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'The Beauty In Breaking' Chronicles Chaos And Healing In The Emergency Room


This is FRESH AIR. I'm Dave Davies, in today for Terry Gross. Most of us have had the experience of heading to a hospital emergency room and having a one-time encounter with a physician who stitches our wounds, gives us medication or admits us for further treatment. Our guest today, Michele Harper, is a career ER doctor and one of roughly 2% of American physicians who are African American women. In her new memoir, she shares some memorable stories of emergency medicine - being punched in the face by a young man she was examining, helping a woman in a VA hospital with the trauma of sexual assault she suffered serving in Afghanistan and treating a man for a cut on his hand who turned out to have incurred the wound while stabbing a woman to death.

But Harper isn't just telling war stories in her book. She writes that she's grown emotionally and learned from her patients as she struggled to overcome pain in her own life, growing up with an abusive father and coping with the breakup of her marriage. Her book is called "The Beauty In Breaking." Michele Harper is a graduate of Harvard University and the Renaissance School of Medicine at Stony Brook University. She was chief resident at Lincoln Hospital in the South Bronx and has worked in several emergency medicine departments in the Philadelphia area where she lives today.

Though we both live in the same area, COVID-19 kept us from meeting in a studio. She spoke to me via an Internet connection from her home. Michele Harper, thanks so much for being here. Welcome to FRESH AIR. You wrote a piece recently for the website Medium - I guess it was about six weeks ago - describing the harrowing work of treating COVID-19 patients. How are you?

MICHELE HARPER: I'm - I feel healthy and fine. We're only tested if we have symptoms. But I feel well. Thank you.

DAVIES: You described in the piece that you wrote about the mask that you wore over your face. I mean, there was the mask on your face. And then there's the transparent shield. It was fogging up. Did you get more comfortable with it as time went on? Or was it a constant worry? Am I inhaling virus?

HARPER: I think it's more accurate to say in my case that you get used to the fact that you don't know what's going to happen. So you do the best you can while you try to gain some comfort with the uncertainty of it all. The fact that, for this time, there are fewer sicker patients gives us the time to manage it. But you don't - it's really the comfort with uncertainty that we've gained.

DAVIES: Have things improved? Is there more protective equipment now?


DAVIES: Really?

HARPER: The change is that we've had donations. For example, the face shield I talk about is different than the one we have now because we had a donation from an outside company. And we use the same one. So we reuse it over and over again. The N95s we use, there's been a recycling program. So they're recycled through some outside company. And so that has allowed us to keep having masks. But the shortages remain. And so we're all just bracing to see what happens this fall.

DAVIES: Let's talk a bit about your background as you describe it in the book. You grew up in an affluent family in what you describe as some exclusive neighborhoods in Washington, D.C. You went to private school. But your childhood was not easy. You want to describe some of the family dynamics that made it hard?

HARPER: Well, it's difficult. It's difficult growing up with a batter for a father and his wife, who was my mother. So it was always punctuated by violence. Some salient memories that just remind me of the insecurity of it - there would always be some kind of physical violence. And my brother, who was older than me by about 8 1/2 years - he's older than me. So he would - when he was big enough, he would intervene and try and protect my mother. And I remember one time when he was protecting my mother - and so I ended up fighting with my father - how my father, when my brother had him pinned to the ground, bit my brother's thumb.

And I remember thinking - and it was a deep bite. I mean, I ended up helping my brother get care for that wound. And I remember thinking to myself, what could lead a person to do something so brutal to a family member? And if they could do that, if they could do an act that savage, then they are - the message that I took from that is that they are capable of anything. Whatever their wounds, whatever their trauma, it can make them act in this way. So it never felt safe at home.

DAVIES: You describe being 7 years old and trying to understand this. And that continued until, I guess, your high school years, because you actually drove your brother to the emergency room. How did you see your future then?

HARPER: At that time, I saw my future as needing to get out and needing to create something different for myself. So for me, school - and I went to National Cathedral School. For me, school was a refuge. I enjoyed my studies. I knew that I would do well enough in school so that I would be independent emotionally and financially, that I wouldn't feel dependent on a man the way that I saw the dynamic in my home, where my mother was dependent upon the financial resources of my father. And I felt that, in that way, I would never be trapped. And also because of the pain I saw and felt in my home, it was also important for me to be of service and help to other people so that they could find their own liberation as well.

