This memoir begins in Africa, where Dr. Grim is with Médecins sans Frontières managing a meningitis outbreak in Nigeria. Conditions are appalling, but she has come here because of burnout: "so I won't be back home and in the ER" (11). Later in the book, she describes her other "escapes" from the Emergency Room, caring for war refugees in the Balkans.

The book centers, however, on life in an American emergency department, as Grim remembers it from the vantage point of Africa (where she does eventually become nostalgic for well-stocked supply cupboards and a more comprehensible chaos). She organizes her stories into a series of "Lessons in Emergency Medicine," in which she addresses the reader directly. After going through a step-by-step account of death in the ER, illustrated with several moving and alarming cases, she concludes: "Congratulations: you have successfully declared someone dead. Now, as an encore . . . you'll get to do it all over again" (28).

The ironic, even bitter, tone warns us of the difficulty of working in such perpetually crisis-ridden circumstances, but it does not conceal a vulnerability that seems necessary to doing the job well, such as when Grim has to tell a family that the father has died of the heart attack he had at his daughter's wedding: "you just stood there," she says, "looking at the corsage, the tuxedo and the pearls . . . You had no idea what to say and you don't really remember what you finally came out with" (26).

The stories are organized around several lessons: "How to deliver a baby," "How to crack a chest," "How to write a prescription" (which includes a discussion of addiction to prescription medication and a withering account of the doctor who overprescribes), and, as if it's as inevitable as the rest, "How to burn out."

By the book's final chapter, emergency medicine has merged, along with the vaccination of refugee children and the impossibility of treating tetanus in Nigeria, into the story of almost unreasonable determination in the face of endless frustration--but this, Grim shows in her final chapter, "Why I do what I do," is the point. Against this backdrop her final story, about the rescue of a child, makes its point: the feeling of saving a life explains all the rest.


This is a powerfully written presentation of the difficulty of being a doctor under conditions that do not protect health. Poverty, war, urban violence, human carelessness, all act to thwart the benevolent purposes of medicine. The author's frequent exasperation is vividly conveyed, but we are also given a sense of the wider implications of what this kind of medicine teaches: in a place where, as she puts it, "lunacy prevails" (206), despair just might be avoided by focusing on short term, limited, success.



Place Published

New York



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