Please Choose One

Please choose one:

The three words blink in front of me on the computer screen.

Please choose one:

 Patient is
Male Female

I click “Female.”

I watch as the auto-template feature fills in the paragraph for me based on my choices.

Patient #879302045

Patient is: thirty-eight-year-old female Status: postmotor vehicle accident. Please acknowledge you have reviewed her allergies, medications, and past medical history.

I click “Yes.”

Have you counseled her about smoking cessation?

I click “No.”

A little animated icon of a doctor pops up on the screen. His mouth begins to move as if speaking. A speech bubble from a comic strip appears next to it.

“Tip of the day: counseling for smoking cessation is important for the patient’s health and part of a complete billing record.”

The animated doctor smiles and swings his stethoscope like a pocket watch.

I click “Acknowledge.”

A new screen appears.

Please choose one:

The patient’s current emotional state is best described as:
Distraught Calm Agitated

I turn away from the computer to look at the patient. She lies curled in a ball on her side. Her bare feet stick out from the sheets and are halfway off the gurney. I notice she wears a turquoise-blue toe ring. She stares straight ahead. She plays with her patient ID band, twisting it round and round with her other hand. Makeup is smeared around small brown eyes. She stares blankly at the wall behind me. I clear my throat. She doesn’t blink. I clear it louder. Still nothing.

I look back to the computer. The same screen is still there.

Please choose one:

The patient’s current emotional state is best described as:
Distraught Calm Agitated

I turn back around.

Blond hair is matted to the right side of her face where tears have dried it to her skin. A thick strand of it hangs across her eyes, and I wonder if it annoys her. I watch as tears re-form in her eyes and run sideways across her face. A teardrop starts to grow on the side of her cheek. More tears start pooling until finally they fall from her face onto her tear-soaked pillow.

Her chest rises and falls at a rapid pace. She is breathing fast, almost panting. It is a raspy sound. I bet if she spoke right now, her voice would sound raw, the kind of scratchy raw that comes after too much screaming. But she doesn’t speak. She just lies there breathing with a thousand-yard stare fixed to her face.

The computer dings.

Please choose one:

I click “Distraught.”

The computer takes me to a new screen.

Please choose one:

Patient’s primary reason for being distraught:
Emotional Physical Other

The patient starts moaning. I look over. She makes a guttural sound—just loud enough for me to hear—that is part wail and part cry.

I click “Emotional.”

That selection triggers a new screen with new choices.

Please choose one:

What is the reason for patient’s emotional problem?
Intoxication Psychiatric Neurologic

Hmm. I look at her and try to decide which to choose. She is in a hospital gown. Her clothes were cut off with the trauma shears when she came in. She still smells like gasoline, blood, and burnt plastic smoke. It burns my nose sitting this close to her, and it makes my eyes water.

There’s dried blood mixed with car oil and dirt on her chest. There is a lot of it. It covers her shoulders and the top of her breasts like a red patchy shawl, yet she is not injured. She has been examined and x-rayed and CAT scanned from head to toe. Her body is fine.

The computer dings again impatiently, prompting me to choose one.

Please choose one:

What is the reason for patient’s emotional problem?
Intoxication Psychiatric Neurologic

I click the “Next” arrow at the bottom of the screen to try to advance the page without choosing one.

Page incomplete; you must choose one.

My mouse circles the screen hesitantly. I guess I will click…“Psychiatric.” In a way, emotions are psychiatric, I tell myself.

My choosing “Psychiatric” has opened a new screen.

The patient shifts on the bed. I look over. A glimmer on her head, reflecting the fluorescent lights above, attracts my attention. I lean in closer. There are shards of broken up windshield glass scattered throughout her hair. Some are brown from dirt—from where she lay on the ground—some are stuck to her head from blood, and some are scattered on the sheet below her. The shards twinkle on the bed like little stars.

I frown. The nurse was supposed to clean her up. I wheel backward on the doctor stool across Trauma Room Two to the door. I lean my head out through the curtain.

I look around. I spot the patient’s nurse. She is sitting on the other side of the ER, working at a computer. I know she is trying to enter data from the patient’s visit to get her charting done. “Well,” I think, “maybe someone else can help us.

I scan the ER. There are doctors and nurses everywhere down here, yet all those I see sit at computers with their eyes chained to the screens and scowls on their faces while they click and type, click and type. I bet the hospital could burn down around them, and they wouldn’t notice.

