The WaWa of Medicine

The Crazy, High-Pressure, Rewarding, and Sometimes Soul-Wrenching Life of an Emergency Room Doctor

“WE ARE THE WAWA OF MEDICINE. It’s shift work. We’re necessary, we’re efficient. We can do—and have—everything you need.”

Likening an emergency room doctor to the beloved catch-all convenience store of the East Coast may seem like an odd characterization, but David Patchefsky speaks from some experience. For the past 22 years, he has served as an ER doc at Lankenau Medical Center, a hospital just outside the city limits of Philadelphia. Their patients are almost an equal mix of the suburban middle class and urban poor. Like shift work, David’s story lacks a grand sweeping narrative. Instead, it is episodic, told in daily anecdotes. Assembled together, they reveal the nature of his work/craft.

“The other week, an older woman who had some heart history comes in. She’s dizzy. It is a common complaint, but dizziness can mean anything from vertigo to room spinning, to just ‘I don’t feel right.’ The cause could be dehydration or a slow or fast heartbeat. They can be anemic or be on medications that make their blood pressure drop when they stand. It could be many things. This one was easy. Her heartbeat was in the 30s, which is low. Normal is 60-100. We ran a cardiogram, and she was in heart block. Her electrical conduction system was on the fritz.

This was during the day. Bankers’ hours. The whole staff is in the hospital. I call the cardiologist. They will probably take her upstairs and put in a pacemaker. That’s a lot of what we do. Triage. The cardiologist comes down. He says her blood pressure is fine, and as it’s three or four in the afternoon, the pacemaker can wait until tomorrow. Before she is admitted into the hospital for the night, things went bad.

She goes into cardiac arrest. She stopped breathing. She started turning blue, and she has all kinds of different arrhythmias from no heart rate to ventricular fibrillation. There were a bunch of young doctors in there, part of the admitting team, but she was still in the ER, and she was still my responsibility. ‘I’ll deal with it,” I said. ‘Get out of the room!’ We didn’t need thirty people there. I shocked her and got her back. With her instability, I had to put in a temporary pacemaker. With a permanent one, it’s an incision under the skin in the chest. There’s a lot of staff and an x-ray machine called a fluoroscopy. They put wires in, it’s done very sterilely. When I’m doing a temporary, that means the shit has hit the fan. It’s essentially placing a big IV line and then floating a wire through the big IV I just placed in the neck. I do maybe one a year.”

The cardiologist arrived when David was finished. Once stabilized, she was brought upstairs for her permanent pacemaker. The patient survived.

“Managed panic, that’s what’s happening for me when she goes into cardiac arrest. My own heart is racing in these situations. There’s a lot of cursing, a lot of fuck, fuck, fuck, fuck. But it’s managed panic.  It’s what I do.”

Some kids know they want to become a doctor before they understand exactly what that means. David was the reverse. His own father was a doctor, but David did not have an early ambition to be the same. In his undergraduate days at Columbia, he was unsure what his path would be. He took some basic science courses—physics, biology, and the like—and found they came easily to him. “I had an aptitude for science, and I was always exposed to medicine through my family. A combination of being open-minded and directionless in college led me to medical school.” 

Upon graduating from Thomas Jefferson University’s medical school program, he chose to specialize in emergency medicine. “I considered surgery. I liked it. It’s a very controlled environment. You’re the captain of the ship. But the lifestyle, always being on call, was unappealing. With emergency medicine, you get to do a little bit of everything, it’s immediate, and once you’re not at work, the time is yours.”

After twelve years in typical schooling, four in university, four more in medical school, and three in residency, David was a practicing ER doctor. Still, he was green. “Besides treating, diagnosing, or even triaging, one of the big things in emergency medicine that we do is trying to figure out who’s sick enough to stay in the hospital versus who can be managed by their doctors as an outpatient. When I initially became an attending, I was very cautious. I was afraid to send people home. I’d order every test and I tried to admit everybody.”

He also learned early of the heart-breaking moments he would have to manage. “There was a teenager in the suburbs. He was riding an ATV on some trail and got clipped at the neck by a rope. He was brought into the ER. In these cases, patients don’t look like they’re in distress. They’re lying on a board. They have a hard collar around their neck, and they can’t move. But I remember looking at the x-ray of his spine. Typically, the vertebrae, the bones in your neck, are pretty much one on top of the other. Like a stack of coins. His stack was severely misaligned. It was jaw-dropping, and his parents were there, crying. I had to talk to them in a private room, tell them, ‘We’ll do what we can, but it doesn’t look like he’ll ever walk again.’”

Two decades later, David says, “It's one of the things that just stays with you.”