Adventures in sitting: The man inside the shell

He was a handsome man once; now his scrubby patches of untrimmed beard and age-taut skin were indicative of a strong man gone to seed.  His eyes were slightly mismatched, much like his thoughts which emerged form his brain in perfectly animated little phrases and movements. If you weren't listening to his words, you might not even notice that strung together, they made little sense. He babbled, cursed, cooed, laughed, and insulted, often incomprehensibly only to himself.  He would not stay clothed and was constantly reprimanded by the physicians to stay decent.  "Hey, it's hot in here, ain't it?" his eyes rolled wildly at me. "It feels ok to me." "Well, they wouldn't mind, *would they*?" and he would begin to tug his shorts down.  Halfway down, he would forget what he was doing and I would pull them back up.  When his sitter left for lunch, I knew that I was inevitably going to have to watch him.

He stared at me for a few minutes as I avoided eye contact (my rule number 1 when in close proximity with a psychiatric patient). Yet, he seemed harmless enough. "Hey, I'm hungry! I had a sandwich... like, I had... like here." I pointed to the half-eaten tray on his lap. He clapped his hands in excitement as he remembered. He suddenly proclaimed, "I feel, like, so lucky.  You're one of the good ones, aren't you?" Cackling and smacking his lips, he began to babble.  In the middle of his soliloquy, he suddenly turned to me. "HIV isn't real, right?" His large eyes focused on mine.  "It is, I'm afraid," I replied.  "I don't wanna die. Am I gonna die here?" "Not here, I don't think," I replied. "Oh, ok," he smiled, and bit into an orange without peeling it.  

"I need to go pee pee," he announced. I helped him as he grunted to his feet and he let me drape the faded johnny coat over his shoulders. He waited patiently as I scrambled for a urine cup and moved jerkily toward the bathroom. Halfway to the toilet, he had forgotten what he was doing there. Turning around to look at me, he asked conspiratorial way, "do you do drugs?" "Er, I can't say that I do." "Well I, I, I have... a secret..." "And you want to tell me?" He nodded, "I know I shouldn't... but... like... but..."

He had lost his train of thought again. As he gathered them, he twirled the urine cup in his hand like a wine glass, like he was at a party and he was trying to tell a story.  I motioned him toward the toilet and he dismissed it with an impatient wave of the urine cup, insistently trying to continue his story. "Yeah, yeah, ok... but anyway... yeah, like... you like music?" I smiled, "I do like music, a lot." His eyes sparkled, "oh, I do too, but you know, I never liked what's his name. Famous guy." "There's a lot of them." "Yeah, ok, you're right. But I was a pianist, you know and I can't get enough of Chopin."

I was still nodding and smiling, but I could not help but notice that his speech seemed more fluid as he talked about his passion.  "Ooooh, I just got a new cd of Chopin etudes, played by the BEST. You know who that is, right?"
"There are a lot of great ones out there," I replied, "you're going to have to give me a hint." '
"You're right, but he is the BEST. Arrau."
"Claudio Arrau?"
"Yeah. But I forget where is he from?"
"I really have no clue, sounds French."
"Oh, really? I thought he was from Brazil!"
Now I had to look it up. Wikipedia stated that Claudio Arrau was Chilean and I felt a chill- not just the chill that you feel when you realize that your neurosyphilic psychiatric patient high on meth is more with it than you are, but also the chill when you realize that you've made a real connection with someone.  He was no longer merely bemusing, but a tragedy of growing proportions.  I felt a pang of pain hearing the scars of his heart, seeing the scars of the drugs and hard-living on his body, and examining the scars of his rotting mind.

I gently led him back to his stretcher- he had forgotten to actually use the bathroom, but didn't seem to need to anymore. He bounded joyfully onto the bed still clutching his urine cup and immediately began to remove all his clothing. The sitter was back from lunch and I was relieved from my duty of watching him.  As I rejoined the world of the functional and cognizant- the same world of the judgmental and callous- I could not help but think about the descent of what used to be a handsome, cultured, and intelligent man into the meth-baked shell he had become. Often we can't see this downward cascade of events that is precipitated by first times- the first rush of a new drug, the first fun time at a bar with sketchy patrons, the first date with what will become a bad boyfriend. How can we avoid these poor life-changing decisions?

The more I think about it, the more I realize- we really can't. We are at the mercy of chance, whether we accept it or not.

S

Worst Boyfriend Ever

If your girlfriend is pregnant and decides against an abortion, please don't take it into your own hands help her change her mind.  It's a life-changing choice to drive the car into headlong traffic, sending her into the operating room- and in many more ways than one.  But of course, being the lucky **#%(* you are, you'll get off with only a misdemeanor because she doesn't want to press charges!!!

Luckily, the nursing staff sees what kind of *(#%)%)(#@* you are when you try to threaten/control/thrash/scream at us, and you got knocked out pretty quickly.  How dare you.

This is what I want to do to you!!

