WIND TUNNEL | Kenneth Weinberg
Working the E.R. is an assault on the senses. The sound of an ill, frightened infant, screaming uncontrollably as she rolls in on the ambulance stretcher; the sight of a deep scalp wound, skull exposed stark white against the red and gray splotches of torn flesh; the feel of an abscess filled with pus and ready to burst, or the smell of hemorrhagic stool, passed by the alcoholic whose stomach ulcer is oozing blood, all waft and commingle as the work day unfolds. Fortunately, most of the time these sensory attacks percolate just below the surface, not affecting ones concentration and workflow, but sometimes, unexpectedly, they burst into consciousness, triggering such strong emotional responses that they bring things to a grinding halt.
After working 15 years as a full time Emergency Physician I thought that I’d become inuredto these visceral attacks, no matter how strong. I believed I’d seen, or felt, or smelled it all.
One hectic winter afternoon I was proven wrong.
It started subtly at first, something nearly subliminal…
Then suddenly a particularly foul and unfamiliar odor erupted, permeating the entire ER. It seemed to be emanating from a new arrival who’d just meandered past us.
I had finished sewing a laceration and was walking back to my desk when this occurred.
“Ken, why don’t you finish your charting on that patient’s laceration?” suggested Margie, my Physician’s Assistant. “I’ll go find out what this is all about.”
Margie had worked with me for several years. She was a little dynamo and, before I could even turn around, she had run off, like a hound on the scent of a quarry, her nose leading her to a cubicle in the back of the ER.
Ten minutes later she returned. The edges of her mouth were curled down, the skin on her forehead crinkled.
“I need your help on this one,” Margie said, as she shook her head slowly back and forth.
“What’s the scoop?” I asked, curiosity and repugnance swirling round in my brain.
“Patient’s last name is Y. Her husband brought her here, insisted that she come today. She has the most amazing tumor I’ve ever seen. After examining her I recommended that she be admitted. She agreed but freaked when I mentioned surgery and now she’s balking at even staying in the hospital.”
As the Attending Physician in charge it was now my turn to visit Mrs. Y. Walking back to her cubicle I recalled prior cases where a patient would clearly be ill to my clinical eye but would refuse to recognize the seriousness of the problem, sometimes angrily challenging my diagnosis and treatment recommendations. I thought of one man I’d seen recently who’d been experiencing several hours of chest pain at home. He’d finally been convinced by his wife to come to the hospital and, when I saw him he was pale, sweating profusely, clearly uncomfortable as he sat on his stretcher. I’d gotten an EKG, then told him gently but firmly that he was having a heart attack and that we needed to act right then to prevent any further damage to his heart. Before I finished my sentence he’d pulled off the cardiac electrodes, jumped from the stretcher and bolted out of the ER, running past me, the nurse and, his astonished wife. Five minutes later he’d been brought back in from the hospital parking lot in cardiac arrest.
I guessed, per Margie’s observation and my own olfactory response, that Mrs. Y’s condition had to have its own extreme, yet similar, sense of urgency, tinged with that same lack of acceptance. That she would contemplate leaving the ER without treatment for this seemed evidence of either dementia or psychosis or, deep denial.
I considered these possibilities, and a strategy I could use to convince her to stay, while I walked back to her room.
As I entered the cubicle I first saw Mr. Y, wringing his hands, pacing, eyebrows arched. By contrast, his wife was sitting calmly in a chair, harlequin reading glasses perched on the bridge of her nose, perusing a Ladies Home Journal.
Her voice was light, almost bouncy.
“Thank you so much for coming back here, doctor. Margie said you’d give me your opinion on how I should proceed.”
“We need help bad, doc” interjected the husband. He stared directly into my face, eyes opened wide in frustration.
I looked again at Mrs. Y. She was an elderly woman, missing most of her teeth, yet stylishly dressed and speaking with what struck me as aristocratic assurance. Her contradictions were as evident as her medical condition. She sat, exuding an air of faded elegance, as well as a skunk-like fragrance I’d never before encountered. It arose from a tumor on the right side of her head as large as the head itself.
“Mrs. Y.,” I began, trying as best as I could to hide my incredulity, “how long have you had this growth on your scalp?”
“Oh, about a year or two, I think,” she responded sweetly.
I tried to imagine how she and her husband had been able to tolerate this unbelievable invader of their space for any period of time. It was a tremendous mass, well covered by skin and patches of hair, it’s weight causing her head to list a bit to starboard. Despite having left her scalp largely intact, the tumor was oozing a yellowish, viscous liquid from the several rents it had obviously caused in the dermis as it grew beyond even that pliable tissues ability to expand.
