A hospital staff member holds up a bullet removed from a patient in the ER at Henry Ford hospital. Photograph: Bryan Mitchell for the Guardian
On a Wednesday, Malhotra and Martin are deciding whether to remove the bullets from a man who has been shot multiple times. Contrary to televisual opinion, bullets are generally left inside the body unless they actively present a danger to the patient or interfere with future medical procedures.
They decide one bullet will need to be removed, so a screening can be performed, while the others will stay. All the residents are out taking tests this day, so Martin will perform the procedure himself.
Get the metal pan! Martin jokes, aping the Hollywood convention of a gruff doctor dropping each slug into a brass surgical tray with a solid plink.
Martin pantomimes the motion, holing up his fingers dramatically, and Malhotra chimes in with a ding! when the phantom bullet falls. Everyone laughs.
We have 50 of those pans in the back, he says to me, clearly kidding, but the joke belies the typical gallows humor used as a coping method of those cops, firefighters, soldiers who work with death daily.
The children are the most difficult, Martin tells me later, shaking his head. I like joking around, but when someones sick its no time for joking. You need to buckle down and know what to do and take care of the patient. Put the patient first.
A woman sits with her elderly mother, who wears a breathing mask. She has a degenerative nervous system disease and will one day stop breathing, her mind fully alert, because her brain can no longer tell her diaphragm to contract.
The same day, another family, in the corner and speaking a foreign language, huddles around a matriarch quite literally kept alive by machines. Although this person they love cannot communicate with them, they cannot in turn let her go.
A scared teenager has a dislocated shoulder. A hilarious elder gentleman tells anyone within earshot his historic life story as he lies in bed with chest pains. A professional woman is terrified by a mysterious rash. Martin inspects them all with the care of a good dad scrutinizing scrapes and bruises on a calming child.
The national healthcare battle seems to be waged largely with swords of political ideology and money rather than bodies and souls, and the man lying with bullets lodged inside his frame can seem an afterthought. They say a single death is a tragedy and a million is a statistic. Some of those statistics, the faces and the names and the bodies behind the giant numbers thrown around by politicians, are sitting in the ER today.
I can feel the bullet in the skin right here, Martin tells the gunshot victim. (As with every other patient in this story, US law protects the privacy of medical information and thus prohibits providing identifying details of patients or their situations.) Im going clean it off, numb it up and pull the bullet out.
As he cleans the wound on the mans forearm, a circular bruise about the size of a basketball with a small slit in the center, the aural landscape in the ER is lush. Beeps and blips and alarms and dozens of voices are overpowered only by the heart monitor tracking the mans pulse, a steady ding, ding, ding.
The procedure takes about two minutes. The blips from the heart monitor become faster as the doctor places a needle loaded with numbing drugs inside the mans forearm DING DING DING and faster still when the doctor expertly digs around in his body for the bullet DINGDINGDINGDINGDINGDING.
Is it out? the patient asks.
Martin drops the bullet in a plastic pan with a hollow thud. The bullet appears to be .45 caliber, with bits of flesh and blood attached, jagged and mushroomed from the impact. If not for the rifling inscribed on the body, it might look like a moon rock or a miniature bonsai tree. Almost all bullets, regardless of provenance, go to the police.
Can they reuse it? Martin jokes, as he whisks on to the next person.
The man in bed is apparently relieved the procedure is over, the hands of the doctor having preformed their work perfectly. His heart rate has slowed back to a steady, plodding rhythm.
The American Health Care Act keeps certain popular provisions of the ACA, such as guaranteed coverage for those with pre-existing conditions and allowing children to stay on their parents plans until theyre 26 years old.
It does away with others, including the individual mandate, or forced enrollment, and many of the taxes levied on the wealthy to pay for the program. Starting in 2020, the bill proposes to reduce the planned Medicaid expansion and, over time, in effect eliminate it.
Roundly criticized from nearly every corner of the political spectrum, the bill will undoubtedly go though many revisions, and the House speaker, Paul Ryan, has promised that this is only the first step in a Republican overhaul of healthcare. What does seem clear is that the bill will do little to further reduce the number of Americans without health insurance approximately 30 million and will probably reduce the number currently insured.
The nonpartisan Congressional Budget Office has put the number at 24 million fewer people insured by 2026. And although the figure is notoriously difficult to predict with scientific rigor, as creating control groups in giant healthcare studies of this nature would be unethical, two Harvard Medical School professors put the number of deaths directly due to an ACA repeal at 43,000 people each year.
As the Republican healthcare bill and, more generally, healthcare in the US is debated, the broader question outside of the minutiae of individual bills and policies is: how, as a society, do we define success in healthcare reform?
Is it measured by how many individuals receive healthcare? Or how comprehensive the coverage is? Is it how much money is saved on the national level, or how many people no longer have to declare bankruptcy because of medical bills?
Is it about the patient with the blonde braids laying before Martin on the operating table? She has been dropped off by a good Samaritan who found her unresponsive and lying in a gutter. Rushed into the recess room by nurses, the patient is nearly catatonic and slipping further into herself, barely able to answer questions, finally drifting completely out. One of the residents lifts her hands and they stay as they were placed, stiff, like when a dog lies on its back. Doctors yell to her. Nothing.
Watch this, Martin tells me.
A resident loads clear fluid into a needle and injects it into the woman.
Fifteen seconds, nothing.
The woman snaps out of bed and opens her eyes, absurdly conscious and alive, wonderfully lucid. Shes just received a dose of Narcan, a drug to reverse heroin overdoses. The result is stunning and immediate, as if shes arisen from the dead.
Where am I? she asks.
Youre in a hospital, the doctor replies.