Tiny Cities Made of Ashes

In the pilot episode of ER, a popular television show in the early nineties, there were a lot of statistics about ER’s. Characters would mention that ‘80% of emergency departments were…’ or ‘over half of all emergency physicians report that…’ It’s odd that the story got off to such a clumsy start, because the ED is, for me, where stories begin.

What they did well, at the beginning, was their portrayal of an urban ED’s griminess and denizens. Unfortunately, as ER cleaned up its exposition style, it also cleaned up its furnishings and structure as well as its patient population. Urban ED’s are, uniformly, grimy and smelly. Because of my time there I’m on a first name basis with more crack whores than school teachers, although to them my first name is simply ‘boo.’

There, amid the homeless having chest pain and teenage girls with babies and purulent discharge, laying in the gurneys between the splashes of vomit and blood, absorbing the stench of the senile men who have feces—both dried and fresh—being slowly and carefully removed—attempting to leave the friable skin intact, listening to the angry—sometimes cogent, sometimes profanely random—tirades, are the people who are going to come into my care, who will become my patients.

I suppose what strikes a newcomer when they look across the ED is the shabbiness of the curtains. They are the only thing that separates the patients, and they are usually left half open so we can see if they are pulling out their IV or Foley catheter, eating their diaper, having a seizure, falling out of their bed, or having anything else befall them.

The plaster on the walls is peeling and cracked. Every wall, door frame and counter has a dent about three feet off the ground from where the gurneys hit as the patients are brought to CAT scan or Ultrasound, up to their room or down to the morgue. Despite the appearance of the plaster, the structure is solid. Many ED’s are in old radiology suites and the walls are lined with lead.

Because of the lead walls, cell phones do not work in here. Despite the signs, people new to the ED are surprised at this. Their faces betray a fear of its larger significance. They are cut off from the world they knew when they arrive in here.

They are in the shadowlands.


I had already noticed the man who would become my next patient, laying thin and gaunt, struggling a bit for his breath as a small group of plump women stood around his gurney. They were not un-goose-like, these women. Their necks outstretched and on the lookout, turning from him to the desk, from him to anyone who might help their fallen gosling. I—as always—avoided making eye contact with random ED patients or their families.

I would become involved in his care in a few hours, after lunch, after the ED had done the work that they do. I mention him now, because he and his gaggle of women are going to factor fairly large into the story, and this was the first time I saw them—refugees from the land of the healthy, taking their first step into the new country: The Land of 10,000 Diseases.

They would come to hate me. All of them would. This man’s last act—for he won’t have air in his lungs for words—will be one of contempt for me, a last ditch effort of defiance before his breath stops and he dies.

But at this moment, I did not know them and they did not know me.

It was simply time for lunch and I was finishing my admission of our drunken friend. I grabbed my lab coat and flung it on. The weight of the pocket-guides and pens and penlights in its lower pockets gave it the weight needed to arc up and fall against me in an—admittedly ridiculous—flourish. I dropped drunky’s completed orders and chart into the clerk’s rack and headed out of the ED, leaving the blood and vomit, the odors of shit and piss, the echoing tirades, the dingy curtains, the falling plaster, the regulars—whom I count as my friends, the crack whores and homeless, the senile, invalids and infirm—as well as its newest gaggle of citizens, whom I would be shortly meeting.

I was heading into the sanctum of the doctors’ lounge. Barbeque pork and banana pudding, served on Mondays, with coca-cola in glass bottles.