Book Review

Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER

N Engl J Med 2001; 344:861March 15, 2001

Article

Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER
By Pamela Grim. 307 pp. New York, Warner Books, 2000. $23.95. ISBN: 0-446-52423-9

“I, Dr. Grim, will kill you if you touch this IV.” This is the sign taped by Dr. Pamela Grim above the sickest patients in her makeshift intensive care unit — a fly-ridden tent — during a meningitis epidemic in Nigeria, where she works as an emergency physician with Médecins sans Frontières. Here she relies on little more than chloramphenicol, fashions most of her own instruments, and steps over the bodies of patients she is unable to save. By contrast, in an American emergency room, she deploys a dazzling array of high-tech drugs and equipment to resuscitate her patients, many of whom are victims of violence and themselves combative. In Just Here Trying to Save a Few Lives, Grim tells the stories of patients in both these places, as well as in eastern Europe. Everywhere, her objective as a doctor remains the same: she must bring the wounded and the dying back from the brink of death, often with little more than instinct and sheer determination.

Grim describes the treatment of patients who enter the emergency room at her urban American hospital with caustic wit and fearless honesty. This is not the emergency room depicted on television and in romance novels, where every doctor is attractive and every aorta is easy to spot. In fact, Grim seems to take satisfaction in destroying these notions. This is the messy world of violent injuries and unexpected catastrophes, where a crowd of nurses and technicians frantically collect vital data from wrecks of human beings while she guesses at diagnoses, scours her memory for drug indications, and stares at the electrocardiogram, praying for a sign of life. Peering into a patient's open chest, she says simply, “The truth is, you can't see anything. Nothing is textbook.” In the emergency room, there is no time for theorizing or for judging or casting blame. Grim thus also deconstructs the myth of the physician as all-knowing. We come to see the good doctor as a human being who is able to manage an impossible crisis under extraordinary pressure, and we are grateful for it.

In fact, Grim makes it clear that she would accomplish nothing in the emergency room without the help of her colleagues and assistants, whom she portrays in detail and with humor and admiration. There is the ever-present cadre of nurses, whose no-nonsense attitude, quick wit, and even quicker hands provide the reality check much needed by both patients and physicians; the terrified obstetrics intern who struggles bravely to perform a cesarean section on a woman whose head is perforated with bullet wounds; and the police officer who calms an enraged cocaine addict by singing a Cole Porter tune. There is the fellow physician who, during an emergency thoracotomy in a gunned-down teenager, refuses to stop working despite a needle-stick injury. “`I let go,' he tells you, `then this kid dies. Now sew up the goddamn hole.'”

None of these accounts, however, would have the same impact without Grim's descriptive language and her vivid narrative style. Her first-person voice often shifts to the second person and the present tense, so that we as readers experience the crises exactly as she does: “You are up to your coat sleeves in the blood in this boy's chest. The blood has cascaded down onto the floor. There are two inches of blood where you are standing. Your shoes are soaked in it.” Seeing through her eyes, we also sense the intense turmoil in her mind. “Think, think,” she prods herself as she tries every conceivable way to restore a normal rhythm to a woman's fluttering, failing heart. Even as she outwardly assumes command of the resuscitation effort, Grim freely exposes the private pressures and uncertainties of each passing moment during the “golden hour” — the first, critical hour when a patient may either live or die. And although she may acknowledge the “glow” that comes from averting death, she gives credit to her coworkers, to chance, or to cosmic oversight. “I thanked God . . . for saving my sorry ass once again,” she says after one case, making it clear that the work she performs is much larger than herself.

In stark contrast to the pressures — and luxuries — of the urban American emergency room, Grim reports the mass illness and suffering she sees in Nigeria as well as in Bosnia, where she administers vaccines to hundreds of children, and in a no man's land between Kosovo and Macedonia, where she drifts in a sea of ghostlike refugees, looking for those who are ill and too weak to seek help. In Nigeria, she encounters a man who lies wracked with pain, his joints locked and his head cradled in the lap of his brother. Grim manages to diagnose tetanus, and after reviving him on her own — “Praise God but pass the penicillin” — she must argue with local medics in an unsuccessful attempt to save him, grieving over the lack of proper means to relieve his suffering. In the United States, people injure themselves and one another deliberately and are treated with the most advanced care; elsewhere, thousands suffer silently.

Grim's book will make fascinating reading for anyone with an interest in emergency medicine. Without breaking the flow of her narrative, Grim translates terms that may be unfamiliar to lay readers, such as “tension pneumothorax” and “Foley” catheter, into colloquial terms. Her colorful definitions are worthwhile reading for all: an agonal rhythm is “the heart's electronic death rattle,” and the rib-spreading tool named after Fienchetto is a “physician's ghost” in the thoracotomy tray. Only for “anencephalic” does she first resort to the dictionary to explain why the image of one infant she delivers lingers especially long in her mind. With humility and clarity, Grim manages to convey the unthinkable horrors, and the epiphanies, of walking the line between life and death. “Here it is, the naked heart,” she says. “And even though you've seen this before, even though you think it should be no big deal, it feels absolutely unearthly.” So it will to her readers as well.

Linda A. Khym, M.A.
Boston, MA 02115