DAVIES: I don't want to dwell on this too much. But one of the things that's interesting about the story, as you tell it, is that, you know, there was this imperative, as there typically are in families of - in battered families, to keep it secret, to keep the whole - keep a respectable front. And the police were summoned only once. And that was a time that you called. Tell us what happened.

HARPER: Yes. And they were summoned, probably, a couple of times. But there was one time that I called.

DAVIES: What was going on when you - what made you call that time?

HARPER: It was another fight. And it felt dangerous. And I put it that way, there was another fight, because there was always some kind of fight where my brother was trying to help my mother. And so then my brother became the target of violence from my father. So I ran downstairs and called the police. And the police did show up. And when they showed up, they said, well, I suppose we'll just arrest you both, meaning my father and my brother. And it was a devastating moment because it just felt that there was no way out and that we - we identified with my brother as being our protector - were now all being blamed for the violence.

And my mother said, well, she didn't want to pursue charges if it meant my brother was going to be incarcerated. So the police just left. They didn't ask us if we were safe. I'm the one who answered the door, and I was a child. They didn't inquire about any of us. They left. Then, thankfully, my father then left for a little bit also. So it felt like there was nothing left to do but continue to live in silence because there was going to be no rescue. And I was - the only rescue would be one that I could manage for myself.

DAVIES: Eventually, your father did leave the family. And your mother eventually remarried. And you - I guess, gradually, you kept some contact with your father, then eventually cut off Off contact altogether. You got into Harvard, did well there and went to medical school. School was kind of a refuge for you?

HARPER: It was. Growing up, it was. Certainly it was my safe haven when I could leave the home. Then along the way, undergrad, medical school, that was no longer a refuge. That was just being in school. And that's just when the realities of life kicked in. And I specifically don't speak about much of that time and I mentioned how graduation from undergrad was - pretty much didn't go because it was tough being a Black woman in a predominantly white, elitist institution. So the experiences that would apply did apply.

DAVIES: I'm going to take a break here. Let me reintroduce you. We're speaking with Dr. Michele Harper. She is an emergency room physician, and she has a new memoir about her experiences. It's called "The Beauty In Breaking." We'll continue our conversation in just a moment. This is FRESH AIR.


DAVIES: This is FRESH AIR, and we're speaking with Dr. Michele Harper. She is an emergency medicine physician who has written a new memoir about her life and experiences. It's called "The Beauty In Breaking." You tell a lot of interesting stories from the emergency room in this book. All of them have a lesson of some kind. And one of them that I wanted to focus on was one of the last in the book. It involves a 22-month-old baby who was brought in who apparently had had a seizure. And I should just note to listeners that this involves a subject that will - well, may be disturbing to some. It is not graphic, but it is in some respects troubling. You want to just describe what happened with this baby?

HARPER: Yes. She was rushed into the department unconscious, not clear why but assuming a febrile seizure, a seizure that children - young children can have when they have a fever. And usually, it's safe. It's not an issue. And they get better. Well, she wasn't coming to, which can happen. She remained stuporous. And there was - there was just something about it that made me more concerned. I had nothing objective to go on. Her physical exam was fine. She looked well, just stuporous. She was there with her doting father. Everything seemed to add up. And so when I was ordering her tests, I didn't need to order liver function tests. They have no role in a febrile seizure. But I just left it. I didn't know why. I kept going, and something about it was just concerning me. Well, as the results came back one by one, they were elevated. Her X-ray was pretty much OK. I mean, mainly we get that to make sure there's no infection causing the fever. And there was no pneumonia. But she wasn't waking up, so I knew I was going to have to transfer her anyway.

So I started the transfer. I spoke to the pediatric hospital that would be accepting her. And then I got a call from the radiologist that while there was no pneumonia, she had several broken ribs, different stages of healing, so they happened at different times. And I thought back to her liver function studies, and I thought, well, they can be elevated because of trauma. She looked fine physically. There was no bruising or swelling. But I was really concerned that this child had been beaten and was having traumatic brain injury and that's why she wasn't waking up. So I call the accepting hospital back to let them know that. And when I got follow-up on the case later, that's exactly what had happened. It was traumatic brain injury, and that's why she presented with altered consciousness that day.

