July 25, 2018
Get to know me: I die for books but I live for television. The former is my bff, the latter is my one true love. Give me a meaty, well-written drama with an ensemble cast of Emmy nominees who can transport me to another time, place, or life experience, and I’ll binge it on a loop until it becomes embedded in my emotional memory like a song. Earlier this year, ER, the 15-seasons-long saga of daily life at County General in Chicago from the perspective of its emergency department, finally became available to stream (on Hulu). Created by novelist Michael Crichton, the show debuted in 1994 and holds up like a motherfucker; even its so-called bad seasons toward the end that no longer included anyone from the original cast make Grey’s Anatomy look like General Hospital when it comes to its medicine. Never pandering to its audience, ER calls procedures by their proper names and manages to educate, even as it works to destroy you emotionally with its too-often relatable human dramas. So, for months I’ve been watching all 335 hours of the show at home. Since episodes are often on as background noise the way some people do with NPR, I figured I’ve absorbed at least 1,000 hours of medical school by now, practically a junior resident. Right when I was missing the high of seeing an undiscovered episode ever again, I had the pleasure of meeting editor Megha Majumdar at Catapult, who told me about Paul Seward, MD, a now-retired pediatrician turned emergency department specialist, whose first book Patient Care is just as mesmerizing a read as seasons 1 – 4 are to watch. I couldn’t put it down.
What’s more difficult, getting a medical license or a book deal? Both involve saving lives, obviously.
To get a medical license you must spend years learning how to be a doctor. It’s hard. But if you have some aptitude, and keep putting one foot ahead of the other, you will probably succeed. To get a book deal, you must spend years learning how to write. But if you have some aptitude, and keep putting one foot ahead of the other, you will still probably not succeed. My current agent, Wendy Levinson, was the twenty-sixth to whom I submitted a query. You must have written something that is at least “good,” but it also helps to have the luck to find the rare person who likes it enough to risk their own professional reputation on you. For that, “luck” is not a good enough word; it does not express the gratitude I feel.
Have you always been a writer?
I have been writing all my life, but not for publication. I did it for fun, for relaxation, for comfort. (I have lots of bad poetry in my bottom drawer.) And I have published a few professional publications, and two philosophy papers. Back in the early nineties I wrote a novel. It went nowhere. I rewrote it about five years ago. Once again, nowhere. So, I took a course in writing nonfiction and wrote the first two stories in the book. My wife liked them – much better than the novel, so I wrote more. And here we are.
What’s your process?
I try to write at least five hundred words a day – or rewrite about a thousand. I succeed anywhere from zero times a week, up to six or seven. I write in two stages. The first is to have a general idea in my head and then try to put it on paper as fast as I can, editing nothing, correcting nothing, not trying to make any organized sense, but just letting the story come out randomly on the page. Those sessions usually last about an hour. Then I sit down with that pile of garbage and – word by word, line by line, shoving words around, cutting slashing, changing – I rewrite. That process ends when either I have something I can show to someone else, or it clearly needs to be tossed. That second phase is easily ninety percent of my writing time.
Who are the writers that inspire you? Did you read other books to prepare for the writing of your own?
I am a random and sporadic reader. I can go a few months without reading a book; then I will read four or five. I recently read When Breath Becomes Air and was struck by the line, “When there is no place for the scalpel, words are the surgeon’s only tool.” Humbling. Then there are books I love. These include every science fiction book written in the fifties and sixties. I grew up on Heinlein, Asimov, Pohl, Niven, Leinster etc. The Lord of the Rings trilogy came out during my first year of medical school. I think that cost me one grade point, but it was worth it. Books that I reread include Shogun, and all of Conan Doyle’s Sherlock Holmes stories. After seeing Les Miserables for the first time, I read the unabridged novel aloud to my wife. She slept through the entire battle of Waterloo but otherwise was kind. I have a taste for children’s books that really aren’t. The Hobbit; The Narnia series; all of Lewis Carroll; pretty much anything by Neil Gaiman, particularly The Ocean at the End of the Lane, The Anansi Brothers, and Neverwhere; the His Dark Materials trilogy by Phillip Pullman.
Let’s talk medicine. What is the most common reason people come to the ER?
There are only three reasons why people come to an ER: Medical emergencies; informational emergencies; and social emergencies. The first is when they are obviously sick or injured and correctly feel that they need care. The second one sounds similar but is different. They are sick or injured in some way, but don’t know if they need care and come to find out, and if necessary receive it. And the third is maybe the subtlest: they have an illness or an injury and whether or not they think it is dangerous or urgent, they have nowhere else to go. Those are all good reasons for patients to seek health care. The problem is that, too often, the ER is the only place they can find it.
I learned in the book that a sudden onset of sweat can be cause for alarm – that’s a good tip. What is happening in the body when that happens?
