When the Diagnosis Is Cynicism

  • Share
  • Read Later
Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area

Do you remember subway tokens? The two-color chunky metal coins cost about a dollar back in 1988,the same year I read Tom Wolfe's Bonfire of the Vanities, a truthful book about the hard social and political realities of New York. I read most of it "on site" in my call room at Harlem Hospital. One night, the phone in that room rang and I was told to come down to the Emergency Room fast. They had a 16-year-old boy there who was bleeding to death; his leg had been run over by a subway train. He was, the voice said before hanging up, a token sucker.

I was working my mouth and eyes, clearing my throat, feet independently pushing my just-awakened body into the glare of the corridor. I thought I'd probably heard wrong. A "token black" maybe—some gang member pushed off the platform? Or a marijuana smoker (as in Steve Miller's famous line, "I'm a midnight toker")? The jargon varies by hospital and, like all residents, I strove to be up on it.

He was a really young kid. He was starting to pass out, but he still displayed the smooth forehead and expressionless eyes of the silent treatment that apprehended perpetrators can give. His right foot was mangled—bits of sneaker mixed in with clotted blood, bone, cartilage and tendon. His left leg was hanging by skin. The jagged stump of his tibia stuck out just below the knee—pretty much what you would expect from the wheel of a subway train. Even in Harlem, this was pretty bad.

There is very little pride in doing a surgical amputation.There was no question that the leg was gone—we have ways of telling if one can possibly be saved. The important case was really his right foot; the outcome here would determine the kid's ability to walk. It was a long and tedious case with lots of debridement, our word for cleaning. And it was sad and late at night, so we talked. I eventually asked what exactly "token sucker" meant.

The old subway turnstiles opened when you slid a token into a very narrow slot on top. Tens of thousands of dirty New York hands pushed them in all day. You could, apparently, put your lips over that slot and, with a hard inhalation, suck a token back up out of the machine. Then you could ride the subway for free, or sell it to someone for something less than a dollar. This was, of course, illegal. My patient had been spotted doing it. He had run, the cops had chased, and he had crossed the track just in front of an oncoming train, but then...he tripped.

For a stinking dollar token? How would the person who chased him feel? My mind went back to another ER I had worked in, this one in Boston.

I was then a second-year resident in general surgery on trauma call. The radio said they were coming from Roxbury with a gunshot wound to the groin. Four Boston policemen "accompanied" my patient through the electric doors. He had been resisting arrest, even tried to run down a cop with his car. That probably explained why one of the cops had my patient's face mashed down into the black vinyl foam pad that covered the gurney, in the process asphyxiating him. The other two were taking turns yanking his arms up behind his back and punching his kidneys. The fourth officer was ramming the tip of his nightstick into the base of the patient's spine. Two on one is unfair, three is brutal, four—even for a good cause—just turns your stomach. I had to argue with them to let me roll him over.

My best attempt at gallows humor—"You can't actually suffocate my patient in here, officers"—got a bit of a smile out of them. Gasping, spitting and biting, the patient came up for air long enough to curse everyone and say that he would find and kill each of them. This got his face shoved back into the plastic again, but now he was on his back; I was sure they were going to break his neck. So I started the biggest IV I could and just pumped in morphine until he shut up. We spent the rest of the night with the senior residents sewing up his femoral artery—a great case.

As for the patient, he turned out to be about as hateful as anyone I've ever met. They took him away to Shattuck, the prison hospital, the next day. But he kept his leg. We eventually learned the trouble started with an innocent accident: a third party had backed up into his Cadillac and a heated but non-violent argument ensued. When an unmarked police cruiser pulled up, Cadillac man jumped into his car and took off. Yes, the cops probably could have let this one go too, as the token sucker story reminded me. The feeling was now familiar.

By the time I was back in the call room for my half hour of downtime before morning rounds, I realized I had formed an opinion about cops and perpetrators. It was based on two cases. It wasn't scientific—based instead on what we call "anecdotal evidence"—but still impacted how I would think about people in these circumstances for a very long time. After 25-odd years of accumulating anecdotal evidence in ERs and elsewhere, there are two things I can say for it.

The first is that there is a natural tendency to absorb, recall and live by the negatives. It's a survival instinct. Jaded and burned-out nurses and doctors are made in big-city ERs. The few who work there for decades and don't get cynical are special and possess a virtue I admire. When dealing with reality they see past the ugly and dangerous. They are not irrational idealists, blinded to all but the politically correct conclusion. But they are vulnerable. To recognize and learn from these few great ER nurses and docs should be the highest priority of every hospital, especially those with teaching programs.

Second, it's just hard work sorting out what's apparent from what's true. The tendency to say "this is how the world is because this is what happened to me" infests every mind. Medicine involves thousands of choices among treatments and diagnostics which often don't have any objective, scientific advantages with respect to one another. Yet we must choose. Every doctor knows he or she can find scientific papers that prove or disprove the same idea; "always do this" and "never do this." Sometimes they're even in the same journal. In the 1950s, scientific authorities told the public they should eat butter, eggs and caffeine. Then they said they shouldn't. Now they should again. This tempts us to throw up hands and give up on thinking.

The token sucker was picked up off the tracks by the cop who chased him there. The blood, the third rail and plenty of fight in the boy made it a task fit for a hero. No medals were awarded, and I confess I did not think of him as much of a hero that first night. But he has lived 25 years with that chase. And 25 years removed, I can admit that I might have chased him too.