Bloody Assumptions

A woman dressed in all white rushed in and slapped her hand on the triage counter to get our attention.

"My husband! I need to see my husband!"

S: "Ok, let me look him up in our computer to see where he is."

"Hurry, this is an emergency!" And she burst into worried tears.

S: "It looks like he is not in our system yet. Did he come in by ambulance?"

"Yes. I can't believe you won't let me see him."

S: "Please try to be calm ma'am, you actually arrived before the ambulance did. What is he coming in with?"
She tearfully listed an extensive list of cardiac surgeries and history, his passing out at dinner, and that he had "stopped breathing twice." The triage nurses and I looked at each other- this sounded bad. We looked up to see him coming into our ambulance bay, and Ms. Hypochondriac ran to his gurney.

I followed her, and saw, with horror, a vomit basin filled with bright red foamy stuff. I've seen bloody CHF spit-up before, and this looked just like it. He groaned and seemed weak so the triage team expedited him to critical care before even getting his history.

I brought him into the room and helped the critical care team immediately undress him, take an ekg, and put him on our monitor system, gingerly removing the large red-filled basin to a biohazard bin. Upon looking closer at the bin, I froze. What were those little granules?

I asked Ms. Hypochondriac if it was blood. "Oh, goodness no, he raspberries right before we arrived."

I stared at her blankly as it began to register. "He ate such a big bowl," she added with big eyes, as if eating more would have made a big clinical difference.

Raspberries! Such a big fuss over vomited raspberries!

It was not blood in the basin, which I verified with a gastroccult. I could barely leave the room without letting Ms. Hypochondriac see the grin on my face. I don't think she could have appreciated it.

Working in the ER, we are so hyper-focused on the worst-case scenario that it is sometimes hard to see the most obvious (and comical) possibilities.

S

The Man Who Lived

Poppy Lucky was at a popular upscale restaurant in a nice part of town.  His big Italian family was celebrating his birthday or some equally important event, as one can imagine, with extravagant Italian food, wine, and dancing.  In the middle of  his celebratory dance, Poppy suddenly clutched his chest, fell to the ground, and usually, this is the last memory Poppy would have.

Not this day.  Poppy Lucky opened his eyes to twenty concerned and astonished faces and bright fluorescent lights. "What are you all doing here? Where am I? Why does my chest hurt?"
"Dad!" His son and daughter rushed to his side.
"Why is everybody crying?" Poppy was perplexed.
He would not know until later that the EMTs and Paramedics had performed CPR on his body that had no heartbeat and no breath for half an hour, and even shocked him once with a defibrillator.

"Poppy Lucky, what day is it today?" RN Muscles asked.
"Why, it's Sunday, isn't it?"
"Yes, yes it is," RN Muscles replied, "And do you know my next question, Poppy?"
"No, what is it?"
"Did you go to Church today?"
Poppy thought this was funny and gave us his warm smile.  I could tell that the deep creases in his face were shaped by his frequent use of that big smile throughout his life. He was also pure astonishment. He had many questions, as well as he should have.

As what seemed to be dozens of his offspring, their spouses, their children, cousins, siblings, and family friends took turns to come see him, he began to realize the gravity of his situation.  I could tell that though he was accepting their professions of fear, love, well-wishes, and gratitude with graciousness and well-practiced  humor, he was troubled. It was nearly impossible for him to understand that he had collapsed and almost died.  I don't think he could reconcile nor process the minutes in his life in which he technically ceased to exist.  After all, who really could?

"I'm sorry to interrupt you," I interjected once, "but I'd like to write down your blood pressure and see how you're doing, Poppy." "Well of course, young lady, please come in," he waved me in.
"So, how's his heart-rate?" his red-eyed son asked nervously.
"You know, it is a very stable 70 beats per minute right now," I answered.
"What about his blood pressure?" his son continued perplexedly.
"I think it looks like right where it generally should be at 110/70," I answered.
"What is that blue line? Why is it flat?" his daughter tried, "Why did the machine start beeping?"
"Oh, Poppy, you need to keep this sat probe on your finger, see? It stopped beeping. The blue line is his oxygen level, and it's quite good at 99%" I answered.
"So everything is...okay?" the son asked, a bit incredulously.
"It certainly looks that way," I replied.
"Oh Dad, it looks like the machine still thinks you're alive and that you'll be with us a while longer," he squeezed Poppy's hand and wiped his tears with the other.  This would be an awkward conversation in any other situation, but his words were oddly appropriate for that moment.
"So are you feeling any pain right now, Mr. Lucky?" I asked.
"No, not really, except my ribs, where they apparently worked on me." Poppy shrugged, but I could still strongly sense his uncertainty and sense of wonder at all that had passed.

Perhaps in future days, he will tell his grandchildren and great-grandchildren stories of bright lights, tunnels of darkness, flying angels and the voices of loved ones calling him back into the world of the living, but I saw in those first moments I spent with him an acutely incredulous man.  Those he loved best had convinced him of the biological facts, but it will probably take a long time for Poppy to find peace with how/why he beat the odds of staying asystolic/apneic, of sustaining brain injuries, of being intubated, of not coming back.