I looked from Mrs. Y. back to her husband. He appeared to be in his late seventies, with attire and demeanor that conveyed a sense of command. He was wearing a hounds tooth jacket and rep tie, had on a Rolex watch and manicured nails. I marveled at his apparent tolerance of his wife’s persistence in not dealing with this.
I thought again of the man having the heart attack and a few other extreme cases of denial I’d experienced before. But those cases at least had some nuanced subtlety, enabling me to understand how the patient and family could have refused to acknowledge the problem. I could see no nuancing the severity of Mrs. Y.’s issue. I clearly had to convince her of the need for immediate and aggressive treatment.
Breathing through my mouth as a shield from the smell I continued my conversation, trying to mix authority with compassion.
“I understand how difficult this is for you, the problems and fear the growth of this tumor must have caused,” I said. “The good thing is that surgery will take care of it.”
“But it really does have to be taken care of today.”
“Thank you,” said the husband, “It has been awful for both of us.”
He took a deep breath (I knew not how) and exhaled slowly.
“Doctor,” Mrs. Y. said, “I’m so afraid of the surgery. Won’t it be very painful?”
“No. They’ll put you to sleep and when you wake up it’ll be gone, done with.”
I paused once more.
“You’ve been extremely lucky that this thing hasn’t burst, or given you blood poisoning.”
I hoped that stressing this would be the ultimate motivator, forcing her to make the decision to no longer live with this alien co-occupier of her head.
She sat silently for several moments and I watched as her gaze seemed to turn inward with concern and anxiety and then outward to me in reluctant resolve.
Forcing a smile, she finally spoke.
“OK. I know that you’re right. Would you please notify my doctor? I want him to get me the best surgeon in the hospital if I’m going to go through with this.”
I walked from her room to call John M., her primary care physician. On my way to the phone I realized that I had just learned something new about the boundaries of denial.
“I have Mrs. Y. in the ER” I said to John when he came on the line.
“She’s got a rather large tumor on the side of her head.”
“Is her husband with her?” John asked.
“Absolutely. I doubt she’d be here if he hadn’t persisted and brought her in,” I replied. “Why do you ask?”
“Well, it’s kind of ironic. The first time I ever took care of him,” John answered, “he came into my office wearing a strange hat, very full at the top. The hat hid several tumors the size of golf balls on his head.”
John started chuckling and seemed to be waiting for my amused response.
“John,” I parried back, “this one’s much larger than a golf ball.”
“My God,” John responded, after a pause. “I always assumed she had a strange hairdo. Every time she’d come into the office with her husband we all thought she looked as if she’d been in a wind tunnel and was covering her hair with a scarf.”
Now it was my turn to pause. I felt like I could hear the requisite bdrum bum bum of the drumbeat after a vaudeville punch line.
“There was no wind tunnel, John. I can assure you of that,” I answered.
“She said she wants you to recommend the best surgeon in the hospital for her.”
Three days later I walked upstairs from the ER and went to visit Mrs. Y., who was now recovering from the surgery she’d had not long after I’d last seen her.
In the Operating Room that day they’d successfully removed a benign, 20-pound tumor from her scalp. She was making an excellent recovery.
As I peered into the room I found her sitting in bed, watching TV. Bandages covered all of her head except the face.
“Dr. W.,” she said smiling, as she noticed me in the doorway. “Please come in.”
She extended her hand and brought me next to her.
“I have to thank you for your firmness and the way you spoke to me the other day. I don’t think I would have gone ahead with this if not for you.”
“I’m happy your husband was able to get you to come in. He deserves a lot of credit as well,” I told her.
“Oh, no. He actually wasn’t the one who convinced me.” She paused.
“You know, that day was our 50th anniversary. We were in a Hertz office, getting a car to drive Upstate to celebrate. The man behind the counter forced me to come in. Refused to rent us a car.”
She paused and laughed. “Can you believe that?
At that moment the image of her, scarf strategically placed, pus and stench exuding from her scalp, maneuvering her way into a rental car and heading off up The Taconic Parkway with her husband at the wheel, burst into my brain. I thought about the “wind tunnel”, the depth of her, and her doctor’s denial, her husband’s own tumors and realized what a debt of gratitude we all owed to the agent at Hertz Rent-a-Car.
Kenneth Weinberg has worked as an ER MD for some 30 years and now works in Urgent Care; he is registered in NY State to certify qualified patients to receive medical cannabis. Weinberg, who is active in the Program in Narrative Medicine, is also a photographer, published author and social activist. He is involved in attempting to get Single Payer Universal Health Care as well as educate physicians and the general public about the many benefits of medical marijuana.