Your body has decided that something bad is happening. So you release a hormone called Adrenalin. This causes what is called the “fight or flight” reflex. Your heart rate goes up (that feeds more blood and thus energy to the muscles); Your eyes dilate (you can see better); You breathe faster, (more oxygen to the tissues); The blood vessels in your skin constrict so you get pale (You don’t need blood in the skin, you need it in the muscle); And you sweat – (your body is about to be active, better start dumping excess body heat). You might be sweating for any number of reasons: pain in your belly; low blood sugar; a monster in the living room. But when you are starting to have a big flight or fight reflex while you are lying in bed, at rest and in no obvious danger – then I worry what it is your body knows that I don’t.
You practiced medicine for a few decades. You saw viruses being all but eradicated, and the transformation of the treatment of HIV. What do you think are the biggest threats to public health today?
The biggest public health threats in the world today have nothing to do with medicine. Number one is the potential for nuclear catastrophe. The trajectory of history since Hiroshima has been one of nuclear proliferation in the hands of people who are unqualified to make careful decisions regarding its use. Number two is climate change. It has already produced major disasters in the form of “Hurricane Seasons.” The weather will only get worse.
You’re now retired, but do you find that patients are more informed coming into the ER these days? The internet will make a medical sleuth out of anyone, but even if you just watched tv on the regular, you’d be able to pick up on the basic lingo and procedures. Good thing?
Perhaps, but they may have had access to all sorts of bad information that “must be true, I saw it on the internet.” For example, if people don’t understand drug side effects or interactions, I have to teach them, and if they do know about them I have to be sure that what they “know” is true. There can be lots of surprises. Vaccination phobia is one example. I don’t know what causes autism, but there is no association with vaccination. On the other hand, there is an association with a lack of immunization and present-day damage or death from diseases that used to be as common as colds and now no one remembers.
What recent medical advances most excite you?
The revolution in imaging. MRIs, Pet Scans, MRAs, fiberoptics in the small vessels etc. and the therapies that go along with it – laparoscopic surgery, fiberoptic intubation, ultrasound guided catheterization. From a therapeutic standpoint, it is the increasing use of antigen antibody preparations to target specific tissues. That has already changed the treatment of cancer immensely and will continue to do so. Also I see a growing realization that approaching the body as a bunch of unrelated systems – Cardiovascular, pulmonary, endocrine, etc. is ultimately untrue. All the “systems” relate to one another, and those relationships are both the focus of the illnesses and will increasingly be the focus of the cures.
In one chapter you take the reader through – step by step – the intubation process from the doctor’s perspective. It sounds so tricky, to say the least. Do you remember the first time you intubated a patient, and is that the most pressurized procedure?
The first patients I intubated were premature babies in the Intensive care Nursery at UCSF Medical center in the late sixties. They were a challenge. It’s always a stressful procedure because, while there are lots of physical findings that hint at whether the intubation will be difficult, life is full of surprises. The reason it is so stressful is that, in the ER you will only be doing the procedure on someone who looks like they might die without it. But while it is often a lifesaving procedure, making a mistake and not catching it immediately can kill someone in minutes.
It’s hard to imagine my psychiatrist ever did a surgical rotation. Do all doctors hit all the departments in their training or do you get to skip dermatology? What was your least favorite?
Your psychiatrist not only did a surgical rotation, they did all the others as well. For me, all of them were fascinating. Medical school, while it was one of the most difficult times of my life, was one of the best. It was like climbing a mountain: exhausting, frightening, humbling. It challenged my sense of who I was and what I could do.
There’s a specific energy in the ER and it takes a village to maintain the flow. You touch on some of the roles that make up the team – the paramedic, the clerk, nurses, residents and interns, the attending, patient advocates. Your son is a physician’s assistant, another important part of the ER team…
The correct term is not “Physician’s Assistant”; it is Physician Assistant. There is no possessive relationship. (I must quickly add that my son let me know of my error only a couple of weeks ago, so my book is filled with that mistake.) It is functionally a very similar role to a nurse practitioner. They both require a supervising physician to be able to practice, but otherwise they have considerable leeway in what they can do – as long as their supervisor accepts that responsibility. In many rural ERs, the health care provider on duty is a PA, not an MD. This is not a bad thing.
It always seems like there aren’t enough doctors at a hospital and that they all have too many patients. There are some communities in America that are seriously underserved. What needs to happen to fix this?
My own feeling is that we need to change our categories. The role of “Physician” arose in a time in history in which it was possible for a single person to know everything about the practice of medicine. And that was true pretty much until the early part of the twentieth century. Then such knowledge has been impossible. Additionally, the things physicians do have changed. Some physicians are essentially scientists, some completely devoted to clinical medicine. Some are administrators, lawyers, politicians. At the same time the role of non-physicians in health care is exploding. I believe that we should accord the title Doctor to anyone who is trained and licensed to care for patients. Then we should invent some new terms for the people who supervise them. And we need to look at the amount of time and money that it takes to become a person who can take care of patients. That might solve a lot of supply problems.
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What’s involved in all that hospital paperwork?