“Hey!” I yell.

No one even looks up. The clicking and typing continue.

An old man standing in the doorway of another patient room makes eye contact with me. He scowls as he surveys our ER. He shakes his head in disgust. I blush and duck back into the room behind the curtain.

The computer dings twice now, prompting me to hurry up. I remember that my patient throughput time is monitored, reported, and compared to the national average. A timer has appeared at the bottom of the screen, letting me know that I am four minutes and twenty-eight seconds behind the average ER doctor throughput time.

The numbers keep climbing. If I spend too much time on one patient, I will get a letter from administration for not meeting my throughput quota. I wheel back up to the computer.

Please choose one:

Because you chose Psychiatric, patient was offered:
Counseling Medications Inpatient Care

A sob racks my patient’s body, interrupting me again. She shifts in the bed, leaving crumbling clumps of brown dirt on white sheets. She is absolutely filthy. I wonder how long she lay in that field before someone found her. She still stares at the wall, unresponsive.

I look back at the computer. I didn’t offer her any of these things. Maybe I should lie and click counseling so that I can finish her chart.

I click “Next.”

Page incomplete; you must choose one.

Please choose one:

Because you chose Psychiatric, patient was offered:
Counseling Medications Inpatient Care

I try Alt+Tab. No luck.

Page incomplete; you must choose one.

I give up and click “Counseling.”

Another screen.

Please choose one:

Patient responded to counseling with:
Excellent Improvement Some Improvement No Improvement

I click “No Improvement.”

The little doctor figure reappears on the screen. He’s holding up his index finger, and a light bulb appears over his head as if he’s just had a fantastic idea that he can’t wait to share with me.

“Dr. Tom Tip reminds you: Did you try offering a drink of water or a tissue? Surveys show that sometimes it’s the little things that make patients feel better.”

I look over at her. I can’t bring myself to offer her water. Her knuckles are blanched white from the death grip she has on the side rail. She’s mouthing the word “no” over and over to herself and shaking her head back and forth. Her eyes are wide with terror and do not see me. The skin of her face is pulled taut with fear.

I know that look. She is seeing the moment. I know she is going to see it again and again for the rest of her life. It will come in nightmares, it will come in dreams, and it will come at the worst possible moment of what should be happy occasions. More likely than not, it will even come at the moment just before her own death, no matter how long she lives. She will never escape it. Sixty-eight minutes ago, her brain burned an image into the inside of her skull that she will never be able to unsee.

I click “Skip.”

The doctor icon disappears and is replaced by text.

Please choose one:

Did you offer the patient water?
Yes No

I click “No.”

The little figure pops up again—this time with a stern look on his face and his arms crossed.

“Surveys show patients like it when their doctors offer them water or tissues. Patient satisfaction scores go up. Try it. You might be surprised.”

He uncrosses his arms and holds out a little glass of water.

For a brief second, I imagine punching my fist through the computer screen. It would feel so good to climb the stairs to the top floor of the hospital with the computer stuck on my arm. I imagine spinning in a circle and launching it as hard as I can off the roof of the hospital toward the pavement below. I would give anything to see it smashed, destroyed, and ruined—to do to it what it has done to the profession I once loved.

But I know they would just replace it with another computer and—just as quickly—with another doctor.

I sigh and look around the room.

There is a cup on the counter.

I frown, as it is very dirty.

I pick it up and turn it over.

A child’s tiny bloody shoe falls out onto the counter.

The woman cries out, “Oh God! Oh God! Oh God!” and grabs the child’s shoe before I can pick it up.

She holds it next to her face. She’s sobbing now and starting to scream. “Oh God, oh God, oh God!” She clenches the shoe to her chest. The blood on the shoe matches the blood on her chest.

The computer dings.

“Did you give the patient a cup of water?”

I lie and click “Yes.”

“Good job!”

The computer trumpets out a happy horn sound. It’s hard to hear over the patient’s screaming. The little doctor gives me a thumbs-up and high-fives a hand that appears on the screen next to him.

“Sometimes it’s the little things that make people feel better.”

I click “Next.

The “Patient Disposition Screen” loads.

Please choose one:

Where is the patient going after the ER?

I hover the mouse on the screen for a second, trying to decide.