S

A Good Story Turned Bad

It was supposed to be a funny story, kind of.  A man was sleeping in his bed when a bunch of hoodlums broke into his house, took the giant bottle of tabasco sauce off his kitchen table and hit him in the head with it. It caused a small gash on his neck and a small egg near his temple.

When I came in and saw him, I thought the orange sauce mixed with blood was all blood... until I came close enough to smell the vinegar in the air, stopped, and looked quizzically at him.  After many buffalo chicken wing jokes, we released him and all was well....

A few hours later, another trauma was called and I was surprised to see Mr. Tabasco back so soon. He had fallen after taking a nap because he was very dizzy and got up too quickly. This time, he had a spleen lac and had to get sent to the O.R. : (

Poor Mr. Tabasco.  

S

Code Pride

"Oh my gosh, what is that?" I peered down the ambulance bay tunnel and saw the EMS team running, one of them making compressions on the chest of a man on the gurney.  "There's a code coming!"

Charge nurse quickly pulled a patient out of critical care in time for us to pull a new bed for our new patient.  He was undeniably over 400lb, maybe even 500, and that's not counting the missing portions of his legs below the knees.  Foul, cloudy urine was everywhere and the tangy, musky odor saturated the air, causing more than one nurse to wretch.  The EMT was making half-effort compressions, trying to keep his already urine-soaked body far away from the patient.  He was visibly repulsed and his interest in pretending to do energetic compressions in front of us was waning.  "You wanna take over?" he asked hopefully.  "Not until he's transferred to our bed," I replied coldly.  It took six of us to safely move the large body over to the bed, whence I placed him quickly on the monitor and jumped up, straddling his shoulder.  His large arms were heavy and hung down the side, limiting the space I had.  A foul smell arose from my plastic garment as his sweat rubbed onto me.  "Begin compressions!" And so I began.

Meanwhile, the resident was right next to me with the attending. I could feel his excitement and nervousness at gaining the opportunity to intubate someone.  To young doctors, this was a learning experience and an opportunity to shine, never mind who the patient was.  They obviously didn't identify with this man, who lived a relatively short and limited life.  Huge and diabetic, he lost his legs a few years ago, and ever since, had been immobile.  As he repulsed even the ER team taking care of him, I wonder about the people he knew- whether anyone might have been kind enough to keep him company.  In his final days, he was filthy and had fallen a few times, as his injuries suggested. When he was found by a visiting nurse, he was on the ground.  I breathed rhythmically through my nose as I watched the monitor to make sure my compressions were deep enough though the smell was intensifying.  "Halt compressions!"

The resident had intubated, but there was something wrong.  The tube wasn't down far enough.  The attending moved over and tried to intubate. "Get me the glidoscope," she commanded.  "I can see the cords now." The nurses standing by were nervous- "we need to be doing compressions." "Hold compressions. The cords are *right* there", the attending commanded as she dug the tube down further.  Finally, she looked up, "give me a bougie." By now, I was commanded 3x by various nurses to start compressions, but the attending wouldn't have it. The struggle on her face didn't say whether she was more worried about saving the patient or looking a fool in front of the crowd of people around the bed, but I had my opinions at that moment.  It had now been over two minutes, maybe more since compressions were halted.  I had recovered my breath and was ready to go. "Aha." The attending smiled her beautiful smile- the CO2 detector turned golden- the tube was in, and the patient was still asystolic.

After a few more rounds of compressions, the attending asked, "does anyone object to me calling it?" She called it and everyone scattered, as was customary. Nobody wanted to be stuck with helping clean the crusty, smelly body.  The resident then noticed some blips on the screen that looked like ventricular activity, so he wanted to continue, but was unsure.  "Are you sure? if you want us to continue, then we will continue," the attending prodded, but we could tell she didn't really want to. The resident mumbled something in an embarrassed manner and we did not continue. I was left to clean the body to make it presentable for viewing.  It was just another day in the emergency room, but for this man, it was his last.  They say hearing is the last sense to go- I sure hope he didn't hear what was going on in his last moments with us.

S

Adventures in Sitting: The Strength of the Strongest Bond

"S, we need you pull you out of your current assignment to sit in urgent care." I gave the nurse a strange look. People that require sitting- alcohol abuse/substance abuse/psychiatric problems- aren't supposed to go there.  "I know," she said, "it's a special situation. They'll explain when you get there."

It was a beautiful late summer day and the afternoon sun was still dappling through the trees that were rustling gently in the sweet breeze.  I reluctantly entered the glass doors of the clinic to see that in room one was a woman, feeding a baby, speaking tensely with our manager.  The manager pulled me aside and explained: Mr. and Mrs. Feckless came today because he needed stitches removed from his hand.  They came to urgent care but it became glaringly obvious that both of them had had alcohol, both breathalyzing above .300.  DCF was called and we are waiting for them to arrive- Mrs. Feckless knows this.  "Where is Mr. Feckless?" I asked. "In the drunk tank," the manager said, "just stay in the room with her to watch her with the baby."