DAVIES: Right. I mean, you say that her body had a story to tell. It was crying out for help, and the liver test was kind of an intuition on your part. It made me think that you really connect with patients emotionally, which I'm sure takes longer but maybe also has a cost associated with it. Talk about that a little.

HARPER: It does. It certainly has an emotional toll. I will tell you, though, that the alternative comes at a much higher cost because I feel that in that case, for example, it was an intuition. It was me connecting with her. And as a result, it did expedite the care that she needed. So if I had done something different, that would have been a much higher cost to me emotionally.

DAVIES: You know, I'm wondering if the fact that you spent so much of your childhood in a place where you didn't feel safe and there was no adult or professional that you encountered who could relieve that, who could rescue you, who could make you safe, do you think that that in some way made you a more empathetic doctor, somebody who is more inclined to find that person who is in need of help that they somehow can't quite identify or ask for?

HARPER: Yes, 100%. Now, of course, there are choices. I mean, it doesn't have to go that way. Situations, experiences, can break us in ways that if we make another set of decisions, we won't heal or may even perpetuate violence. But I always seen it an opportunity. I mean, yeah, the pain of my childhood in that there wasn't, like you said, an available rescue option at that point gave me the opportunity as I was growing up to explore that and to heal and think to myself I want to be part of that safety net for other people when it's possible. So it did open me up to that realization. And it was impetus for me to act because it's one thing to realize. It's another thing to act.

DAVIES: You did your residency in the South Bronx in a community that had issues with drug dealing and gang violence. And you write that while you knew violence at home as a kid, you know, you didn't grow up where - in a world where there was danger getting to school or in the neighborhood. What was it like getting acclimated to that community and the effect it had on the patients that you saw?

HARPER: First of all, shout out to Lincoln and Lincoln residency because that was one of - professionally, that was one of the most rewarding times of my education and career. So actually, I specifically picked that program or I knew I wanted a program like it because that is where I feel comfortable, and that's where I feel at home. Clinically, all along the way - I prefer clinically to work in environments that are lower-resourced financially, immigrant, underrepresented people of color.

So it was a natural fit for me. I mean, was it difficult? And is it especially difficult working in these hospitals where we don't have enough resources for patients, where a lot of the patients have to work multiple jobs because there isn't a living wage and we're their safety net and their home medically because they don't have access to health care? That's depleting, and it's also rewarding to be of service.

DAVIES: I'm, you know, just thinking that you were an African American woman in a place where a lot of the patients were people of color. You've also worked in big-city teaching hospitals where that was not as much the case, I assume. Did you feel more appreciated in the Bronx?

HARPER: Yes. And even clinically, when I'm not, like when I worked at Einstein Hospital in Philadelphia, it's a similar environment. I'm always more appreciated in the community and even within hospital systems. It's more challenging when that's not the case. You know, I speak about some of my experiences, as you mention, where I was in a large teaching hospital, more affluent community, predominantly white and male clinical staff.

And just to speak to this example, I was going for a promotion, a hospital position, going to remain full-time clinical staff in the ER but also have an administrative position in the hospital. And I was qualified, more than qualified. And I didn't get the job. And my emergency medicine director was explaining that even though there was no other candidate and I was the only one who applied, they decided to leave it open.

And he apologized because he said that unfortunately, this is what always happens in this hospital - that the hospital won't promote women or people of color. And he said, but, you know, I hope you'll stay on with me. You know, hopefully, one day we can do something different. And so I left because that was too much to bear. And I did find out shortly after - not soon after I left, there was a white male nurse who applied and got the position.

DAVIES: You know, you write in the book that you navigate an American landscape that claims to be post-racial when every waking moment reveals the contrary. And you wrote that before the recent protests and demonstrations, which have prompted a lot more focus on the nation's experience with slavery and racial injustice. I'm wondering if nowadays things feel any different to you in hospital settings and the conversations that you're having, the sensibilities of people around you.

