Emergency! (22 page)

The call about the patient had come in a few minutes before four.
This night had not been much different from most: A young woman needed stitches, having cut her finger on the broccoli line at Consolidated Canning; a couple of drunks had blood alcohols drawn for the California Highway Patrol, protesting their innocence in slurred, coarse voices—voices that frightened a child needing antibiotics for her ear infection. The ebb and flow of various stomachaches, backaches, headaches continued until 2
A.M.

I was ready to crash when the scanner called for a paramedic unit at 4
A.M.
“Man down near the Clear Creek Bridge. Fire and police are on scene.” Damn! This is not what I want after being up all night. The two night nurses share my lack of enthusiasm. Jenny sits on a stool near the radio filing her nails. Mildred yawns. I go looking for coffee. As I'm pouring, I hear the radio again. “Rockridge Base, this is C-7, Code Two traffic.”

Jenny's voice, “Go ahead C-7, this is MICN Duncan.” I continue searching for sugar. “Hi, Duncan. This is C-7. We're at Clear Creek Bridge. Police found a fifty-year-old man on the sidewalk, unconscious. No ID, no name. He looks drunk but has a cut on his head. He's waking up but can't remember what happened. Vitals are stable. No other injuries. We've got him in c-spine precautions. Any orders?”

“No, that's fine. What's your ETA?”

“We'll be there in five. The guy keeps talking about his shoes, which is peculiar since he doesn't have any. C-7 clear.”

The exam room light is harsh, shadowless. The man with no name and no shoes is strapped on the gurney, staring at the ceiling. His scalp is turbaned by a large blood-soaked bandage. I make no move to unstrap him yet, observing for a moment longer. His rainsoaked clothes exude an odor of urine. He's wearing a gray sweatshirt, loose and stained, with
FRESNO YMCA
in faded letters. The sleeves are worn through at the elbows, exposing bony arms. His hands are callused yet delicate. His threadbare wool pants are loose about his hips, the zipperless fly partially closed with a safety pin. Bare feet, crusted with
mud, protrude from torn cuffs. His chest rises and falls effortlessly. In fact, his entire body seems at peace. Only his bloody face reflects his recent violence.

As I look, he speaks. “Look, Doc, they took my shoes.”

Startled by the sound of his voice, I step forward. “What's your name? You know where you are?”

“Sure. Rockridge Hospital.”

“Know how you got here?”

“Ambulance. Geez! Doc, my head really hurts!”

“Your neck hurt too?” I palpate his cervical spine.

“No, just my head. Hey, damn it! They took my shoes. Those were good shoes—work boots from the Goodwill. Hey, why do you got me strapped down like this?” His eyes are scanning the room, his peacefulness replaced with agitation. “My name is Cal. Cal Foster. Come on, Doc, let me get up. I'm all right.”

“In a minute, OK? I want to look at that head wound first.”

The nurses have come in while we are talking. Quickly, Jenny checks his blood pressure, pulse, and respiratory rate. I unwrap the dressings over his head as she finishes. The forehead wound is long and deep. I remove the straps. “So what happened?”

He talks, I probe. “Not sure, Doc. I've been drinking a little wine tonight, can you tell? Just staying dry under the bridge,” he continues. “I was going to … Oh, shit! Now I remember. A couple of guys came up—wanted my bottle. I gave it to them—no trouble. One of these guys was really wild-eyed, fast talking—in Spanish. I didn't understand what he was saying. He started waving my bottle around. Hell, Doc! I moved out from under that bridge real quick-like, down toward the river—backing up—but him and his buddy just kept coming. Next thing I know there are cops around: My head hurts. I'm wet. I'm cold. My shoes are gone.… Hey! Can'tcha give me something for this headache?”

“All right, Cal, but I gotta sew you up.”

“Go ahead, Doc. Don't wanna ruin my good looks.” He lets out a wheezy laugh, hitting me with the fetid odor of stale cigarettes and cheap wine.

“Well, this is what I'm here for,” I grouse to myself. I put on a mask. Cal and I are going to be close for awhile. I get my gloves and prepare the instruments as Mildred scrubs off dirt and blood, exposing the raw wound edges.

Cal closes his eyes and starts humming. I numb his forehead and begin my first stitch.

“Whatcha humming, Cal?”

“Oh, nothing.”

“Sounds familiar.” I keep sewing.