I entered the room and introduced myself.  Mrs. Feckless saw me and said, "I don't need to be babysat with. This is my baby, I would never hurt her." I diverted the conversational path by simply asking, "so how old is she?" She scanned my face and decided there was no intention of harm. With the indulgence of a proud mother, she smiled and said "7 weeks tomorrow." I admired the little one, who could not? The minute fingers, perfectly arranged little eyebrow hairs and eyelashes, a bow around her head, little stubby legs, the fresh smell of new life.  She is going to be such an exotic beauty, with olive skin and dark blue eyes.  This skein of conversation let Mama Bear put her guard down, and she told me about caring for Baby Feckless, bathing her, feeding her, rocking her to sleep.  Meanwhile, the baby was cradled in her arms and didn't make a peep, her gentle eyes at peace with her surroundings.

She was so gentle with the baby, knowing exactly what to do with every hiccup, burp, squeak, or kick of a little leg.  They knew each other better than anyone else.  The baby rested comfortably in complete trust, nestled on the mother's chest; it was the epitome of Madonna and Child, transcending time, space, culture and it was beautiful to see.  They gazed at each other with an unspeakable bond that was almost visible, shimmering in the air.

Mrs. Feckless looked younger than she was, but the lines on her face told me she didn't have the easiest life.
"She is the best thing I have. The only thing I have," Mrs. Feckless sighed, "I used to live in a half-way house. Then I met my husband. Everything changed. Everything bad that happens to me happens because of him!"
I paused, "... is he good to you?"
"Oh, he's the best. He's my best friend and we understand each other. We love each other so much.  It's just that he can be so stupid sometimes. Never shuts his mouth and now look, DCF is coming again."
"Again? You mean this isn't the first time?" I was incredulous.
"No, hah, it's ridiculous. The day she was born, I was alone. He was drinking and being an ******* on the streets. Then he realized he was gonna be a father and started calling my cellphone nonstop, screaming at me and the nurse telling me to hold it while he comes in the room. I mean how can you hold it? I was having a baby! The nurse told him never to call again and not to come in, but he burst in and caused a scene cause he was drunk, you know.  They called DCF that day.  But he's good to me, he really is."
On the day the baby was born. Unbelievable.

She was comfortable with me and made easy conversation, cradling the baby close.  The baby had dozed off and slept comfortably, positioned next to her mother's neck.  Maybe she never had anyone to talk about this with or maybe I was just a receptive listener, but she relished in the details of describing exactly how the baby would smile only at her, and how to decipher the squeaks that the baby used to communicate with her, and how gentle, quiet, perfect this baby was compared to her now teenage son, who was a nightmare baby.

"You don't have any children, do you?"
"Oh, no," I laughed, "that's... far in the future."
"It's a good thing. I was your age when I had my first. I was barely a baby myself and I had to grow up real fast.  If I had any advice for you, since you're nice and sweet, it would be this: travel, go to school, have fun, and never settle."
"Oh, I'll never settle, don't worry about that one."
She smiled at me and DCF walked in.

"Can you step out?" asked the severe woman wearing severe high heels.
"Of course," I said, feeling a chill and they shut the door behind me.
The tech that brought DCF over pulled me aside. "When those drunk fools came stumbling in, you know what he said to me? He looked me in the eye and said *****, get these ******* sutures out of my hand now. And I was like uh, hold on, sir. I told them he was drunk and was like you need to call DCF. You know what, they deserve this for being idiots. That baby is not safe with them."
I listened in silence. Maybe... but could anyone else take better care of someone else' baby when the mother is already attentive? Mrs. Reckless didn't seem very drunk at all- in fact, I would consider her to be more competent than many mothers with very young children I've seen in the ER so far.

The door cracked open and I heard, "I need to call my supervisor, so just hold on."
"Please don't take my baby from me, please, I'd die without her, please."
"I said I would call my supervisor. Please wait a minute."  The she-wolf in heels nodded at me and I went inside.

"I told him not to drink, but then he got ME drunk, and I never drink. You can ask any of them and now look!" Mrs. Feckless started crying and I got her a box of tissues, "He ***** up so many times. I do it once and now I'm being punished for it. It's not fair! I've done everything I was supposed to do- I sat here quietly, I waited, I didn't make a scene... but I'm still being punished."
She cradled the sleeping baby in her arms and kissed her several times. "Never, never... They're all liars. I don't believe a word they say.  She wants to put my baby with a foster family and says I'll get her back, but I don't trust her. I don't trust none of them. I just want to go home with my baby!"

I heard the clinic door open and watched 3 county officers walk in.  DCF came back in and I exited the room and grilled the officers.  Mr. Feckless had been arrested and Mrs. Feckless was papered. She may well be arrested as well. That would get her fired from her hard-won job at a supply depot.  I couldn't help but feel a cold horror, like I was taking part in something terrible and wrong, like a hapless grad student working in the monkey room under Harry Harlow.  http://en.wikipedia.org/wiki/Harry_Harlow

DCF came out once more and asked another tech to go inside and "distract her" with the paperwork. Mrs. Feckless was helpless and laughed bitterly, "I know what you're doing. You're taking my baby away."
"No, we're just making sure she's healthy," DCF said as she slowly wheeled the stroller out of the room.
"But what about all her clothes and things?"
"Well, do you have a bassinet at home? If you give us your keys, we'll take what she needs for her stay."
"But how am I going to get in and out of my house?" Mrs. Feckless looked so worn.
"We'll figure that out."
"Where is my husband? Did he get arrested? I'm have to leave him... this is too much, I can't take this. I'm losing my baby..."
"You won't lose her forever if you go to the session tomorrow as it says on this paper, since it is your first offense. If you do everything like we say, you'll get her back soon." The DCF woman said.
"How soon? Tomorrow after the class?"
"It depends."
It was too cruel.