HARPER: That's a great question, and I am glad we're having the conversations and that there is space for the conversations. Is it different? No. Nope - not at all because different would mean structural change. What I'm seeing so far is a willingness to communicate about racism in medicine, but I have not yet seen change. I'm hoping that we will. That takes a little more time, you know, equitable hiring, equitable pay. It's yet to be seen, but I am hopeful. This will be a lifetime work, though. I always tell people, it's really great. I love the protests. I love the discussion. And as we know from history, this is a lifetime commitment to structural change. So I hope that that's what we're embarking on.

DAVIES: We're going to take another break here. Let me reintroduce you. Dr. Michele Harper is an emergency medicine physician. Her memoir is "The Beauty In Breaking." She'll be back to talk more about her experiences in the emergency room after this short break. I'm Dave Davies, and this is FRESH AIR.


DAVIES: This is FRESH AIR. I'm Dave Davies, in for Terry Gross. My guest is Dr. Michele Harper. She spent more than a decade as an emergency room physician. She has a new memoir about her experiences and how her work with patients has contributed to her personal growth. Her book is called "The Beauty In Breaking."

You know, ER doctors and nurses have a lot of dealings with police, and there's a lot of talk about reforming police these days, you know, defunding police in the wake of protests of police killings of African Americans. And apart from your many dealings with police as a physician, you had a relationship with a policeman you write about in the book, an officer who was getting out of a bad marriage to a woman who was irrational and very difficult. And in reflecting on their relationship, you write, (reading) it's strange how often police officers frequently find the wackadoos (ph). I suppose it's just like ER physicians, psychiatrists, social workers and all of us in the helping fields.

And that description struck me. Do you think of police in general as being in the helping fields?

HARPER: I do. I mean, I feel that that is their mission. There have been clear violations of that mission, deviation from that mission. But that is the mission, should they choose to follow it.

DAVIES: You describe an incident in which a patient was brought in - I guess was handcuffed to a chair, and there were four police officers there who said he swallowed a bag of drugs, and they wanted him treated, I guess, you know, the stomach pumped or whatever. You want to just describe what happened here? This is an interesting incident, the way it unfolded.

HARPER: Yes. So, you know, initially, he comes in, standing - we're all standing - shackled hands and legs. And they brought him in because, per their account, they had alleged that it was some sort of drug-related raid or bust, and they saw him swallow bags of drugs. So they brought him in because part of their legal work is to prove it. So they wanted us to prove it and get the drugs out.

The patient, medically, was fine. He was in no distress. He had no complaints. He did not - well, no medical complaints. He did not want to be in the ER. He didn't want to be evaluated. He didn't want to be examined. The officers said we were to do it anyway. And the consensus in the ER at the time was, well, of course, that is what we're supposed to do. This happens all the time, where prisoners are brought in, and we do what the police tell us to do. If the patient doesn't want the evaluation, we do it anyway.

DAVIES: And what would they have wanted you to do, other than to evaluate his health?

HARPER: Well, what it would have entailed - in that case, what it would have entailed was we would have had to somehow subdue this man, since he didn't want an exam - so we would have to physically restrain him somehow, which could mean various nurses, techs, security, hold him down to get an evaluation from him, take blood from him, take urine from him, make him get an X-ray - probably would take more than physically if he would even go along with it. We may have to chemically restrain him, give him medicine to somehow sedate him.

And then if we found it and we're supposed to get it out, then we'd have to put a tube into his stomach and put in massive amounts of liquid so that he would eventually pass it. Each step along the way, there is risk - risk to him being anywhere from injured, physically, to death. That's what it would entail to do what the police were telling us to do.

So I didn't do it. And I told the police that not only was that request unethical and unprofessional, it's also illegal. And my staff - I was working with a resident at the time who didn't understand. She said, well, we do this all the time. And, you know, of note, Dominic, the patient, and I were the two darkest-skinned people in the department.

