Only moments before the crisis, the little boy in the emergency room looked perfectly fine. Then Dr. Patrick J. Crocker noticed that the boy's condition had changed drastically.
”The child now appears flushed,” he remembers. “I touch him to awaken him, and he is hot as hell. His fever has climbed to 105.8, and he is not actually sleeping. He is virtually unresponsive. What the hell happened?”
How many times had Crocker, former director of the Emergency Department at Brackenridge Hospital, Children’s Hospital of Austin and Dell Children’s Medical Center, faced this sort of situation?
The story started with a benign report to Crocker by ER personnel: “Some mom is here saying her doctor sent them over because they think this 3-year-old has meningitis. The kid looks happy to me. What do you want to do?”
At first, he had a patient without critical symptoms. A parent in a tizzy, perhaps fueled by the age of the internet, with its Pandora’s box of terrifying digital advice.
The 3-year-old was playing with toys. The boy did have a slight fever. What was he doing in the emergency room?
His family doctor, too busy to deal that day with a panicked parent, sent the boy over, which infuriated Dr. Crocker at first. He presumed this was a case of “patient dumping.”
The mom was convinced of the worst.
“Her child has a fever, and, therefore, he has meningitis,” Crocker thought. “I can tell this one is going to take some time. When faced with this situation, I always remember I am a parent, too, and she is simply frightened and concerned for her child.”
Even after years in the ER, Crocker found it difficult in certain circumstances just to listen, especially after making a quick diagnosis.
Nevertheless, despite the chaos around him, Crocker took down a lengthy medical history. And despite the mother’s apparently overblown response, he ordered blood and urine tests.
Thirty minutes later, when the blood test results came back, Crocker went to deliver the good news that the boy probably just had a virus. Meanwhile, the kid appeared to be napping, and his mother was now calm, since a doctor had paid attention to her concerns.
The urine test, however, contained traces of blood. And the boy, apparently napping, was almost unresponsive.
A nightmare scenario: He told the mom that her child was in critical condition. He performed a quick lumbar puncture and then treated the boy for possible septic shock with antibiotics.
“The little boy has no simple virus,” Crocker realized. “He has life-threatening sepsis brought on by meningitis.”
The antibiotics did the trick. Two days later, the boy was watching cartoons in the intensive care unit.
“I say hi to him, and, of course, he doesn’t remember me,” Crocker recalled. “His one question: ‘Why am I wearing a diaper? I don’t wear diapers anymore.’ I am so relieved and happy for him I could cry but don’t. Instead, I share a laugh with the staff."
The blood, urine and spinal fluid all grew the meningococcal bacteria. Simple lab work, even when it seems unneeded, can save a life.
“Always listen to Mom,” Crocker concluded. “She just might be right.”
This is but one of 40 compelling ER anecdotes from Crocker’s still-new book, “Letters From the Pit: Stories of a Physician’s Odyssey in Emergency Medicine,” a memoir that, according to Amazon, is already selling well. Each chapter comes with a crisply told tale graced with a humane conclusion.
Originally from northern California, the tall, trim and silver-bearded Crocker, 65, spent his first years as an Army resident at Fort Hood. After a spell at Seton Medical Center, he moved over to Brack, the city’s main trauma center until Dell Seton Medical Center at the University of Texas took its place in 2017.
After more than 30 years in emergency rooms — including a children’s ER that he co-founded with ER nurse manager Travis Pipkin — Crocker has retired with his wife to a ranch near Bandera.
“Letters from the Pit” takes the form of unsent notes to Jack, his best friend from his youth. Some are reports that he wrote early in his medical career, including a knotty explanation of the ER hierarchy. Other chapters more closely resemble real letters, beginning and ending with personal thoughts. But almost all rise and fall while recounting a riveting ER story.
“That was my dream, to be the director of busy, big-city, trauma-center ER,” Crocker says at a coffee shop after a visit to the fenced-off remains of Brackenridge, set to be demolished. “During my first few weeks at Brack, I was shocked by the combination of a true emergency case sitting there side by side with a kid with an earache. So I first set aside four beds just for kids. That grew into the children's ER, and I did that, too, for 20 years, overlapping with my Brack time. I spent my last eight years at Dell Children’s for several reasons, not the least of which was seeing my baby grow up.”
