Originally applied to battlefield situations, it is now a recognized system in mass casualty situations. like for example the annual New Year’s Eve ER situation. The minor wounds and pains (all patients think theirs are life-threatening) are ignored for the moment. That’s why it is not surprising that the ER is the most complained-of area of the hospital. Another concern is that overcrowding can be harmful to patient care; there is also the problem of medical staff fatigue.

In the future, redesigning the ER into zones based on patient need, detailed evidence-based algorithms, x-rays and CT scans read by artificial intelligence or even a robot assistant, may help the ER human staff. The robot, particularly, may be able to provide basic information, tentative diagnoses and even treatment plans and prognosis in an instant by analyzing large data (the patient’s entire medical record) to shorten patient waiting time and reduce decision errors.

Despite these changes, the ER will remain a place where lives are saved and suffering is alleviated. As the father of modern medicine Sir William Osler said, everywhere the old order changes, and happy are those who can change with it.

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Dr. Jose Luis J. Danguilan, a thoracic surgeon, is the former executive director of the Lung Center of the Philippines.

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