The Heat of the Night
by Ray Fowler, MD
Copyright Jan 1, 1988

(Time in Space Home)

            Almost twenty years ago, when I was this wet-behind-the ears green-horn living in Douglasville, Georgia, long-haired, sandals-wearing, freaky type, living out the sixties in the early eighties, I was working in the emergency department at Parkway Medical Center. Fresh out of training at the Medical College of Georgia, I was just over 25 years old, wide-eyed, excited, and raring to go.

            Emergency medicine remains to me one of the most exciting places to be. For me, it was the only job that I could do. I’d dabbled in pre-law, looked hard at thoracic surgery, and even made a start at going back to do research. Then, an old friend from Augusta offered me a job working in an emergency room, and I never looked back.

            From the start it was such meaningful work. Every single thing that I had taken throughout medical school was somehow relevant. Wound care from surgery; acute psychiatric management; obstetrics, orthopedics, pediatrics, geriatrics, intensive care, neonatology: Every discipline with which I had had some interaction was useful and constantly being applied.

            And, BOY was I busy. Mainly, I was really obsessive about wanting to be accurate. I felt like I know nothing, even after all that training. Probably 8 times out of 10 I would call up the private guys on the phone while looking after a patient to ask “what in the world is this”, and “what in the world do I do with it?”

            Years passed, and tens of thousands of sick and dying filled the beds of my examination rooms. My hair grew shorter and thinner, and my eyes grew weaker. But, the clinical experiences mixed with the desire for accuracy and closure in each event stood by me. My expertise grew, and I became a “safe” physician. A safe doctor is one who has pretty much seen everything, usually more than once, and who has learned the right thing to do for a particular problem

            In emergency medicine, about 90 per cent of patients will usually get well by themselves. It is our job not to hurt those people. Think about it. Why use an IV if you don’t REALLY need one? Why give nitroglycerin to a twenty year old football player with chest pain that has been hurting ever since he was struck on the side of the chest by a helmet, just because protocol says that you can? Why give adenosine to a 25 year old woman with a pulse rate of 130 who is very anxious and has also been vomiting?

            So very often withholding care WHILE RENDERING EVALUATION AND ASSISTANCE may be the proper course of action. Back in the old days I was truly the one to jump on a particular therapy if there were a chance that it might be necessary. These days I have learned that doing the right thing for the right problem and the right time is the ticket to success in patient care.

            I remember well one night in the emergency room with I was about 28 years old. Parkway sits adjacent to the expressway near Six Flags amusement park west of Atlanta. The particular section of that highway is at the bottom of a long hill with a smooth section of four-laned highway. People absolutely FLY down that road. This patient had been brought in by EMS, horribly injured: Crushed chest, smashed face, broken limbs, hemorrhagic shock. We were preparing to crack his chest to cross-clamp his aorta. The tools were ready, the staff was poised, and I walked to the counter to don my gown and gloves.

            Then, for a second, I looked around the room. I noticed, for the first time in my career, that in this most critical situation, with a patient’s life hanging by the most slim margin, there wasn’t a single person in the room over the age of 30. At 28, I was the old guy in the area (a few white hairs having appeared in the interim). Yet, each in his/her own way, we were relative experts in our field. Certainly at that moment, we were the right people to be caring for that man in that hospital.

            Yes, in the heat of that night I was born suddenly to the reality of what I had signed on to do. I realized that my boyish playfulness had drifted away and had been replaced by a solemn duty to be an ultimate patient advocate. The lives of these patients were in my hands. I blinked my eyes, straightened my glasses, slipped on my gloves, and the nurse handed me the scalpel.

            Look around you, Medics. You are the most qualified people by far to be doing what you are doing in the field. We ALL look to you for leadership, maturity, and sensibility. You MUST leave behind any childish notions of evading responsibility or of shirking the duty to perform.

            On every patient, every time: You are there, in the heat of that night, in charge. Here are your tools, there is your vehicle. It’s your turn.