Rachel H. Kowalsky M.D., M.P.H.
New York Presbyterian Hospital, New York, NY
This is how the phone call went: “I’ve got a kid here, run over by a lawnmower. He’s got some deep lacerations. I gotta send him over to Children’s.” The child’s vital signs were worrisome—a fast heart rate, a borderline blood pressure.
“OK,” I said, grabbing a pen. “How did it happen?”
“Yup. Ran him over. I’m sending him by air.”
I was speaking to a physician at a rural Missouri hospital. Our connection wasn’t good, but I could tell that he was tense, upset. The urgency in his voice bothered me. “Is there anything else?”
“The cuts are deep. I did the best I could with them. He needs a plastic surgeon.”
“OK,” I said, “Send him over.”
I’m a New Yorker. In the New York City emergency rooms where I trained, there were few lacerations that would merit an airlift. In New York, most children’s lacerations are caused by (in the language of the emergency room) child vs. furniture, skateboard vs. tree, or bike vs. pothole. But there was no use arguing with the referring doctor; the St. Louis hospital where I worked during that memorable year never refused transfers. We were one of the few children’s hospitals in the 500-mile stretch between Memphis and Chicago.
There I was in St Louis. Our family had relocated there for my husband’s fellowship in orthopedic surgery. It was my first year as a full-fledged emergency room doctor, and my challenges were twofold: to adjust to my new role as an attending physician, and to acculturate to the state of Missouri. If the charge nurse said, “The kid in room five fell out of a deer stand,” I had to google “deer stand” before I went in to see him. I needed to know, how high is a deer stand? (answer: it depends what type), and why do people fall out of them? (answer: alcohol or bad luck). If a patient said her child “always wakes up with the chickens,” I had to ask, “what time is that?” I had to learn what the playgrounds were like, and which were the dangerous intersections, so I could understand how accidents had happened. These details mattered for understanding the lives and injuries of my patients. They were just as important as heart and lung sounds, the morphology of a rash, or the shape of a laceration.
There was a hush, the sweep of the double doors. The boy with lacerations had arrived.
He was filleted cleanly down the middle. A deep line ran down the center of his face, his neck, his abdomen. When he breathed, blood bubbled up out of his face.
I smiled, which is a reflex for me when I need to gather my thoughts. What I felt was complex: surprise, anger; somehow I had missed the real story from the referring doctor.
I know lawnmowers. My dad left when I was 11, and it became my job to mow the lawn. My mom paid me twenty dollars, which was a windfall for me back in 1980’s Connecticut. We had a 22-inch rear bag push mower. I’d fill it up with gas, pull back on the starter rope to start the engine, and heave it back and forth across my yard. The whole yard, front and back, took me two hours, during which I listened to my Sony Walkman and obsessed over the straightness of the line between the tall and the freshly-mowed grass. Then I spent my twenty bucks, typically on Barbie doll horses. I was always very careful never to come in contact with the lawn mower’s blade, positioned out of the way beneath the deck.
Such a lawnmower cannot be pushed over a child without real intent, real effort. I told this to the charge nurse. “Uh uh sweetie,” she said, “This wasn’t a lawn mower that you push. It’s a lawn mower that you ride on.” She left to grab some supplies.
Nick, the trauma surgeon, arrived. “Lawnmower?” He looked unphased.
“Not just any (expletive) lawnmower,” I said. “It’s a lawnmower that you ride on.”
He glanced at me, not friendly or unfriendly, and he narrowed his eyes a bit. After that we worked in silence, inserting a central line, getting fluids and blood into the boy until the operating room was ready for him.
A few hours later, when the boy’s surgery was complete, Nick came back down to the ER. “A lawnmower that you ride on,” he said, “is called a tractor.”
“A tractor,” I echoed. The 22-inch lawnmower of my childhood appeared briefly in my mind, evaporated, and was replaced by a 1000-pound piece of farm equipment.
“I grew up on a farm,” he said. “Ever been to a farm?”
“For apple picking,” I said, understanding that this was ridiculous.
“She’s a Yankee,” offered the charge nurse. “Look at her glasses.” They were thick-framed Alain Mikli’s.
“Nice,” he said.
I had always been proud that I’d trained in New York City. I felt like I had seen it all. I had cared for the children of the homeless, of new immigrants, of famous actors and even foreign royalty. I had seen most infectious diseases, puzzled over the toxicological enigmas that derive from the city’s night club scene, and cared for children with transplants of every possible organ. The city’s many parades, approximately 70 per year, provided ample opportunity to evaluate heat stroke, panic attacks, and violent injury. But I was unprepared for that day. Within the borders of my own country, I had been speaking a different language from everybody else. It was based on my own set of experiences, my frame of reference, my very identity.
To work in a busy ER, you must be able to decode all the signals around you, from the numbers on the monitor, to lab values, hospital slang, and the stories of your patients. I had missed a critical part of the code, and it shook me.
But it also taught me to leave my life story at the door. Because the story that’s told and the story I hear may not be one and the same. It was the year I learned to listen.
A few weeks later, a physician called me about another laceration. “I got a lac,” he said. “My office is closed, they’re coming to you.”
“How did it happen?”
“Fell against a chair.”
“Is it deep?”
“Naw. I’d sew it up myself if I were in the office.”
“Anything else I need to know?”
“Like what?” The silence opened up between us.
Is he filleted down the middle? Can he move and breathe?
“Is he sick?” I finally asked
“Heck no. He fell against a chair!”
The boy was dressed in tiger pajamas, and his face was painted orange and black with a resplendent set of whiskers. I smiled to myself, a genuine smile; he had a clean, simple laceration on his forehead. Nothing else. As I sewed up his wound, I made conversation. “I like your costume,” I said.
“Roar!” said the boy.
“Did you have a parade today?” It was Purim; I was taking my daughter to a Purim carnival after my shift, and costume parades are a big part of the holiday.
“Nope,” he said. “I had a baseball game.”
“First game of the season,” said his mom. “They dress up.”
“Oh right,” I said, putting in his last stitch, knotting it, snipping off the ends. The image was easy to conjure up: a pep rally with cheerleaders, probably a band, and a bonfire. Well, maybe not a bonfire; that was from a movie I saw when I was a kid, with a pep rally and a bonfire.
Maybe not a pep rally, either. Did they have those for baseball? For 7-year-olds? “Tell me all about it,” I said. “Tell me just exactly what you mean.”
Rachel Kowalsky is a pediatric emergency medicine physician practicing in New York City. She studied comparative literature as an undergraduate at Brown University, and has always been interested in the intersection of medicine and the humanities. She has published her short stories and reflective essays in diverse venues, from the book Real Life of a Pediatrician, to the medical journal Pediatrics. She has been an invited reader at the 92nd St Y, and guest artist at New York Mills Cultural Center. She teaches in Cornell Medical School’s LEAP course, and designed a narrative medicine curriculum for pediatric residents.