The only way healthcare professionals can communicate with one another is via the medical record; that’s where the story is. Second, it is used for billing. And third it is a legal document that may be used in a malpractice suit to defend or criticize the care given. All of these are important. The problem is that even with all the technology in the world at our disposal, we have yet to develop the means to create a medical record quickly, accurately, and completely. I wish I could say I understood why that is.
That’s another book. Bagels & cream cheese is the cornerstone of any ER professional’s diet. True or false?
You’re forgetting the Lox. We do drink a lot of coffee – but that turns out to be good for you. Seriously though, I think most of us take care of our diet and exercise more than most. We see the consequences of failing to do so. Where we screw up is failing to adequately manage our need to work nights in a way that does not mess up our circadian rhythms. More and more it is clear that that kills you if you do not respect the need to sleep.
What did you do to blow off steam after a long shift? Do all doctors play golf?
Sleep. I would come home from day shifts, eat dinner, have a glass of wine, and spend some time with my wife talking about each other’s day. Then I would go to bed. If I was coming home in the morning from a night shift, I would eat some breakfast, spend time with my wife, then drink some milk and go to bed. Usually I would sleep till midafternoon and then start to be human. I didn’t usually have any steam left to blow off. When I was younger, my thing was running. I wasn’t training to run marathons; I was running marathons to make myself train. Now I walk, swim, and now and then do some running. But I don’t think there are any more marathons in my future. What is “Golf?”
A common trope of medical dramas is that eventually a character will find his or her loved one in their ER in need of heroic measures. The doctor always ends up being the one to shock the dying loved one with the paddles. Would this happen in real life, or is there a strict policy against treating family members?
The only rule that I know is that you can’t write prescriptions for controlled substances for family members. (Duh.) We try to be informed consultants to our family members when they are seeing their own doctors. That too is not without emotional risk, but it’s the sort of thing that anyone would do. Would I ever defibrillate my own wife? If I was in the room and there was the defibrillator and my wife was in cardiac arrest, hell yes. But so would anybody. As an aside, that’s a good reason to learn CPR and to have an inkling of how to run an AED. (It’s easy. Turn it on and listen to and follow the instructions. Then push the button if it tells you to.) It’s not that you will necessarily save them. But you won’t have to live with the thought that perhaps you could have. A major function of CPR is to reduce the guilt feelings in the participants. Also, sometimes it works.
Is the number one question you’ve been asked at a cocktail party about being a doctor, “Can you really use a pen or plastic straw to perform a tracheotomy?”
First of all a tracheostomy is not an emergency procedure. The emergency procedure is called a “Cricothyrotomy” and it is done higher up, just below the Adam’s apple. And yes, it could be done with a pocket knife. However, it is a dangerous procedure even when done by those who are trained in it. Its not hard to cut a hole in the cricothyroid membrane – but significant bleeding is frequent and unless you already have a good hold on the opening, it is very easy to lose it in the blood and fatty tissue that will fill the wound. Also, you need to have a tube to put in that hole that is big enough to breath through. A soda straw is too small, and it will collapse when you inhale. A pen is a little better but not much, and that’s if the patient is breathing normally. Try it. Take apart a ballpoint pen and try to breath through the hollow part. Do you think it would work for very long? Or that someone else could breathe into it to support you? If they are choking, try the Heimlich maneuver instead.
The number one question I actually get is: ‘You’re an emergency doctor? Man, I bet you’ve seen some crazy stuff, huh?” By that they usually mean objects that people put inside themselves and can’t get out. To me that’s just another variation on taking out a splinter.
People also ask about simultaneous patients, one who is a victim, the other a perpetrator of the same crime. (Pick what you want: auto accident; abuse; armed robbery.) The answer is that you take care of the person in front of you as best you can. You never know what really happened until much later, and it doesn’t matter. Those are questions for the police, for lawyers, for judges. Our job is to take care of the people who present to us to the best of our ability.
Have you ever been the doctor on the plane, the good Samaritan at the restaurant, or happened to come across the scene of an accident?
A few times by the roadside. Mostly in those cases I found that the most important thing I could do was do the ABCs and stabilize the neck, until the EMTs got there, and then get out of their way. The roadside is their venue and they manage it well. Once I was on an airplane when a passenger had a seizure. My treatment was mostly to put him on the floor and make sure he had a good airway and didn’t aspirate vomit. The seizure didn’t last long and, when he woke up, he seemed OK. However, he had never had a seizure before. Because I thought he needed further evaluation promptly, I asked to have an ambulance meet the plane when we landed and take him to the hospital. We were over Connecticut at the time, so the captain came back and asked if we could go on to Boston or did we need to land at a local airport. And now I have a small confession: When he asked me that question, a thought arose from that wonderful part of my brain that will forever be fourteen years old: You know, if you said he needed to turn this plane around and land at Hoboken, then he would turn this plane around and land at Hoboken. You are the MAN. I told the pilot that Boston would be fine.