Abstract
By Paul Austin. New York: W.W. Norton, 2008, 297 pp., $24.95.
An important element of palliative care practice is to highlight how a patient's narrative and life story is impacted by diagnosis and care choices. These stories are frequently presented in the palliative care literature and the mainstream media. In contrast to these patient-focused stories, Something for the Pain by Paul Austin focuses on the experience of the physician/healer. The stage for this work is an emergency room (ER) medicine practice. The central character is an ER physician who narrates accounts of his work and personal tribulations in a reflective and highly entertaining memoir.
There are many multidimensional plots and subplots a writer and storyteller with medical expertise can delve into and examine. The ER serves up dramatic and frenetic events that demand a unique professional skill set and character. Many successful television productions have utilized the ER and other hospital settings as the backdrop for dramatic case presentations and character development. Austin's work details with precision the subtle aspects of medical culture and practice, and offers an insightful dissection of the core human experience not possible in a 60-minute time slot programmed for ratings and mass appeal.
One theme explored through many vignettes is medical culture, which Austin portrays as having the dysfunction typical of any hierarchical human organization that prides itself on its members' ability to learn as if “drinking from a fire hydrant.” Such unrealistic expectations contribute to a feeling of alienation and dehumanization. Austin illustrates this with the startling response of a physician mentor who commented on Austin's own family challenge of raising a daughter with Down Syndrome amidst an evolving medical career. “Forgive my bluntness … Take her somewhere, leave her with competent people, and start over.” Such thoughtlessness highlights how uncaring the “caring professionals” can be to each other, as well as to patients, a theme that repeats in the undercurrents of other chapters.
All seasoned emergency physicians and ER personnel will recognize instantly the archetypal scenarios that speak to the collective ER experience: the great challenge of maintaining human compassion and professionalism in the midst of horrific trauma, abuse, and hostile patients and families. “Part of the deal about being an ER doctor is that you often have to care more about people than they do themselves … If I don't, I fake it until I find something that humanizes them.” For those inclined to learn the nuances of the role of emergency physician, Austin provides a clear window into acute care and its relationship to the rest of medicine. “The other specialists may know more about any given disease than we do, but most of them couldn't handle the chaos as well … most ER docs have sufficient ego to walk out into the ER and pick up a chart … no matter what the problem is.”
Caring for critically ill patients and playing a role in the traumatic events of others presents an ER physician with tragic and life-altering experiences. As Austin describes:
This small thing on my stretcher wasn't a child: he represented a series of decisions I had to make … On some level, it didn't matter whether the small wet thing would become a child again or would be taken to the morgue: our only hope for solace would hinge on working quickly and efficiently. I packed my emotions down into a place where they wouldn't interfere.
The burden of responsibility for unerring diagnostic acumen and medical care is at the heart of Austin's clinical stories. These stories reflect the life and death polarity of many ER encounters, especially when a case ends badly. As a colleague states, “Paul, I don't make life and death decisions … I make medical decisions. I work as carefully as I can, but it's not up to me who lives and who dies.”
In the end, the author strives to articulate not only his professional journey, but also his personal struggles, as he searches for meaning in the stories that unfold in the ER and his own life. As anyone who has had a career in emergency medicine can attest, the ER is a hard, raw environment that spans the ranges of misery to mystery. As the title suggests, it can be one of the most difficult and painful places to practice a healing art. But as Austin illustrates, it is also an inspired setting that helps reveal the wonderful complexities of life that at times make no sense at all. To that end, Austin is successful in the telling of his story, a story that speaks for all who care for patients in the ER.