In "Of Human Bondage," W. Somerset Maugham, himself a physician, wrote of the clinics in a turn-of-the-century London hospital: "But on the whole, the impression was neither of tragedy nor of comedy . . . It was simple and complex; joy was there and despair; the love of mothers for their children, and the men for women; lust trailed itself through the room with leaden feet, punishing the guilty and the innocent, helpless wives and wretched children; drink seized men and women and cost its inevitable price; death sighed in these rooms; and the beginning life, filling some poor girl with terror and shame, was diagnosed there. There was neither good nor bad there. There were just facts. It was life."
It has always seemed to me that Maugham set the gold standard for writing about medical practice with these few lines. There is today, however, a variant on hospital clinics that did not exist in Maugham's time -- the emergency room. From humble beginnings as the stop at the end of the ambulance run, the emergency room has grown and flourished as a high-tech salvage center for the critically ill as well as the doctor of last resort for those with lesser problems who lack a personal physician.
The emergency room, in turn, has spawned trauma centers, urgent care facilities and the like for the specialized treatment of people requiring quick attention. All of "these entities are the descendants of Maugham's "rooms" and those who write about them walk in his large footsteps.
"Trauma Center" by Randall Sword and Janet Keller chronicles three days in the life of Dr. Sword, who is an emergency room director at a Los Angeles medical center. Life in the inner city is violent and, in consequence, the emergency room is the scene of nonstop human and medical drama. Sword and Keller write well enough, and the action rolling through the doors carries the story easily. The book, though, is a much better work than the string of vignettes that constitute the plot might suggest because, using flashbacks and asides, "Trauma Center" is also Sword's autobiography.
A graduate of a textile college and a Peace Corps volunteer in Africa, he settled on medicine later than most and had to struggle to get into medical school. After an internship in the Canal Zone and two years with the Indian Health Services in New Mexico, he became an emergency room physician in California and rode the crest of the new specialty to his current position.
The emergency room, he tells us, is addicting, gratifying and destructive to those who work there. The 12- to 24-hour shifts worked by the E.R. doctors are at once grueling and ego-buoying, such that the busy, exhausted physician nearing the end of a stint often experiences a kind of E.R. high. Sword reports his ex-wife's complaint that the best part of him is spent on his work while she gets what is left over. "I don't know that I would agree with 'best,' " he comments. " 'Real' -- the most 'real' of me goes to work. Because nowhere, except in the emergency room , do I feel so totally alive, so self-actualized."
He continues, " We face an opponent that can never be beaten, an enemy manifested through despair and hopelessness. The costs to our personal lives are high. Few can come home as we do, drained of energy, reduced to our most elemental needs, and expect any kind of relationship to survive."
Sword writes warmly of his former wife and his daughters, whom he sees on visits spliced into his work schedule. He tells us as well about his psychiatrist, his hefty income and the suicide of a fellow E.R. physician.
"Emergency Room" by Edith Alston and David Cutler covers much the same ground but in a longer and less personal fashion. The action sequences are well written, but the plot is managed in a cumbersome and confusing manner that leaves the reader awash in anecdotes, struggling to discern what message comes from the quantities of personal anguish experienced by patients and doctors alike. In this story the lives of the E.R. doctors are, if anything, more glamorous and less rooted than in "Trauma Center." Based in California, the protagonists jet across the country to staff emergency rooms in distant states. They own planes, drive Porsches, make six-figure incomes, use drugs, get divorced and are generally unhappy.
Both books document the emergency physician as a late 20th-century soldier -- and, to some extent, victim -- of the industrialized society. The doctors, like their factory-bound cousins who emigrated from the countryside a century earlier, have left their base in medical practice to become highly remunerated piece workers in a medical factory setting, where neither continuity of care nor community identity are worth much. The emergency room circumstances are no more their creation than the "Dark Satanic Mills" of 19th-century England were the product of the workers who toiled in them. But the emergency physician, like the industrial laborer, is drawn by industrial opportunity and, at the same time, alienated from settings and values that have served as human anchors in previous times.
The volumes leave me persuaded that while the patients of Maugham's rooms have much in common with the clients of today's emergency rooms, the doctors are quite different. This difference goes well beyond the obvious technological superiority of the contemporary physicians. The E.R. doctor of "Trauma Center" and "Emergency Room" is unsure of who he is. Despite enormous skills and dedication, despite psychiatrists and private planes, the relationship between work, family and community has become obscured -- painfully and destructively obscured. I am left wondering what the new specialty of emergency medicine, which is proudly heralded in both these books, proposes to do about this very serious vocational lesion.