Quickly, matter-of-factly, efficiently, it was all done and she was asked to leave.  I gave her a hug and told her to take care as she was escorted out, silent and broken, by the officers into the gorgeous afternoon. I watched her look longingly as they walked right past the van where DCF was tying in the still-sleeping baby.

S

Adventures in Sitting: The One that Broke Me

There was a time, y'all, not too long ago, that I was living in the valley of kittens and rainbows. Every patient, regardless of ailment or creed would get a blanket, a sandwich, and a smile (if the medical situation allowed). People weren't incapable of evil- sometimes their disease states just made them grumpy. Even my rowdy drunks didn't mean any harm- their curses and threats were forgotten by them before the next time they request an urinal or sandwich. If you were kind to them, I thought, people would respond in kind.

Oh to be young and naive! A shift in the drunk tank soon cured me of that.

Entering my shift in the drunk tank, I was given report of my 3 patients. There was Ms. Opportunist in the middle, Mr. Passed Out in the back, and Mr. Two-faced in the corner. Mr. Passed Out was passed out, Ms. Opportunist was sitting comfortably, and Mr. Two-faced was sleeping in his stretcher- he had been like that all day, the tech told me. Ok, that's fine, I replied, anything I need to know? Nah, they've been quiet all day, she said.

I was all set. My cart was equipped with water, sandwiches, and whatever else. Mr. Two-faced rolled over and woke up.

Mr. TF: Hi, miss, can I get a drink of water?

S: Sure, here you go.

Mr. TF: Thanks a lot, you're really nice.

S: It's my job.

Mr. TF: Miss, can I get just another glass? I'm parched.

S: Sure.

Mr. TF: Thank you so much. That really hits the spot.

He was very polite and kept to himself- he was easy-going and quiet. He asked for a sandwich half an hour later, stating he hadn't eaten in a day or two. No problem. He was very thankful for it- so thankful, he asked for another one. Again, no problem. He was comfortable, I was comfortable, things were good.

I checked his vital signs and breathalyzer- he was on the cusp of sobriety where the residents might release him, but still a few points higher than the dogmatic new resident might like. He asked whether he was going home, so I let him know it would be a little while longer. No problem, he said.

He was as sober as was possible for a chronic drunk, I could tell, and was getting restless. I let him go to the bathroom. When he returned, he perched on the edge of his stretcher. He acquiesced when I asked him to sit back all the way, though.

Without warning, he got up and walked to the side of his stretcher. Warning bells sounded in my head.

S: Hey Mr. Two Faced, what are you doing?

Mr. Two Faced: Just looking to see my stuff is here.

S: When you're done, can you please sit in the stretcher?

Mr. Two Faced: Sure, honey, anything you ask. Where is my stuff?

S: Isn't it back there?

Mr. Two Faced: No, where is it?

S: Let me check in the back closet..

Mr. Two-Faced: is it there? My big bag full of all my clothes?

S: Hmm, no, I didn't see it. I will call the nurse to see if she saw anything in the section you came from.

Mr. Two-Faced: Aw ****, I can't believe you guys lost my ****. again! Twenty times I come here, twenty times I lose every *** **** thing I own. I am homeless, y'know, I dont have much. **** me. **** you.

S: I'm calling the nurse, hold on.

Mr. Two-Faced: No, Get a manager over here, right now.

S: Mr. Two-Faced, I am doing all I can to locate your belongings. Will you please give me a minute, sit for a bit and we'll see what's going on?

Mr. Two-Faced: All my clothes! I don't have nothin'. All my ******** clothes. You guys better have a lawyer, cause I'm suing your ******* ****** for all it's worth. Take my clothes, eh? You'll pay for it.

S: Nobody here wants your clothes, Mr. Two-Faced, we're searching for your stuff right now.

Mr. Two-Faced: **** you. All of you are losers. You're phony. You pretend like you care then you lose all my ****. Well **** you.

S: I didn't lose anything. You were here before I came in.

Mr. Two-Faced: You work here, you lost my ****. End of story. You don't give a **** if I live or die or if I lose all my ****. You rotten *****!

S in a soft voice: I do care, Mr. Two-Faced. I'm really sorry you lost your stuff- really, I am. We're doing our best to find it and it has only been a minute since I made that call. Please, just hold on and I'm sure your stuff won't just disappear. Nobody here would want your clothes.

Mr. Two-Faced: **** you. I want a manager. RIGHT NOW. Go on, do your job, call the ******* manager cause I am gonna sue all of you *******. Dirty ******, what are you waiting for?