I click “Home.”

Please choose one:

How is the patient doing after your care for her?
Improved Not Improved Other

I look at her again.

I click “Not Improved.”


This time the whole screen flashes. The little doctor is back, hands on his hips. His face is stern, and the speech bubble appears next to his head. The letters are in red this time.

“Patients who are not improved should not be sent home. You clicked Psychiatric as her primary issue. Perhaps some medications would help the health care consumer. Would you like me to recommend some choices available on the hospital formulary?”

I ponder the question. Is there a drug for this? Something that will make her feel better? Something that doesn’t wear off, like, ever?

I click “No.”

Are you sure? The computer asks again.

I click “Yes.”

A big red flag now pops up on the screen, and the computer buzzes like a halftime buzzer in a sports game that I have just lost.

A note of this patient encounter has been sent to your hospital administrator for chart review of this patient. It is the goal of our health care facility to make patients feel better before they are discharged. You have acknowledged that you failed to do so. You will likely receive a lower patient satisfaction score for this.

Please acknowledge.

I click “No.”

It flashes again.

Please acknowledge.

I click “No.”

Please acknowledge.

I click “No.”

A box pops up.

I am sorry, valued health care provider—do you not understand the question? Would you like to fill out a service ticket?

Yes No

Please choose one.

The words blink at me on the screen.

I look over at the patient. She is on her side again, sobbing as she cradles the tiny shoe to her chest. Her eyes are squeezed shut, and she’s rocking back and forth so hard the whole gurney is shaking.

I look back at the computer.

Please choose one.

I look back at my patient.

Please choose one.

Suddenly I get it. I choose.

I reach down and unplug the computer. The screen goes black.

Without the noise of the computer fan whirring, the room is suddenly silent—save for her quiet sobs.

A strange feeling comes over me—one that, after so many years, I almost forgot existed.

I remember who I am and why I am here.

I stand up and take a deep breath. I step toward the patient and begin the long, tedious process of gently picking out the shards of bloody glass stuck throughout her hair. As I start to work, she opens her eyes and blinks.

She sees me.

The terror that fills her eyes fades just a tiny bit.

For once, the computer stays quiet.

I pick through the strands of her hair. The three words blink in my mind over and over.

Please choose one.

Please choose one.

Please choose one.

©Philip Allen Green

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14 thoughts on “Please Choose One

  1. This is heartbreaking. I know this is fiction but it so precisely describes the heart rending frustration and anger that I feel every time this happens. It drives me to do something more for people. I haven’t found a way to do enough in the Er environment so I channel that energy into the relationships I have through my church. I wish I could do more there though. Thank you for writing this.

  2. This story was very well written. Those of us old enough to see the sad changes in the administration and philosophy of health care can sadly relate to this account. Health care is now all about profitability and time efficiency instead of careful workups and taking the time to teach and relate to our patients with care and compassion. Thank you so much!

  3. Beautifully done. Clearly demonstrates what the commoditization of medicine has done to it as a profession – we are on the verge of losing our heart and soul as professionals. We have allowed medicine to be corporatized with devastating results. Eisenhower, in his 1960 farewell address, warned about the military-industrial complex. He had no idea that it would be dwarfed by the medical-industrial complex. Medicine is now fully money-driven. We have lost our way and must regain it before it is too late. Medicine is about alleviating suffering and nothing else. Our fiduciary responsibilities must be to the patients who need us, not the stockholders driving for-profit healthcare companies. We have to take back the reins of our profession before we truly go over the proverbial cliff. Keep on with your terrific writing!!

  4. My organization provides residential and coomunity supports. It is what we encounter all too frequently when people with mental illness or intellectual disabilities get to the er before we can get to them. Guessing games can cause horrific and/or discriminatory outcomes! Thank you for raising the red flag!

  5. Phil: is this actually true in the sense that you ER guys have this program and it runs through this stuff? And you can’t move on without making a choice, no matter how inappropriate? Stunning.

    Is this where ERs are now or are you projecting slightly into the future?

    1. The software in the story is fictional but the constant disruption and competition for the physician’s time is real. I talk more about it in a second piece I wrote about the same issue.

      If there really was a little doctor swinging a stethoscope telling me what to do with my patients I think there would be a lot of broken monitors. 🙂

      Thanks for reading.

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