Q: Are emergency room physicians a different breed from most doctors?

A: The lives led by many, many physicians are very boring. I thrive on the action. I thrive on the responsibility. I thrive on the challenge and I thrive on the RPM. My original goal when I was 15 or 16 years of age was to go to the Naval Academy and be a jet fighter pilot. That sort of challenge and living on the brink, I thought, was a very glamorous and challenging and exciting lifestyle. My vision went to pot. I'm just as nearsighted as can be. Yet I've always been attracted to the idea of being at the center of the action.

For many, it's an adolescent trip that they outgrow. They're not happy spending their life with that kind of high-octane lifestyle. Those of us who made it a career find that the idea of sitting in the same office behind the same desk talking to patients without the constant possibility of the roof caving in is rather boring. I'm happiest when the ER is very, very busy. When we have a large number of anxious patients who want our assistance. When we have some patients who are in very serious difficulty. Because I've trained for nearly a decade to rescue people from life- threatening situations.

Q: Is it a high?

A: A true emotional high. You did a lot of very important things on behalf of a lot of very sick people. It's a feeling that what you did was important.

Q: Another physician has told me that if she or any of her relatives needed the services of an emergency room doctor, they'd go to you because of your cool under pressure. How do you detach yourself from a situation which involves wounds, real people, real suffering? The anguish doesn't bother you? The gore?

A: If the patient dies. As long as the patient is alive I don't even notice the blood. I don't even notice the vomit. You just focus on trying to get the patient back from the brink. When you've done it enough times and you're confident in yourself -- you know you can do it -- you know that the most important thing the patient needs is for you to be cool, calm and collected. And do it right the first time. That's just not something you learn from reading medical journals. It's something that comes with years of doing it.

Q: Are there any deaths that are harder on you than others?

A: I've never had a child die when I didn't cry my heart out. I think we all feel that way. The death of a child whether it's traumatic, poisoning, asthma, heart disease, sepsis, is particularly devastating. The child had so much to live for. And usually what happened to a child wasn't his fault. It wasn't because they were having a shoot-out with the police, robbing a bank. They were on their skateboard and they got hit by a car. It wasn't their fault. The new emergency room physician -- I don't care how experienced he is -- never forgets a child has died on him. That's when you sit down with the parents and you all cry together. Those are very hard.

Q: Do you find yourself working for long periods of time on someone you know is already dead but you just want to take one more shot at it?

A: A patient brought to me in full cardiac arrest -- I've never gotten them back after 30 minutes. But I have resuscitated middle-aged men with a wife and three kids for over an hour hoping for a miracle. I know I wasn't going to get it but I sure as hell was going to try.

Q: There's always hope?

A: If you're cold-blooded and analytical you know there isn't. But sometimes there are miracles.

Q: Have you ever had any miracles?

A: Absolutely. There are basically two types of miracles. There's the type of miracle where the patient had an unusual problem and you did something unusual to save their life, and the other kind of miracle is that you thought of something that nobody else thought of and you solved the problem, just as a lucky shot.

I think probably the miracle that I'm most proud of was a big, strong burly Baltimore longshoreman. He had been complaining of a sore throat. He had a rare condition called epiglottitis which resulted in acute obstruction of his upper airways. He couldn't breath. The anesthesiologist was there and couldn't get a tube in the trachea.

Q: That's the windpipe?

A: Yes. I took a knife and slit his throat and opened his trachea. Then he could breath. Whereupon he woke up and sat up and pushed me away. After a struggle with the strongesst human being I've ever met in my life, we finally got the tube in his airway. He had a wife and five children.

Another case I saw was an elderly man who's a very prominent political figure in Washington who came in the emergency department unable to speak with what appeared to be a stroke. The family was devastated and it appeared this man wouldn't be able to talk. As a longshot I gave him some glucose in the vein. He woke up completely and all the symptoms of his stroke had gone away and he was normal. He ended up having a very rare insulin-producing tumor that was making his blood sugar drop precipitously.

Q: How did you figure that out?

A: I had the previous day read an article about how low blood sugar can sometimes present neurological findings just like a stroke.

Q: A lot of miracles might just be the luck of the right medical journal you picked up at the right time?

A: That's one of the things that makes it a miracle.

One of the cases that scared me the most was the elderly alcoholic who fell down and was brought in by the rescue squad. The rescue squad wanted their collar back. It was the only one they had. This was in Baltimore County. I told them they couldn't have their neck collar back until we'd got some X-rays. Anyway, I kept the collar, took him to X-ray. He had a terrible fracture behind his neck. We put him in tongs to stretch his neck to keep him from killing himself. He was there in the tongs looking straight up and proceeded to vomit vast quantities of blood and started thrashing around and gasping and aspirating. I very gently looked in his mouth. I knew that if I tilted his neck the wrong way I'd cut his cord off and he'd be dead. Then we had to get the tube through the blood, through the gore and through the vomit into his airway. He was bleeding to hell and aspirating his blood. This man was going right under my nose. I had to do something. I gambled and won.

Q: What's the best time to visit an emergency room to be sure to get highest quality of care?

A: Emergency rooms are the quietest between 8 in the morning and noon. It has several advantages: the staff is fresh, and all the sophisticated support systems in the hospital are available -- the X-ray lab, etc. If it's Monday through Friday the overwhelming likelihood is that the doctor in the emergency room is a full-time emergency physician and not just a part-timer who's trying to earn some extra money at the weekends.

Q: What's the difference between that and 4 a.m. on Sunday morning?