“Yeah? Well, it's from
Hair
. You look old enough to remember the sixties.”

“ ‘Aquarius'—right?”

“Yeah, Doc. Did you know I was in that?”

“In
Hair
?”

“Yeah. In San Francisco. Small part. I was studying at the Actor's Workshop. Hell, I did directing, acting, set design, the whole thing. That's my career. Or was my career. I got off track a little.”

“A little? I'd say you're way off now. What happened?”

“Sort of fried my brain, I guess. You see I was making ends meet by living with chicks, sort of a gigolo type. North Beach. Played a beatnik role. The older chicks dug it—letting me stay at their pads, then kicking me out. I'd go back to drinking wine and getting sandwiches at the mission—just keeping it together enough for a little work in the theater. Then I started doing methedrine, then acid, then ludes. Meth and ludes. Up and down. Moved to the Haight, became a hippie. Lotsa free love. Lotsa free everything …” his voice fades.

I'm still sewing. His wound extends from his forehead to far above his hairline. “I lived in the Haight in sixty-eight and sixty-nine,” I tell him. “I used to eat lunch in Buena Vista Park once in a while.”

“Hell, Doc, I buried my dog in Buena Vista Park.” He opens his eyes and looks at me. “How much more you have to sew?”

“Not much,” I reply, “but I have to shave your head a little to get to the wound up here. Maybe I should shave it all, kind of give you a Buddhist monk look.”

His eyes widen further, fixing me with a penetrating look. “I am a Buddhist monk!”

“Come on, Cal …” I protest.

“Honest, Doc.” He's not smiling. “I lived in Carmel Valley. Same retreat as Ira Sandperl, Joan Baez, the whole bunch of them. Shaved my head, wore robes, meditated …” his voice saddens. “Meditated myself right into the nut house and five years of Thorazine. Called me a paranoid schizophrenic.”

“Are you?” My question is flat, nonthreatening. I return his gaze.

“Not anymore. The shrinks now say they were wrong. Now I'm a manic depressive—a lithium and Cogentin man. Actually, I'm doing a lot better.”

“Sleeping under bridges? Rolled for wine and shoes?”

“Listen, Doc, I've got a girlfriend now. We've made plans. I think we'll do it. She and I both got disability checks. We're going back to the land. Maybe Mendocino.” His eyes close again. I finish the last stitch and remove my gloves. Mildred begins cleaning the remaining blood from his forehead.

I turn back to Cal. “You can go when she's finished.”

I look up at the clock. It's 5:30
A.M.
and my back aches. My feet are sore. I'm definitely ready to call it quits for the night. I stretch and walk to the emergency room glass door. The rain has stopped and pale light is changing the sky in the east. I look down at my shoes. They're old but sturdy. Good for someone on his feet a lot, and Mendocino's a long way on foot. I return to Cal's room.

An hour and a half later, I slosh out the back door of the ER, headed for my car. The pavement is cold and wet under my bare toes. To me, it feels good. It's no longer night. It's morning.

KENT BENEDICT, M.D.

Aptos, California
    

C
ommunication in the Emergency Department is a vague art, taught (ad nauseam) in school, mastered only in practice. Medical personnel can write an entire history and physical without using a single word, symbol, or initial recognizable to the average layperson. In the ER, it's not only what we write and say, it's what we really mean when we write or say it.

Picture an eleven-bed emergency room on a moderately busy afternoon. Mr. Patient in bed 5 has a lacerated arm. I am the trusty physician's assistant assigned to deal with bed 5, but as I survey the room, I notice there is no place for me to sit as I repair the laceration. I have been on my feet since early this morning and getting to sit down is one of my favorite reasons for repairing lacerations, so as I hastily assess Mr. Patient and move on to bed 6, I tell a nearby volunteer: “I need a stool in bed five.”

Now, the volunteer is fairly new to the department, and eager to do a good job. She has not yet caught on to the standard reply to a request from a physician's assistant, which is usually “Get it yourself.” But she has been exposed to the art of ER communication; she knows the SOB in bed 1 is not a bad person but “short of breath,” and she knows “bed four needs a chest” is not a physique appraisal but an X-ray appraisal. So, when she hears my request, she approaches the treatment room nurse and says:

“The P.A. needs a stool in bed five.”