At this moment, Ms. Opportunist- can I please go to the bathroom?

S: Sure, but come right back.

I watched her from the door as Mr. Two-Faced starts pacing and screaming at me again. I have never had anyone scream at me like that, voice breaking from all the strain. What did I do to deserve this? I FED him, I thought with revulsion. I am keeping homeless psychotics like this alive so they could abuse me and abuse the system.

Mr. Two-Faced: This place sucks! All you could do is feed me bull**** about how you care and ****, but you don't give a ****. None of you care. You're heartless ******* who don't care if I live or die.

S: I do care, Mr. Two-Faced. I'm sad you can't see it.

I watched Ms. Opportunist come back out of the bathroom... and run out the door. I had completely lost control. Backing out of the room as Mr. Two-Faced tried to swing at me, I called security, and to my horror, burst into tears.

He had turned a switch and I was unprepared for his sudden outburst, after 12 hours of mind-numbing work already. He had been testing me and knew exactly which buttons to press. I cried for you, Mr. Two-Faced. You are just too broken, biting the hand that you were so thankful for, that fed you not too long ago.

Security jumped on Ms. Opportunist, pinned her down, brought her back, and restrained her. Mr. Two-Faced was thrown out. Mr. Passed Out was still passed out. And I grew up a lot that day. I will never forget the screeching voice, the angry eyes, and the semblance of civility that he put on when I first met him. Should we meet again, I have some choice words for Mr. Two-Faced.

S

Critical Heat

I had some very ill patients today that should not have been in the general emergency section I was working in.

Lady #1 had a blood-glucose level of 35mg/dl. Normal is 70-100mg/dl. At such a low number, she could go into seizures or coma, so we kept a very close eye on her.

Lady #2 had uncontrolled diabetes and a critical high glucose that the meter could not read. She was still "CRITICAL HIGH-NOTIFY NURSE" 4 hours later when I checked again.

But my most worrisome was a middle-aged man, Mr. HMH (Huge medical history). Mr. HMH could barely speak; when he did, it was in a high, whiny, breathless voice. Noticeably weak, he could barely lift his arm for me to wrap a blood pressure cuff around him. His pressure was 80/50, much too low because he kept nodding off with his eyes wide open. Because his skin felt hot, I fetched a rectal thermometer. As the nurse rolled him over, I pulled down the diaper and saw a large stool stuck in the rectum. We also found a bedsore that was unknown to us before. We tried to clean the stool, but soon found that he was completely and deeply compacted with feces. Then, we unwrapped the dressing and found an advanced stage bedsore (http://en.wikipedia.org/wiki/Bedsore) with tunneling into the wound. Ouch! His rectal temperature was 100.0degF, so he had a low-grade fever. When I asked him his pain level 1-10, 10 being the worst you've ever felt, he replied 10.

"Where is your pain, sir?"

"Everywhere."

"Is there anywhere that hurts the worst?"

"My butt."

"Can we roll you off your sore? Maybe that will help."
"Yes, please."

With shaking hands, he held onto the railing and I stuffed a pillow under him to take pressure off his hip.

"Is that better?"
"Yes, thank you, thank you."

"Ok, is there anything else I can do for you?"
"Can I see your arm?"

"...Sure." I handed him my arm. He held it slowly to his lips and kissed it, murmuring, "God bless you. Thank you."

I felt tears spring to my eyes. I patted him a few times on the shoulder. Later, I brought him some orange juice with a straw, that he drank slowly. It must be a terrible experience to be sitting in a stiff stretcher for 10 hours with nothing to eat and not being allowed to move around much.

And then they pulled me out to sit with combative drunks, one of whom told me "you're too nice to live in this country"- thanks buddy... but that's a story for another day. I went to my ER for a ceremony this morning. Upon seeing me, I was recruited to come into work early. It will be a veeery long shift- I know it already. At least I cajoled the charge nurse to switch me out of the drunk tank tonight. :-)

S

Adventures in Sitting: The Core of a Human Being

The whole section was full, which was not an uncommon occurrence in my Emergency Room. The rooms were all occupied and the hallway was crowded with stretchers. I was making my rounds by looking in the rooms to see who were my sickest patients. Out of the corner of my eye, I saw a large grin. I looked up to see a patient waving at me, smiling.

The closer I came to him, the stranger the sight. His forearms were wrapped in bloody bandages and he looked to be sitting in coarse black soil. His hands were black, and on closer inspection, I realized they were black from dried blood. The "soil" was also dried blood. He was covered from head to toe in it, like a cracked body-suit of red-black paint chips. Juxtaposed with his bright smile under a baseball cap, it was grotesque and macabre, like an evil clown. He waved at me each time I walked by, with the same grin, perhaps to unsettle me. I grinned and waved back, playing his dark little game.

Soonafter, I heard the words I expected from a nurse: S, we need you to sit. I already knew who it was for. I pulled up a chair in front of him and introduced myself, asking if he needed anything at the moment. He studied me with narrowed eyes under a baseball cap. His smile didn't reach his eyes. Oh, no, thank you- again he grinned. And I sat down.

