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It was a dark and stormy night. The activity in the emergency room and trauma unit at St. Joseph Medical Center in Wichita, Kansas, made the TV series "ER" pale by comparison. A winter storm had moved into our area, bringing with it freezing rain followed by heavy snowfall, high winds and falling temperatures. All ambulance crews in Sedgwick County were busy with 10-48s (injury accidents), cardiac arrests, fractures of all sorts from folks slipping on the ice and the other more or less routine calls that defined the usual work shift. It would be a night that would stay with me for years to come.

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We who have worked in emergency settings-paramedics, nurses, physicians-are used to the fast-paced, ever-changing atmosphere of the ER. No two shifts are the same. The unexpected is the norm, and true situations are stranger than fiction. The scope of human experience is in evidence, including the classic conflicts of person against person, person against self and person against nature. Consequently, most emergency care providers have a warped sense of humor, which helps us tolerate the tragedies we regularly confront.


This particular icy night was not a humorous one, no matter how warped we may have been. It seemed that the accident victims were coming in multitudes, two to an ambulance, but we were keeping up with the pace. Then we heard the radio traffic none of us wanted to hear. "St. Joe, this is Unit 94. We're coming in with a Code Blue 10-48 victim. She's four years old." Her father was also injured and coming in the same ambulance. Further radio traffic informed us that another crew was on the way with John, the driver of the other car. He was twenty years old and appeared to be intoxicated. The police would be requesting a blood alcohol test on arrival.


As we prepared to receive the victims, the mood of the department became somber. The trauma team was ready for the child, but her injuries were too severe. She died. The dad was mildly injured, but he would be okay physically. The question among the staff was, "Who's going to take care of the drunk that killed the little girl?"


Although none of us wanted to, we prepared to go through the motions, but with a certain degree of loathing. John arrived strapped to a spine board and yelling about his pain. His face was cut up from hitting the windshield. Significant head and neck injuries were indeed possible but were ruled out with a CT scan and x-rays. The extent of his injuries appeared to be the facial lacerations.


When he came back from x-ray, he was still noisy, obnoxious and reeking of alcohol. His blood level was reported as greater than 0.1, legally drunk. He continued to yell, voicing concerns about himself, never asking about those in the other car. All he wanted to know was, "Is it gonna leave a scar?"


Is it going to leave a scar? We were incredulous. How could he think only of that?


The ER began to quiet, and it became apparent that I was going to be the one to sew up John's cut face. The other nurse practitioners had finished their shifts, and I was the only one left. Only the ER physicians and the NPs repaired lacerations, unless a specialist was needed. John's face didn't need a specialist; he got me instead.


As I gathered the supplies, some of the staff suggested to me that I shouldn't use any local anesthetic-John deserved to feel the pain of the needle. Others said I should use 2-0 silk suture, certain to leave a scar by its large caliber and material content. I must admit, I had considered both suggestions on my own, even before they were voiced by my colleagues. We all knew that these techniques weren't right, but they seemed to be just. We all knew, too, that I wouldn't use them, even if part of me wanted to. Justice wasn't mine to decide or to give. As John lay on the gurney with his head draped, he continued to ask, "Is it gonna leave a scar?"


"Yes," I replied calmly, as I tried to work efficiently and quietly, not wanting to converse much with him. I did the best job I could, trying not to make the local anesthetic hurt too much, taking little stitches with the small caliber nylon suture, attempting to keep the working field sterile. It was a difficult job. John was not cooperative and sat up periodically wanting to look in the mirror. Intoxicated patients are often uncooperative unless they are so sedated by their impairment that they sleep through their treatment. John was the former.

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The ER staff specialized in difficult patients, especially the late night crew, which included me. We were used to dealing with the drunk and the drugged, the homeless, the helpless, the hopeless, the mentally ill, the physically injured, those near death and those wishing they were, child abuse, sexual abuse, elder abuse, those whose hearts were failing and those whose hearts were breaking. As a staff, we cared for all of these and more. Our department had recently been renamed, "Emergency Care Services." I came up with the slogan, "Care is our middle name," and the ER supervisor had buttons printed up that said so. Of course we cared.


Sometimes we cared with compassion, and sometimes we cared because we were paid to do it. I cared deeply for the child John had killed and for her family. Did I dare feel compassion and care for John too? I think so. Could I have cared more? Yes, I am certain of that. In a similar situation, would I care more now, some twelve years later? I hope so. I hope that I have grown in my faith over the ensuing years, so my compassion and kindness for John would come more graciously.


At some level that night, I understood that John was also a child of God. God loved him, even though his actions had taken the life of another precious child of God. I believe that I grew a little in my understanding of God's love and grace and what it is to be an instrument of God's peace. I chose not to inflict more pain on John in the way I sewed up his face. I supposed that someday, on some level, he would have to deal with the pain he had caused others, so it wasn't for me to cause him any more than necessary.


John left the ER in police custody, looking better than when he arrived. Yes, there would be a scar on his face, albeit a small one. Healed tissue is forever changed, never the same as before the injury. But, would there be a scar on his heart? His actions certainly left a scar on the child's family and left all of us who worked in the ER forever changed. Was it going to leave a scar? Definitely. Scars give us a reminder of what used to be, and sometimes that's not altogether bad.