Train Wreck

I run down the tracks between metal rails that converge on my goal, a distant pile of wreckage, barely visible. Nothing moves around me. On either side the flat grasslands of North Dakota lie broken only by a lone oil pumpjack, like a huge skeletal bird at the horizon. I am diminished by the sky. Behind me the massive passenger train idles, arrested suddenly on its westward pursuit. I can just make out the shape of a crumpled truck lying half off the track where a country road crosses. “I think it’s bad,” the conductor had said. I expect to find a crushed body in the twisted metal.

The day had started gliding swiftly across America on a family vacation by train. I was sitting in the lounge car reading a book and watching the occasional deer or pheasant retreat as we flew by. I felt no perceptible impact when we hit, just sudden and smooth, unexpected deceleration. Then silence.

The intercom: “Is there a physician on board?”

Arriving at the scene I find a full-sized pickup truck flung carelessly aside by the overpowering mass of our train. I am out of breath and ill equipped, carrying only my paperback novel. Pieces of the truck’s obliterated front-end are strewn for yards, pointing accusingly down the track. The passenger compartment remains mostly intact. The driver sits inside, semi-conscious, a trickle of blood running from a small laceration in his scalp. He might be bleeding in the brain or from a ruptured spleen, I consider, mentally scanning his insides. Having run the half-mile that it took our train to stop, I can do nothing but stand impotently next to the wreckage. I feel foolish and helpless, incompetent outside of the cockpit of my emergency department machine

The ambulance crew finally arrives with the Jaws of Life and leaves with the patient. On returning to the train I receive an undeserved hero’s welcome. My fellow passengers seem awed by the event. Over dinner in a packed dining car that night, the cabin attendant announces to everyone: “One of us here today saved a life.” He remained unswayed by my protestations to the contrary and steadfast in his narrative of heroism. He had missed the point.

Or perhaps I had missed the point. I considered other so-called train wrecks, the ones I see in the ER: the patient with end-stage cancer, riddled with tumor and consumed by chemo; the homeless, schizophrenic drug addict, high and hungry for a turkey sandwich; the surgery gone wrong, open abdomen seeping stool from deep inside, withering despite parenteral nutrition. I may never again run down the tracks to respond to a real metal and blood train wreck, but these train wrecks in common parlance occur regularly. I frequently find myself metaphorically running down the tracks only to stand by the wreckage, unable to affect the outcome.

I catch myself adhering to punishing criteria for success, insisting that the patient’s physical outcome must be durably changed by my action alone or it doesn’t count. When I achieve anything less than this standard and my patients thank me nonetheless, I brush their thanks aside as mere politeness.

Gradually I’ve come to think that my patients’ appreciation is sincere. Our train’s company is not alone in placing value on unquantifiable support from physicians. Sometimes the best we can do, and all we need do, is to simply show up. “Eighty percent of success is showing up,” Woody Allen would say. Too often we fail to arrive, or arrive but fail to be present – distracted by our own obsession with measurable results. There is value in simply playing our role in the narrative and bearing witness with authority and conviction, taking responsibility even when we feel unable to respond.

I called the North Dakota hospital a few days after the crash and found out that the driver had escaped with nothing worse than a bad concussion. I could claim no credit for the good outcome. By my rules for success I had accomplished nothing.

Waiting at the wreck it had seemed like hours before the ambulance arrived. I stood there with the conductor and our medical kit, which included little more than a defibrillator and some Band-Aids. The conductor started frantically pawing through the debris, saying, “Just let me know what you need!”

“Yes,” said a sarcastic voice in my head. “Keep your eyes out for a CT scanner and operating room hiding in that scrapheap.” I stood next to the driver’s shattered window and watched blood slowly drip from his forehead and the pumpjack slowly dip in the distance. We waited for the ambulance and gradually his level of consciousness improved. I did nothing – and everything that was needed.

The story was told and retold thereafter on the train and seemed to give the dining car attendant great solace and satisfaction. Perhaps similar stories are told at home after every metaphorical train wreck I’ve attended, only I’m not present at the dinner table or too distracted to recognize them. So I’ll keep running down the tracks to stand next to the wreckage, at least witness what I cannot change, and try to accept that doing so still matters.


By Noah K. Rosenberg

Noah K. Rosenberg (@NRosenbergMD) is an emergency physician working in Rhode Island and Assistant Professor (Clinical) of Emergency Medicine at the Alpert Medical School of Brown University. He is also an occasional essayist, politics junkie and outdoor enthusiast.

3 responses to “Train Wreck”

  1. Jay M. Baruch says:


  2. Jason Bowman says:

    Beautiful written. It reminded me of a quote by the 16th century French surgeon, Ambroise Pare:

    “The task of medicine is to cure sometimes, to relieve often, and to comfort always.”

  3. libby nestor says:

    really, really captures our mood – I appreciate reading your stuff; thanks.