"So what's your role here in the Emergency Room?" he asked, "By the way, call me Chris."

"OK Chris, I am an Emergency Tech, which means I am an EMT stationed in the hospital."
"So that means that you are pretty useless, since you're not a nurse or a doctor or anybody important."
"According to that definition, I guess am pretty useless, Chris."

He smiled at this, realizing he would have to try harder to get to me.

A nurse walked by, her normal ponytail in a bun. It was a nice look for her. "Hey, I like your hair that way," I commented.

"Thanks!" She said.

Chris suddenly interjected, "C---liar----ough", grinning.

"How do you know, Chris?" I looked at him.

"Because none of you really care."

"We wouldn't be working here if we didn't. We'd burn out so fast."

"I've been here enough times to know for myself."

"If you say so," I replied.

Suddenly his eyes grew wide. "I know what you are!"

"What's that, Chris?"

"You're the watcher!"

I exaggerated the motion of my eyes toward his bandages, then met his eyes. "Would you say that it's unwarranted?"

"No, I guess not." He muttered, de-escalated for the moment.

Chris was the calmest (awake) person I had ever sat for. He made no motion to get up or make a fuss. He just fixed his steady gaze on me. I realized that not only was I watching him, but he was watching me.

I soon found that I was the only one he tolerated; he made several nasty, sarcastic remarks to the friendly nurse and others who came in to take vital signs and breathalyzer tests. Never once did his eyes leave my face, which I kept neutral, to his disappointment.

"So what are you thinking about? Aren't you supposed to be watching me?" he asked, watching my eyes move with the action of the room around me. He didn't realize I've been watching him continuously in my peripheral vision for the past hour.

"So how did they find you?" I turned to face him.

He looked into my eyes. "Because I let them." They were unflinching, aggressive, and challenging, as if to dare me to look deeper into the darkness he believed his soul to be.

"Do you regret it?"

"It's not the first time." He grinned. "But I have to say, it's never been this bad."

"I see. Well, blow into this straw for me." He breathalyzed clinically sober and it was time for him to move into a room for the doctor to see him.

"Cut off his bandages and clean the wounds before I look at them," instructed the doctor.

I emptied a bottle of sterile water and peroxide into a sterile basin, gathered a few plastic pads and containers of sterile gauze.

Under the bandages, in three different places, he had cut his forearm into ribbons, exposing torn muscle, tendons, and strips of skin. Seeing his wounds temporarily took the grin off his face as he examined them with a bemused smirk. "S***, I really ****ed myself up this time."

"Does this hurt?" I gently wet the gauze and towels and set to work, easing the dried blood from and around the wounds. He shook his head no. He watched me much more somberly now as I worked carefully to avoid pulling on the delicate strips of dislodged skin. The wounds cleaned, now I wet a towel with warm water and set to work on his black hands. "Oh, you don't need to do those." I ignored him and cleaned his fingers, one by one. I also wiped the dried blood from his face.

"Can I bring you a clean blanket?" His was bloodied.

"It doesn't matter." I brought one anyway.

"Are you hungry?"

"Maybe a little."

"Let me ask your doctor if you can eat something."

When he saw that I brought him a sandwich, his demeanor changed. "You are the only one in this ******* place that gives a ****. Look at them. Most of them wouldn't care if I died right here. Why do you care? Why do you care so much? How do you care?"

"It's my job," I replied dryly, hiding the stab of sadness I suddenly felt at his questions.

"Well, you do a good job."

"... Thanks, I guess..."

"No, I mean it." I thanked him and examined him once more- this damaged person that took a knife to his own body in such a violent way.

Over a hundred stitches and a few hours later, he was medically cleared to go to the psychiatric section of the hospital. Weeks later, a security guard referenced the guy who sliced his arm open in a horrific way. I knew immediately who it was. They were almost certain he would be restrained given how violent he was upon entering our Emergency Room and surprised he calmed down. The nurse remembered his rudeness and everyone commented on his strange affect. I kept quiet, for better or worse, because I didn't think his demeanor was strange... maybe that is why he chose to talk to me normally and let me see his damaged core- he realized I wouldn't judge him, that I knew that his passive-aggressive acting-out was just his way of dealing with his emotional crisis.

I still think of Chris often and sincerely wish that he has found found at least a temporary peace.

S

Adventures in Sitting: Sundown Showdown

"Hey S, we're going to give you another one."

Aw man. I looked up and saw a quiet little old man (LOM) sitting demurely on a stretcher in the ambulance bay. I already had 3 patients I was sitting with. One had been smoking funny stuff and got violently combative in the ambulance bay. He was in 4 pt velcro locking restraints and medically knocked out, snoring. Hopefully he wouldn't wake up anytime soon. I had one suicide watch who was shifty, and another psychiatric issue lady, who was looking around nervously. At least this new LOM looked quiet.