A: Interestingly, that tends to depend on whether you're in the suburbs or the city. The emergency rooms in the suburban hospitals tend to become more quiet after midnight, because most patients go home to their families -- most patients have a family to go home to. In the heart of the metropolitan area, when the bars close, that's when you start to collect your harvest of the complications of alcoholism. Many of the predators of the night are most busy about 2 in the morning. The muggers, the robbers, the rapists -- those individuals who look upon a slightly tipsy bar patron heading home as an easy target. It's not at all rare for an emergency room in the heart of a business area at 4 o'clock in the morning to resemble the last five minutes of the Titanic.

Q: How do doctors cope with such chaos? Is there a limited staff at that time of the morning?

A: The emergency room staff may be up to snuff. But what may be difficult is to mobilize the support services to take care of a very sick patient. A plastic surgeon is usually much happier to hear from you at noon than at 4 in the morning. And the patients, particularly intoxicated ones, are often not sympathetic with your efforts to help them.

Q: When do you see more crime?

A: If you ever had a Friday night in August when there's been a five-day heat wave and there was a full moon and people are drinking and a lot of people have been paid --.

Q: You'd have a wild night?

A: Oh yes. The chemistry for violence. That chemistry has to deal with a mixture of boredom, poverty, liquor, heat, crowding and spendable money for alcohol. That's just an explosive combination.

Q: Have you ever run into a night like that?

A: Oh yes. More than I care to remember. In fact, I had six or seven gunshot wounds in the same night that came in the emergency room in Hopkins. And one of the patients that was brought to me was a medical student who was shot on the steps of the hospital.

You have to keep a careful eye out for foul play. From time to time you will see cases that don't stack up. There's something odd that's happened. I've had some mysterious deaths that on subsequent investigation turned out to be murder.

I had a patient a few years ago, a young man, who was known to have a seizure disorder. He came in cardiac arrest after a protracted seizure. He was not resuscitatable and he died. On talking to the family it was estabished this was a different kind of seizure. Subsequent investigation thrugh toxicological analysis indicated that he had been given a particularly deadly insecticide.

Q: By whom?

A: An erstwhile friend and associate who selected the poison because he knew that the fatal side effect was that of seizures and he knew the patient had a history of seizures.

Q: How did you figure out the seizures were different?

A: They were longer, more protracted, more drawn out and of a much more violent nature. They were preceded by aberrant behavior very untypical of the patient. The whole clinical scenario didn't stack up. In fact, there have been weeks working in inner- city hospitals where you get to know all the homicide detectives, all about their kids, all about what's going on in their lives because you see each other so much.

Q: I was talking to an emergency room physician who told me that alcohol is about the most dangerous thing in society based on some of his observations. Do you agree?

A: I would warmly and firmly agree with that statement. In one way or another, 25 percent of the patients that end up in the emergency department are there as as a reward for either use of alcohol or being victimized by someone using alcohol. I think if you got rid of alcohol throughout the society -- well, we've tried that. I think if you were able to have a society that could drink in moderation, emergency rooms would be empty.

All of us dread coming to work in the emergency room Sunday morning. You inherit the leftover wreckage of all the drunks who staggered in the previous night between 2 and 4 in the morning.

Sunday morning the first part of your job is to sort out all the sociological wreckage from the previous night. You let the patient sleep it off in the emergency room. When they sober up, additional problems become manifest. It is difficult for a physician to evaluate the intoxicated patient who fell and hit his head. He may be lethargic and confused because of alcohol or as a complication of the head injury. It's uncommon to be able to get a CAT scan at 4 o'clock in the morning on every drunk in the emergency room.

Q: What's the best place in the Washington area to have a severe medical emergency?

A: I have to be a little bit partial. After having spent two years at GW, their trauma teams do a marvelous job. By any grand scale the Washington Hospital Center has the biggest commitment and the largest staff to handle the severely traumatized patient. If I had a gunshot wound in the chest I would want to be at the MedStar unit at the hospital center, and if that wasn't possible I'd want to go to GW.

Q: How do you know how to treat first?

A: If you come into the emergency room bleeding vigorously and there are not life- theatening emergencies going on simultaneously, you'll get prompt attention. If, however, we're treating two patients simultaneously with life-threatening problems, you'll be given a big wad of sterile cotton, told to press down the dressing, and given some warm words of encouragement -- "We think you're wonderful. We'll be back with you just as soon as we can. Okay?"

Q: Have you had someone run out in the middle of an emergency procedure?

A: I've had younger physicians in training out of frustration being rude or abusive to a patient. Being argumentative. Being loud. Being discourteous. Being rude.

Q: They won't ever attack the patient?

A: But we all have been attacked by patients at one time or another. Being an emergency room physician is like being a fighter pilot on an aircraft carrier. You can have all the personal problems you want but you have to have total mental concentration focusing when you do the job.

Q: What happens when you have somebody who's repulsed by the severity of the wound or the pressure in the room? What do they do?

A: They busy themselves doing mundane or non-emergency procedures. They do their best to appear busy to avoid confronting a very unpleasant situation. Anyone who has supervised an emergency room can pick it up in about two seconds. I've had to take over the management of a case where a physician running the case was just too inexperienced, too frightened, too insecure or insufficiently knowledgeable to provide optimum care for the patient. But that's why you have teachers in emergency rooms -- so that the patient is assured that there's a backup system.

Q: Emergency room medicine pays better than most medical specialties doesn't it?

A: It pays better than most outpatient medical fields, although it pays less than most surgical fields. In this town, a physician who wants to work in emergency-room medicine 40 hours a week could expect a starting salary from various groups in the area in a range between $55,000 and $60,000.

Q: Do you ever dread facing the battle situation? Having to gear up every day?

A: Sometimes you get tired. But I can't imagine doing anything else.