Jay Baruch - Tornado of Life: A Doctors Journey Through Constraints and Creativity in the ER

Jay Baruch

The MIT Press

Cambridge, Massachusetts | London, England

2022 Jay Baruch

All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means (including photocopying, recording, or information storage and retrieval) without permission in writing from the publisher.

The MIT Press would like to thank the anonymous peer reviewers who provided comments on drafts of this book. The generous work of academic experts is essential for establishing the authority and quality of our publications. We acknowledge with gratitude the contributions of these otherwise uncredited readers.

The essays in this book are based in real events but changes have been made to protect patient privacy and confidentiality. These essays should not be taken as giving medical advice.

This book was set in ITC Stone Serif Std and ITC Stone Sans Std by New Best-set Typesetters Ltd.

Library of Congress Cataloging-in-Publication Data

Names: Baruch, Jay, author.

Title: Tornado of life : a doctors journey through constraints and creativity in the ER / Jay Baruch.

Description: Cambridge, Massachusetts : The MIT Press, 2022. | Includes bibliographical references and index.

Identifiers: LCCN 2021038778 | ISBN 9780262046978 (hardcover)

Subjects: MESH: Emergenciespsychology | PhysicianPatient Relations | Emergency Treatment | Emergency Service, Hospital

Classification: LCC RA975.5.E5 | NLM WB 105 | DDC 362.18dc23

LC record available at https://lccn.loc.gov/2021038778

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For Jen and Daniel

We can learn a lot about a person in the very moment that language fails them.

Anna Deavere Smith, Talk to Me

Whats bothering you, sir? I ask Mr. A again. Hes like a gentle child, sitting there on the stretcher wearing PJs of Christmas colors. Only he also has a shock of white hair and advanced dementia. Im unable to find the paperwork from the nursing home that sent him to the ER in the middle of the night. He looks as mystified as I feel.

Do you know why the nursing home sent you in, sir?

He answers with bemused eyes and a mischievous smile. I read his chief complaint the triage nurse recorded in his chart one more timeI feel great.

My original plan was for you to step into this book without my forecasting whats to come. The ER invites unpredictability. The practice of emergency medicine is a dance with the unexpected. I wanted to simulate that instability, the shaky ground on which we care for patient after patient, broken bodies and broken stories. Defibrillating a lifeless heart is a gripping moment familiar to most television viewers, but its arguably an easier task than what I believe is a more critical activity, one charged with more dramatic energy: finding the heart of a patients story and responding to it.

Thinking with stories uses different muscles than thinking about stories. When COVID-19 became the story of medicine and our communities, the unexpected swept into all our lives. For too many, the disruption was overwhelming and irreparable. As a result, we became untethered from the stories that once grounded our lives. In her book A Paradise Built in Hell, Rebecca Solnit writes, The word emergency comes from emerge, to rise out of.... An emergency is a separation from the familiar, a sudden emergence into a new atmosphere, one that often demands we ourselves rise to the occasion.

In the ER, where the sliding doors open to innumerable problems, Ive lost count of how often Ive craved to rise to the occasion only to discover Im at a loss as to what that means and entails. Finding clarity in those moments resembles the disorientation one feels staring out an airplane window above a bank of clouds and trying to determine the location of the land below. Even though the landscape is inaccessible to the eyes, youre reassured the outlines will come into focus once you dip lower in the sky. Likewise, in my work in the ER, discovering how to rise to the occasion often requires a paradoxical movement of descent.

I was well trained to recognize and treat acutely ill and injured patients. Unfortunately, my patients bodies didnt always read the same textbooks and journal articles that I did. Their symptoms didnt necessarily point to a disease. Sometimes, patients emptied a trunkload of problems at my feet. Or they were close-lipped and withholding. My training didnt address what turned out to be the most frustrating parts of my emergency medicine practiceworking with uncertainty and stories that felt less like nuts to be cracked and more like messy first drafts.

At times, emergency medicine seems like an emotional and moral contact sport. This book represents my efforts to dig into experiences that left me feeling lost or inadequate, confused or ashamed, unsettled or just plain silly. Often, these dilemmas couldnt be resolved without creating another problem. When faced with uncertainty and ambiguity, physicians are inclined to reach for abstract ideas or point to reams of evidence in the medical literature in search of an answer. What a strange instinct, Ive always thought: to look for solutions to confusing situations by flying higher and farther away instead of making the necessary movement of descent, asking better questions, and thinking more like a writer.

My work as an emergency physician has always struck me as a fundamentally creative act. Caring for patients demands creativity as a clinical skill. This insight is neither groundbreaking nor original. The medical encounter has been compared to improvisation: its unscripted and unpredictable, and requires thinking on our feet, curiosity, and following possible threads rather than closing them off.

An ER visit is a significant narrative event in any patients life, and patients need clinicians who are at least willing and able to engage in that type of recognition. But the ER can be a narrative disaster zone. Communication is hard in crowded spaces, where patients share sensitive information in hallways or within earshot of other patients to physicians and nurses theyre meeting for the first time. Moreover, these strangers might be called away unexpectedly by other urgent matters.

Years ago, after I gave a talk at another medical school, an esteemed professor of medicine said, Youre an ER doc. You dont have time for story. He was right. The ER encounter is one where a pressured listener tries to understand a pressured storyteller while under ever-shifting conditions and constraints. But that doesnt stop people from coming to the ER. And these problems are no longer particular to the ER. Providers in other medical fields and across healthcare wrestle with less time with more patients while staring glassy eyed at computer screens. These obstacles serve as arguments, I explained to the professor, for why creative skills are necessary now more than ever.

Our brains are hardwired for story, and if were not careful, the story we create may be very different from the one a patient is telling. To be an emergency physicianany clinician, reallyis to be a professional listener of stories, which is difficult without insight into how stories work. Medical students spend a semester dissecting the human body, yet theyre unaware of the anatomy of stories. And there are only three principal elements to memorize: character, desire, and conflict. Patients are characters in their own stories, motivated by desires and needs, but obstacles get in the way. In the ER, the burdens of the body are amplified and complicated by social, economic, and mental health troubles that are often the source of a persons distress, only theyre hidden or buried. These external obstacles are often linked with internal hurdles such as fear, insecurity, even love. The patient in the ugly, uncomfortable gown is a person who, like all of us, is scuffling through inner and outer journeys. When tasked with a cloud of problems, clinicians need creative imagination. We must pivot from Whats wrong with the body or Whats the answer to this problem to different questions, namely: What are the obstacles and the stakes in this persons story and why? How does what happened square with what they expected to happen? One cant care for patients without working the fields of their expectation gaps.