My LOM shook my hand and called me dear when he was brought over. He was very polite and asked if I would hear his story- they were moving him from hospital to hospital, he told me, listing the hospitals. Maybe because they didn't know what to do with him, he sighed. This was strange to me- I wondered why none of those facilities could resolve his problems. That and, he just seemed so nice. "Well, sir, just sit back in your stretcher and a doctor will come see you soon." "Thank you for listening, dear, you are very kind." He sat back and watched me. His eyes were lively despite his muted demeanor and turned up at the corners. His manners suggested a high level of education.

For the first hour, he just sat, with his hands folded in his lap, pondering his situation, occasionally staring over at me. I smiled at him and asked him if he was comfortable. "Oh yes, I'm fine." Under "patient behavior", I wrote "calm".

At the two hour mark, he began to shift around. He started moving forward in his stretcher. This put me on alert, and I asked him, Sir, where are you going?

"Well my dear, I'm over 80 years old and sitting in one position is making me very stiff! May I just sit at the edge of this bed just so I could move my joints a little?"

It seemed a reasonable request, albeit one I don't normally acquiesce to, but he really was just a LOM.

"Just stay there, though, and move back when you feel better, Mr. LOM. I don't want you go get run over by a stretcher."
"Of course, dear."

I watched him more closely now. His eyes were shifting and his hands moving. He shifted his weight again and I saw he was going to stand up. "Just to stretch my legs, dear"

"Sure, sir, but you're not supposed to be up."

He sat back down.

He stood up again, then sat back down a few times. I relaxed a little. Poor guy, his legs must be sore.

Under "patient behavior", I wrote "restless".

"What's the weather like outside? Is it raining?" He suddenly asked.

"I don't know either, sir, as you can see, I've been here with you and have not been outside or near a window in a few hours."

"I think I'm going to walk and take a look."

"Sorry sir, you can't do that. I am watching 3 other people here. It's not safe. Can you please sit down?"

He stood up and walked a few steps. Seeing me watching, he said, I just need to take a few steps, that's all. I just nodded and watched him sit back down on his stretcher. Soon enough, he got up again, and started talking to the secretary.

It was a very busy day in trauma. Stretchers, x-ray machines, ultrasound machines, technicians, trauma surgeons were all milling about. We were right in front of the trauma room and the secretary was dealing with a lot of paperwork from the rest of the department.

"Sir, I'm going to ask you to sit down for your own safety. As you can see, there are many people and machines rolling around here. I don't want you to be injured."

"Young lady, I signed myself in here and I can sign myself out. Don't tell me to sit down." His demeanor changed completely.

"Sir, please sit on your stretcher and lie back all the way."

He ignored me and continued harassing the secretary.

"Mr. LOM, I know it's uncomfortable, but you could really get hit by a stretcher there. Can you just sit and wait for the doctor?"

"There was a statute passed last week that says I can sign myself out if I want to! You can't make me sit!"

"Believe me, if such a thing were passed, we'd be the first to know. Now, you're here for a psychiatric evaluation and you should not be wandering. This is my job on the line if you get hit." I tried to de-escalate the situation, but it didn't work.

He suddenly came at me and I took a step back. He towered over me a few inches from my face. "Do you understand English? I won't sit down. Call security if you have to."

He returned to have a perfectly civil conversation with the secretary once more.

Two officers came at my call; Mr. LOM introduced himself to each of them, shaking their hands and telling them how confused he was to be treated this way. He ignored me and the officers spent twenty minutes talking with him. However, when coaxed to sit on the stretcher to talk, he grew agitated and again refused, trying to state various articles of newly written statutes about his rights in the hospital. It was almost kind of funny how the way he looped the security officers around in non-sequitur or circular arguments.

I decided to take a look in his chart to see why he needed a psych evaluation. Apparently, he had attacked an aide at the nursing facility and was pushed from hospital to hospital for his misbehavior until he came here. This was someone who has been and could become dangerous.

The security officers requested doctor's orders for restraints; Mr. LOM was obviously not going to cooperate, so I called his doctor and nurse over. Mr. LOM took each by the hand and introduced himself, smiling and insisting that he was being misunderstood.

He seemed so nice, but reality bites.

The doctor didn't want to put him in restraints, but when I told the story of what really happened, Mr. LOM lunged at me, security caught him in mid-air, and they threw the old man onto the stretcher and put him in 4pt locking restraints. He let loose a litany of curses and threats as I've rarely heard in my sojourn sitting, but to no avail. He was soon sent to the psychiatric ward, so he didn't have the restraints on for long.

A security officer pulled me aside later and told me: Mr. LOM was once a very prominent, well-known lawyer who was lately placed into a nursing home for advancing dementia.

The doctor told me that it was a classic case of sundown syndrome. http://en.wikipedia.org/wiki/Sundown_syndrome

Very scary. What an awful drop he has made from being at the top of the world.

This is a story that replays in my mind fairly often. I remember his intelligent eyes that bent up at the corners and his unrepentant fury. I hope he finds peace and dignity.

After Mr. LOM left, my PCP patient woke up, winked at me and asked me in every way he could think possible for my number/email/contact information for the two more hours I had to sit with him. "This city's a small place, you know, I'll find you." What a creepy job on a creepy day!