Poppy knew he had been given another chance at life the moment he understood what had happened to him.  As he described to me his family, the meal, the dancing, his eyes gained a dream-like state and his voice softened.  I could tell that he was habitually proud and extroverted, but during his stay, he became increasingly contemplative and humble. He will undoubtedly be a changed man after that day. And in some ways, so will I.

S

"So I Was Having Sex Today..."

(in an increasingly serious order from funny to NSFL)

Patient 1: "... when my boyfriend grabbed my boob and now it feels kinda lumpy and sore."

S: "Is that why you came to the ER today?"

Patient 1: "Yes, it's sore and I wanted to get it checked out."

S: *keeps straight face* "Ok, well the doctor will come in to see you in a moment."

Patient 2: "... and my girlfriend was on top ya know, and she was goin' up and down when I look down and it's like a ****in' bloodbath. I was so pissed she didn't tell me she was on her period, and then I started to feel pain, man."

PA: "Well, yes, it sounds and looks like you tore your frenulum." !! ouch!!

Patient 3: "... and I just felt a lot of pain."

PA: "Um, ok, well let's take a look at it. We might have to do a swab for chlamydia..."

...

PA: "... oh my... I think you fractured it."

What the PA won't tell him is that after surgery, it's common to lose an inch or two.

Patient 4 didn't say much, but it was obvious what happened. He had been using a cockring which he did not try to remove until 4 hours later. By then, his scrotum had swollen to about 3 times its normal size and was quite stuck. Our first attempt at using lubrication to slide the ring off was laughable. Even more funny was how our ring-cutter broke with no noticeable dent to the ring. At this, patient 4 finally admitted that the ring was made of titanium! Now, the fire department had to be called and much to the chagrin of a very private patient 4, he was surrounded by a room full of very fascinated male residents, nurses, firemen, and one female tech who was pouring ice water onto the electric saw to keep the ring from over-heating and burning him. After the ring was cut off, patient 4 left us wordlessly, probably too embarrassed to even say thank you to the team that saved his genitals from falling off. (In animal husbandry practices, this is actually how they castrate sheep and calves)

So next time you feel like gettin' busy, be safe! Otherwise, you should know that there is a small but distinct possibility you could end up awkwardly meeting yours truly,

S

Ascites Proprieties

My patient had an enormous belly- the kind one might endow compulsive congratulations... if he were not male. There are some patients one can immediately identify as "sick", and Mr. Ascites was one of them. Liver cancer had turned the well-muscled mechanic into a jaundiced, gaunt specter with an exaggerated paunch.

He didn't say much, but every inhalation was an agonized groan. His belly was taut with mysterious pregnancy. When the doctor pierced his peritoneum with a needle connected to long tubing, putridity birthed violently into vacuum-sealed bottles. Mrs. Ascites was nonplussed and put on samba music from her phone. "Sometimes he fills up 7 whole bottles of that stuff." Since his diagnosis almost a year ago, he undergoes paracentesis once a week. She showed me the needle marks dotting the underside of his belly, puckered like an orange.

Our efforts yielded over six liters of brown liquid.

"And that," Mrs. Ascites remarked, "is why I never drink beer."

As I carried the bottles away, I could feel the heat through my thin gloves and I shuddered involuntarily. It was irrational, but the heat felt like radiating poison. There are so many faces that evil wears in this world, but one of the most powerful, not to mention ugliest, is cancer. It is merciless. No one is indefinitely spared, no one has an out-of-jail-free card- not the bravest, the smartest, the most accomplished, the most seemingly healthy among us.

I looked back once more to see that my patient was shivering, so I took a heated blanket from the warmer and draped it over his bony shoulders. He moaned, for happiness this time. Warm blankets are my favorite way to make patients happy. "Do I look like the lady of Guadalupe, now?" he asked his wife and they shared a laugh. She took his hand and drummed the samba beat on his arm with her fingers.  Cancer was an unwelcome intruder to the warmth of their lives and they treated it as such, with complete irreverence.

S

The Stinky Details

It is the beginning of the month of June, the time of the month still ripe with the promise of nice weather, sunshine, medical school applications (again) and of course, welfare checks. The beginning of each month is a homeless feeding (drinking) frenzy that ends up irrevocably in the ER. Out of twenty patients at any given time today, eleven of them were drunk skunks. And I do mean skunks.

I never spoke with Mr. Stinkpot because when he came in from the rain this afternoon, he collapsed happily in the stretcher-bed and snored merrily throughout his whole stay. Barely rouse-able he would have flown entirely under the radar... but for his unfortunate feet. The pungent ripeness of dried feces, urine, and sweat from his caked-on jeans mixed with the rich earthiness of his socks that had been stuck to his fungus-covered feet too long.