It should be noted that Crocker does not tell especially gory or grotesque tales. Some of the storytelling turns on his own mistakes, such as when, on his first day of ICU service, he treated a respected fellow doctor who was in great medical crisis and whose wife insisted that Crocker do everything possible to save him. Only to find out — after Crocker had, for the first time, finessed some extremely tricky procedures — that the patient had been ready to die. What the patient whispered to Crocker after his revival was an unforgettable invective.
The case of the boy with invisible meningitis brings to Crocker’s mind the medical practice of “anchoring” a diagnosis on a quick analysis of the symptoms and a reluctance to abandon that initial call.
“We often make judgments about serious disease — or just a virus — by looks, not a lot of tests,” Crocker says. “In his case, I was just this close to sending him home to get rest, when I thought, ‘It won't hurt to do a blood test and urine test.’ When I came back, the kid is virtually comatose! It makes you question everything you think you know, and your judgment. How did this happen? Luckily, he came through virtually unscathed.”
Medical personnel also do what almost everyone does: unconsciously blame the patient.
“The most common example now is ‘unnecessary trauma,’” Crocker says. “I mean, you were too freaking drunk to walk, so you fell in the road and were hit by a car. You want to be pissed about it. This didn't have to happen.
“If you can't let those feelings go, you miss the humanity of taking care of somebody who is sick, regardless of how they got sick. Most people go into emergency medicine as an adrenaline junkie, but that's not going to sustain you in a happy career. You have to learn to appreciate the pleasure and joy of just helping a sick human being. “
First, do no harm
Crocker admits that he did watch some medical dramas on TV while growing up, but not always the ones that everyone else found appealing. Early on, he was attracted to “Rescue 8,” a low-budget drama about a rescue squad from the Los Angeles County Fire Department that premiered in 1958 and survived for years in syndication.
“So I wanted to be a fire paramedic,” he says. “As I got older, I realized that there's a whole lot that happens after that.”
He did watch the hit “Trapper John, M.D.,” which ran from 1979 to 1986 with Pernell Roberts in the lead role.
“That’s what I wanted to do,” he realized. “But I wanted to be the guy who lived in a mobile home in the parking lot and came in for 12 hours at a time.”
After decades of grinding hours, Crocker is gratified that hospitals are moving away from those long shifts.
“I don't care if you are Mother Teresa,” he says. “At the end of a busy 12-hour shift, the milk of kindness is drained from your glass.”
Several of the stories in his book are downright funny. In one case, an emergency crew had rushed a man to the ER who was not breathing and looked close to death. What Crocker found in his throat was doubly surprising.
“I still remember pretty clearly looking down the scope at this massive advanced carcinoma,” Crocker recalls. “I didn’t know if I could get a tube down his airway, and if I did, would he bleed and drown in his own blood? So I thought, I’ve got to look again; I don't want to do the wrong thing. On the 'carcinoma,' I see something that looked like an anise seed, also a red pepper flake. It was an Italian sausage. It was so bizarre. I got the forceps, pulled it out, and dropped the sausage on his chest. Everyone was thinking, 'What the hell!' A minute and a half later, he opens his eyes and just goes, ‘Thank you, doctor.’”
One of the most revealing chapters deals with Crocker’s own medical emergency.
“I realized that something was wrong with me,” he says. “I had temperatures over 105 almost every day for 12 days before I got into the hospital. I tried to be the good patient and not meddle with the treatment. But it must have been bad, because my wife and a couple of my medical partners asked, ‘Are you dying?’
“That’s when I realized it was time to get out of the bleachers here. Turns out it was typhus, which is similar to Rocky Mountain fever. I had multiple liver abscesses, and my colon was breaking down. I had lost 28 pounds.”
Although it’s pretty clear that Crocker earned the respect of his colleagues, in at least one case, he felt the sting of disapproval from some in the ER.
“A patient came in with a pretty terminal condition,” Crocker says. “Her private doctor came down to say she wanted no ventilator, in other words, do not intubate her. ‘I don't want to live that way,’ she had told him. Everybody in ER was going to do everything possible, but she didn't want that. I said, ‘I’m going to give you breathing treatments and morphine to relax.’ In two hours, she passed. I was thankful it was not a super busy day, so I could be with her, totally alone. I couldn't bear the thought of this poor old lady dying alone behind the curtain. When she did die, I wasn't happy about it, but we made her comfortable. I could feel it all through ER: ‘He didn't do anything.’ I did do something. Not what you wanted, but what she wanted.”