S

Too Sweet

"Hey, can you go to pedi side and find me numbing cream so I can start an IV?" A nurse asked me.

Uh, sure... it was an odd request, but interesting. I came back to see the child it was for.

Just kidding, it was for room 9, a man in his 60's. The nurse and I walked in to see his glaring face.

"Now I'm gunna tell yous right now, I ain't gonna be nobody's pincushion. There won't be no stick stick stickin', you got that? I won't do it without numbing cream, so yous better go and get it now. And after this, tell the doc I'm ready to go home."

"Well, sir, I just brought the numbing cream. Please be patient with us because we're trying to help you." I said in my most calming voice. He glared.

Oh boy.

The patient has a baseline blood sugar of 400mg/dl every day. For normal people, the range is 70-100mg/dl. He came in today because his sugar hit over 500. Having such a high baseline is extremely dangerous and can cause raging infections and organ failure. His limbs were swollen to at least twice their size, scaly like old tree trunks, and darkened, like he had stuck them in molasses, then Oreo cookie crumbs. There were numerous open sores, like ulcers, pink and unlikely to heal. He didn't seem to care, though, and thoroughly resented being in a hospital. "I'm fine," he snarled, "can't wait to sign myself out of this ****hole."

It was already late in the evening, almost 2100, but in trudged some family members and a young toddler as we were going to begin the process. He ignored us now (thankfully) and started cooing to his grandson.

Grandpa: "Come 'ere. You's a bad boy, y'know that? A bad boy. But it's ok, if anybody messes with you, you say **** 'em."

"**** em," the boy repeats

Grandpa: "Ahaha, that's right, **** them"

Boy:"**** them" (stop saying that! says the mother)

Grandpa:"Pay 'em no mind. you can say **** them too"

Boy:"**** them."

Grandpa: "**** 'em."

Boy: "**** 'em."

The nurse I was with was losing his cool. He had young children at home. I watched the red slowly creep up his face at the exchange. "**** 'em!" "**** 'em!" "**** them all!" "**** them all!"He was still searching for a good vein, finally finding one on the wrist. He cleaned the site, but couldn't take it anymore.

"Excuse me sir, there are some very sick patients next door, please stop yelling- they don't need to hear that."

Our patient jerked his hand away, and shoved his blanket aside, pulling out his penis. "I'm gonna pee. now"

I ran for a urinal, and he peed, nonchalantly, in front of everybody. Finished, he handed it to me with a huff, as if it disgusted him, then went back to cooing at his grandson. The urine dipped positive for lots of proteins (bad sign for kidney filtering), ketones , lots of glucose, and blood.

I handed my 'numbing cream' to the nurse. It is actually quite cool- a refrigerant, if you will;

It temporarily freezes the area of contact, turning the skin white, distracting children from the pain of an IV insertion.

"**** that's cold!"

He barely felt the IV, which is good, but unfortunately it was only good enough to draw some labs, not good enough to use for fluids.

The nurse went out to the hall and recruited another nurse. We returned for round 2.

The patient rolled his eyes, yelled loudly about how terrible this place was, flailed, but to no avail. The doctor came in once more to cajole him and his family did too.

"I'm a let you know- this is the LAST time I'm gonna get stuck, you hear that?"

The nurse looked for a site, cleaning the skin with an alcohol wipe. Filthy! He showed it to me. Sixteen alcohol pads later with furious scrubbing, the alcohol wipes were still coming back black and dirt-like.

"What are you doing? Scrubbin my skin off?"

"Sir, it needs to be sterile."

"You don't need to scrub so hard."

"Well, sir, it's dirty." Oh boy, this nurse had a snarky sense of humor.

He jerked his hand back again and screamed some profanities. "Sir," I ventured, "we are really doing this for you- you really don't want to develop an infection, ok? We're trying to help you. It'll be over really quick, and look, we'll use the numbing stuff again."

He pulled the blanket down again. "I'm gonna doo doo."

"Come on, sir, are you really gonna whip that out in front of everybody?" The exasperated nurse asked. The family took this as a cue to say good night to grandpa.

I rushed out to look for a scat pan.

Coming back, we were to try again.

"So, where are you from?" I tried to distract him.

Grandpa: "Down South."

"Oh, I love it down there, people are so nice."

"You got that right," he smiled, "where you from?"

"well, I grew up right around here."

Grandpa: "really??"

"yeah, hard to tell, right?"

Grandpa: "I grew up here. I got the **** outta here when I could, boyyyy, ain't never comin' back. I'm here to see the family, then gettin the **** outta here."

"I see."

By now, the nurse successfully inserted an IV in the finger and drew the rest of the labs. Unfortunately, he was going to need another IV site- perhaps by ultrasound. Speak of the devil- the transporter was there to take him to x-ray and ultrasound. He left the room and we all looked forward to trying again when he got back.

I sprayed the numbing canister at the back of a co-worker's scrub pants and heard a yelp as the cold seeped through. I think I found a new toy. :-)

S