Browned with concentric rings of yellow, the socks had holes where his feet would rub against well-worn shoes. However, this was no time to admire the joint effort of time and absolute poverty/slovenliness. The smell emanating from his room across the hallway and down the length of all the rooms on the section educed from passersby an extraordinary look of horror and disbelief, myself included.

It was hard not to keel over each time I walked by, which was potentially extremely unproductive, so I decided to take action. First, I found and aerated several bottles of peppermint spirits to clear the air as much as I could to abstain from gagging in close proximity. Then, I went in for the kill. Peeling the socks from his feet revealed much scaly sloughing and thick, yellow nails curled inward from lack of trimming. The janitoress yelled at me from down the hallway to seal the socks in an extra plastic bag before she disposed of them herself in a special container. I then took warm soapy water and a towel, cleaning the horned crevices between his toes of accumulated human filth. Drying the feet, covering them in fresh socks, then throwing a blanket over my efforts cleared the air, except when he shifted his position. Then, small pockets of noxious odors would accost those so unluckily positioned.

How did Mr. Stinkpot become this way? How could he stand to be so dirty? How could he just not care? No one becomes this way overnight; he fell into his situation from one drink too many, too many times. He could stand to be dirty because he had acclimatized to it. His nose no longer recognizes his own reek as foreign. And lastly, of course he doesn't care. To care would be excruciating. One phrase I hear most often amongst drunks is "I don't care/I don't give a ****/who the **** cares/what do you care/no one cares/other potentially impolite permutations. It is impossible to care when nobody in the world cares for you.

I am almost certain he will not notice his feet are clean when he wakes up. But my almost is by no means certain; perhaps in his depth of winter, he might yet discover within himself an invincible summer.

S

Proctologian Mimicry

Mr. Jumpy eyed me suspiciously. "Don't let her near me! I say, don't let her come anywhere near me!" He shuffled to another side of the bed.

"Why, what's wrong?" A nurse asked.

"I can't believe she did that to me, that doctor there," he pointed at me. I had been nowhere near the new elderly patient, so the nurse smiled and humored him, "what did that bad, bad doctor do to you, Mr. Jumpy?"

"I'd know her from anywhere. I will never allow anybody to put a finger there again, you hear? Now if you'll excuse me, I'm going to hide my anus."

I have logged another "first" to my list of experiences. This was definitely the first time I was mistaken for anyone's proctologist.

For the rest of the morning, everytime I walked by, he would mutter and shift, presumably hiding his anus. He watched me as I went about my duties and eventually allowed me to give him a pillow/blankets.

"You know what," he mused a few hours later, "you' all right. Just never do that to me again."

"Ok, Mr. Jumpy, I promise that you have nothing to worry about from me."

Mr. Jumpy didn't turn out to be mentally ill, surprisingly... he was just a man terrified of rectal exams.

S

My Friend Betty

I was doing an EKG on my patient Ms. Sloppy, lifting one large breast to put on stickers when I spotted Betty scurrying across a pale leg. I followed my first instinct and grabbed Betty in a piece of gauze. Gingerly, I opened the gauze and Betty looked at me for a second and we were friends at first sight. Then she attempted to scurry to the underside of my gauze, perhaps to get closer to me.

I tried to tip her into a urine cup, but I had to use my gloved fingers to carefully fish her off the gauze, though she used her spider-silk-thin legs to cling as she might a particularly hairy leg, perhaps. Engorged to about six times the size I'd previously seen, Betty the bedbug seemed comfortable enough where she was. I shook the cup, which made her lose her balance and she landed on her back, delicate legs waving in the air.

She is the perfect parasite, carefully designed to glide on light, feathery legs that help her otherwise cumbersome body escape detection. Her glossy ectoskeleton was clunky (due to overeating, perhaps) but aerodynamic and provided sufficient armor to make sure she did not suffer from being knocked around the cup I carried in my pocket. I had a long and busy day, but this did not fatigue Betty as much as it did me. Every time I showed my new friend to my co-workers, she would wave her little legs with just as much energy as before.

She had a magical effect on everyone she met. Psychosomatic pruritis followed everywhere she went.  And everyone was itchy (to meet her). 

The janitors had the most interest of all in big Betty. As the first line of defense against colonization in the hospital, I would have imagined them to see her family more often than anyone else. But no, they surrounded the little orange urine cup and they spoke in hushed tones like there was a mystical aura around it. The infestation of bedbugs isn't just physical... it's psychological, they whispered, awestruck and reverent. I hear they're impossible to get rid of and even if you do, you still feel like they're there, another added, like some sorta curse. All nodded.

At the end of the night, though, I put a quick end to our friendship; though we had a great time all day, Betty was getting feisty, clinging onto the sides of her cup, perhaps attempting escape. The janitor who watched me wouldn't believe Betty was gone and exclaimed every few seconds that 'the legs are wavin'! ' But I knew... Betty had already gone to a big bed in the sky.

RIP Betty

S