At that point, at that time of the day, I was the only Black attending physician, and the police were white. My trainee, the resident, was white. And she called the hospital medical legal team to see if that was OK and if somehow she could go over me - because she felt that she was entitled to do so - to get done what the police wanted done. Turns out she couldn't, and the hospital legal told her that I was actually quoting the law. So we didn't do it, and I discharged the patient, which was his wishes. So he left the department.

And that was an important story for me to tell not only because, yes, the police need reform. This man has personal sovereignty. He has bodily integrity that should be respected. But the hospital, if I had not intervened, would have been complicit. So the medical establishment, also, clearly needs reform. These aren't - the structural racism isn't unique to the police, unfortunately.

DAVIES: Right. And in this case, the resident, who kind of tried to go over your head to the hospital, was a white person. You were the attending person who was actually her supervisor, but she thought she could take this into her own hands. You know, the dynamics are interesting there. I mean, did you worry at all that there's a chance he might have actually taken the drugs and that he could be in danger from not getting treated?

HARPER: And yes, you know, that's - and I'm glad you bring that up. That's an important point. And one of the reasons I spoke about this case is because one may think, OK, well, maybe it's not clear cut medically, but it really is. Somebody who is of sound mind and medically competent is allowed to make their own decisions, whether or not we agree with them, because we have to respect patient autonomy and patient wishes.

And I don't know whether or not he took drugs. I don't know if the allegations against him were true. He said it wasn't true. You know, there's no way for me to determine it. And I would say, we have patients refuse evaluation in the ER all the time or change their mind, decide they want to leave. I mean, I've literally had patients who are having heart attacks - and these are cases where we know, medically, for a fact, they are at risk of significant injury or death, where it's documented - I mean, much clearer cut than the case we just discussed, and they have the right - if they are competent, they have the right to sign themselves out of the department and refuse care.

So the only difference with Dominic was he was a person considered not to have rights. We know, in medicine, people can make their own decisions. They are allowed to, you know, when certain criteria are met. They're allowed to do it. So what was different about Dominic was that he's dark-skinned, he's Black and that he was with the police. What was different about me in that case when my resident thought I didn't have the right to make this decision was because I was dark-skinned. That's the difference.

DAVIES: And we should just note that you were able to calmly talk to him and ask him if he would let you take his vital signs. You did. And that gave you some level of reassurance, I guess.

HARPER: Yes. I mean, it's a - I mean, and that is important. Do you know what I mean? It's a clinical determination. Of course, if somebody comes in mentally altered, intoxicated, a child, it's - there's different criteria where they can't make decisions on their own that would put their life in jeopardy. This was not one of those circumstances.

DAVIES: The resident in this case who sought to go over your head and consult with the hospital's legal department - did you continue to work with her?

HARPER: Oh, yeah, all the time. We had frequent shifts together.

DAVIES: Yeah. Did your relationship grow? Was it OK?

HARPER: No. There's (laughter) - it did not grow or deepen. I don't know what happened to her afterwards. But, you know, I'm a professional, so I just move on and treat her professionally each shift.

DAVIES: Let me reintroduce you. We're speaking with Dr. Michele Harper. She's a veteran emergency room physician. She has a new memoir about her experiences called "The Beauty In Breaking." We'll continue our conversation in just a moment. This is FRESH AIR.


DAVIES: This is FRESH AIR, and we're speaking with Dr. Michele Harper. She's an emergency medicine physician. She has a new memoir about her experiences in the emergency room and how they've helped her grow personally. It's called "The Beauty In Breaking."

After some time at a teaching hospital, you went to - you worked at the Veterans Administration Hospital in Philadelphia. This is a building I knew. I drove a cab in Philly in the late '70s, and some of the most depressing fares I had were people going to the VA hospital and people being picked up at the VA hospital. And you give a pretty dispiriting picture of the place in some ways. You write that the hospital would be so full of patients that some would wait in the ER, and then you would be expected to care for them in addition to those arriving for emergency care.

One of the more memorable patients that you dealt with at the VA hospital was a woman who had served in Afghanistan, and you had quite a conversation with her. And I should just note again for listeners that there's some content here that might be disturbing. It's not graphic, but it is troubling. You want to just tell us about this interaction?