The volunteer looks a little embarrassed. The nurse looks at me and asks: “You need a stool in five?”

I answer: “Yeah.”

If communication is an art, we begin to create a masterpiece.

The nurse asks the nurse's aide to get a stool specimen container and instruct the patient in bed 5 while she makes the requisition.

The N.A. approaches bed 5. Mr. Patient is wearing a hospital gown. His laceration is not readily visible. The N.A. shows the specimen container to Mr. Patient and tells him he must provide a bowel movement in the little bowl. Mr. Patient tells her she must surely be mistaken, and refuses. What to do?

The nurse's aide approaches Dr. Hart. Dr. Hart is the supervising physician on duty. He does not know Mr. Patient in bed 5 from Adam, but he trusts his faithful physician's assistant. The N.A. tells him: “The patient in bed five won't give a stool specimen.”

Dr. Hart gives sound advice: “If it is just for a stool culture, we can get by with a rectal swab. Check with the P.A.”

The N.A. approaches me and says: “Can I get a culture swab on bed five?”

I am confused. I ask: “Who suggested a culture?”

She replies: “Dr. Hart.”

Well, I was not aware that bed 5 needed a culture, but I respect my omnipotent supervising physician. Perhaps he knows something about the patient that I missed. A weakened immune system? Contaminated wound? I decide I will investigate further before the specimen is sent to the lab. In the meantime, so as not to look foolish, I answer: “Sure, go ahead.”

She goes to bed 5 with her culture swab. We can only imagine what transpires. What did not transpire was the obtaining of a rectal culture. She tells the treatment nurse: “Bed five is refusing his culture.”

Refusing? She has been busy with other patients, but could it be that bed 5 was becoming a problem patient? (Now, everyone knows, once an ER nurse has labeled someone a problem patient, then that is what he is. Period. If you cross that bridge, buddy, there is no going back.) The treatment nurse, of course, knows the role of a physician's assistant. She approaches me and says: “Bed five is a problem. He is refusing his culture. You'll have to get it yourself.”

Refusing his culture? A problem patient? What news is this? Did
he read some
Reader's Digest
book titled
I Am Joe's Wound?
Some magazine article on how doctors are getting rich off of unnecessary lab tests? Well, I would speak to him. I approach Mr. Problem Patient.

“I understand you don't want your culture.” I go on to wax poetically about the dangers of undiagnosed infections, the need to discover what type of bacteria he may be harboring, and the importance of cultures in general. I am getting nowhere. Mr. Problem Patient is adamant. And I'm not sure, but does he look a little confused? Apprehensive, maybe? Of course! Not to worry. I try another approach.

“Don't worry about any pain during the procedure. I will numb the area first with some Xylocaine.” I then lay the syringe in full view on the counter and go in search of a stool on which to sit as I close the wound. Didn't I ask the volunteer to find me one?

As I culture, clean, and close the laceration, Mr. Problem Patient is very quiet. He has tucked the blanket tightly around his waist. He looks a little pale. I'm not surprised—many a strong man has gotten woozy at the sight of blood. When I finish putting on the dressing, he practically runs from the exam room.

As I dictate the note, I see there is a requisition for a stool culture clipped to the chart. The story unfolds.

Bed 5 never did return for his follow-up. Not surprising. After all, he was a problem patient.

RHONDA L. PERRY, P.A.

Honolulu, Hawaii
     

T
he GYN nurse put another patient in the next available stirrups and called me. “A four-hundred-pound fourteen-year-old with severe, generalized abdominal pain. LMP now. Never sexually active,” she informed me.

I went into the GYN room and introduced myself. The patient was extremely obese, sweaty, and screamed with pain intermittently. My first thought from about four feet from the GYN examining table was that the patient had a ruptured appendix.

The patient told me that she had been in pain for twelve hours, was nauseated, and had vomited. She had never been pregnant and had never been sexually active. Her menses had begun two years previously and had been irregular. The patient's mother, a woman of similar body size, told me that the patient had become irregular after gaining 150 pounds during the last eighteen months.

The patient's exam was not remarkable. The pain was in remission during my abdominal exam. The patient's gut was enormous and prevented an adequate abdominal exam. I ordered blood. While the blood was being drawn, I asked the patient in private if she had ever been sexually active. She said no. Furthermore, she said no one had ever touched her “down there,” and she refused to have a pelvic exam.