HARPER: So she was there for medical clearance. What that means is patients will often come in - VA or otherwise, they'll come in for some medical documentation that medically, they're OK to then go on to a sober house or a mental health care facility. So they're coming in just for a medical screening exam. So that's what she was doing. She wanted us to sign off that she was OK because she was trying to get her her career back, trying to get sober. And it's a very easy exam. She was young. She was healthy. Her vitals were fine. Her physical exam was fine. There was nothing to it. And it's the end of my shift. I could wrap this up in 10 minutes, and then I could go home.

But this is another example of - as I was leaving the room, I just - I sensed something. I mean, she said that she had been through a lot. And it just - something about it - I couldn't let it go. And I felt that if I just left the room and didn't ask that I would be ignoring her pain. So I did ask, and she told me what she had been through in the military was her supervisor and then her colleague raping her. And apart from this violation, this crime committed against her - the violation of her body, her mind, her spirit - apart from that, the military handled it terribly. And their next step was an attempt to destroy her career. So not only had they done all this violation, but then they were trying to take away her livelihood as well.

So in trying to cope and trying to figure out what to do, she started drinking, and that's why we're seeing her getting sober. And so it was a long conversation about her experiences because for me in that moment, I - and why I stayed was it was important for me to hear her. It was important for me to see her. While she was fighting for survival, I felt that what I could do, what the others of us could do, is not only help her find health again. But I could amplify her story because this is an example of a structure that has violated her. And it's not just her. It's many people. But I could do what I could to help her in that moment and then to address the institution as well.

DAVIES: You know, the ER doctor has these intense encounters, but they're usually one-time events. What's it like not to have follow-up, not to know what became of these folks?

HARPER: There are times and it's really difficult because we want to know. We want to know if the patient's OK, if they made it. I mean, of course, if they're admitted to the hospital, we can - we usually get follow-up. You know, did they pull through the heart attack? Did they pull through the infection? But if it's just a one-time event in the ER and they're discharged and go out into the world - there are people and stories that stay with us, clearly, as I write about such cases. So in that way, it's hard. On the other hand, it makes the work easier just to be the best doctor you can and not get the follow-up. In that way, it can make it easier to move on because it's hard work. It's emotionally taxing. And we have to be able to move on.

DAVIES: You know, you write in the very beginning of the book, in describing what the book is about, that you want to take us into the chaos of emergency medicine and show us where the center is. You say that this center has the sturdy roots of insight that, in their grounding, offer nourishment that can lead to lives of ever-increasing growth. There's another moment in the book where you talk about having tried to resuscitate a baby who was brought in who died. And it's a long, agonizing process, you know, administering drugs, doing the pumping. And eventually you call it.

And you said that when you went home, you cried. And you had not been in the habit of crying through a lot of really tough things in your life. And I'm not sure what the question here is. But I think there's something in this book about what you get out of treating these patients, the insight of this center of emergency medicine that you talk about. Can you just share a little bit of that idea?

HARPER: Yeah. And in that story and after - when I went home and cried, that was a moment where that experience allowed me to be honest. And, you know, while I haven't had a child that has died, I recognized in the parents when I had to talk to them after the code and tell them that their baby, that their perfect child - and the baby was perfect - had passed away, I recognized in them the agony, the loss of plans, of promise, the loss of a future that one had imagined. So I could relate to that. And you're right. My being there with them in the moment did force me to be honest with myself about - that's why it was so painful for the marriage to end. That's why it was painful to not have the childhood that I wanted or deserved.

There was all of those forms of loss. And in that moment, that experience with that family allowed me to, in ways I hadn't previously, just sit there with myself and be honest and to cry about it. And I think that that has served me well. That was a gift they gave me. It wasn't about me. But it was a byproduct. It was a gift that they gave me that, then, yes, allowed me to heal in ways that weren't previously possible.

DAVIES: Michele Harper, thank you so much for speaking with us.

HARPER: Thank you.

DAVIES: Dr. Michele Harper is an emergency room physician. Her memoir is "The Beauty In Breaking." Coming up, Maureen Corrigan reviews "Mexican Gothic," a horror story she says is a ghastly treat to read. This is FRESH AIR.


Dave Davies is a guest host for NPR's Fresh Air with Terry Gross.