Chip on my shoulder

"Hi sir, welcome to the emergency room at ____, my name is S and I'd like to know what brings you here today?"
"Well, I've got this pain in my tooth here." He winced as he pointed. So did I, in sympathy.
"That looks pretty painful- what happened?"
"I was eatin' potato chips and one of them got stuck. I can still feel it even." He winced again. So did I, but not in sympathy.
"On a scale of 1-10, 10 being the worst pain you've ever felt, what are you feeling now?"
"It is better than it was when it first happened, so it's like a 4 now. But earlier it was a 10."
"I see... Have a seat, a nurse will talk to you soon."
"Ok... can I get anything for the pain, ma'am? They wouldn't give me anything in the ambulance."
"I think the nurse will see you really soon, so I'd wait for her opinion."
"Oh, ok."

She had heard the exchange, gave me a look, and threw him unceremoniously into the pile of charts to go to urgent care and he was discharged 5 minutes later.




But really- calling an ambulance for a potato-chip induced dental pain? Really??
S

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

Teenage Wasteland

Work hard, party harder. Ah, college, when it was ok to be so young, so dumb, and have so much fun.  Remember all the free food, all-nighters, and especially the huge parties? The parties with beer on the ground, dark corners, and unlimited alcohol for pretty freshman girls? Labor Day weekend was the prime kick-off school-year party time and I was nostalgic, almost.

Sitting in the drunk tank on the morning after the first big party weekend of the year, I had a full-house, but an unusually young one. The college girls had awoken and were giggling at the snoring homeless man between them. They had probably never been so close to one before. The drunk tank is a great equalizer in that respect.  Their expensive clothes were disheveled, their recently trimmed hair mussed, but they were still young, still beautiful, still able to recover gracefully from being blackout drunk.  They were also great socializers, still in the middle of that magical period of freshman year where everyone could potentially be your friend. They made fast friends amongst each other and discussed outfits, boyfriends, and the Iliad. They also attempted to needle me into letting them leave, as infrequent visitors to our fine establishment usually do when they have gotten bored of sitting in the drunk tank.

We had an assortment of students that day, male and female, ranging from the super pretentious schools to state schools to community colleges. They quickly fell into a hierarchy, the ringleader a clever-looking brunette from one of the most prestigious institutions in the country. Finding me sympathetic but impermeable to begging, she needled, wheedled, and stopped everyone who walked by with her sad story.  She flashed a bright smile and smoothed her hair, sitting rigidly upright with her hand raised as if she were in lecture. She was charming and I have to admit, I thought she was just in the wrong place at the wrong time...

After 2 hours of fruitless attempts, however, the underage little minx slouched down, sighing, "well, I might as well get comfortable since it looks like I won't be leaving anytime soon." Her whole countenance had been an act! I asked her nonchalantly what she meant and she grinned, explaining that people tend to do what you want them to do when you look pretty, neat, and are charming. "I wish I had a mirror. I probably look horrible, otherwise, I'd have been out of here if that resident thought I was cute," she sighed. She knew so much yet so little. She was well-practiced in the art of manipulation way beyond her years; perhaps that's how she came to matriculate at one of the most competitive undergraduate schools in the world.

People like my little patient often do slide around the rules- their increased intelligence and will to mislead do confer them advantages. For example, she did not get expelled that day like some of her drunk tank compatriots from state and community colleges. In fact, I would be surprised if she came off with more than a slap on the wrist.

I'm sure I won't see her again, but I know that she will be out there in society, slithering her way up to the top on the golden ivy-laced path.

S

Earwiggy

Reason 1 to rid your apartment of cockroaches: they're gross and totally unsanitary.

Reason 2 to rid your apartment of cockroaches: they depreciate the value of your property.

Reason 3 to rid your apartment of cockroaches: they might crawl in your ear when you sleep so you wake up to a munching sound. Then, you have to come to the ER for the PA, then nurse, then tech to try to fish it out. It might wave antennae at you as you look futilely through the otoscope. Then, when you kill it with viscuous lidocaine, you might push it in further. Finally, people will come in with these things to get the job done.

So much for sleeping tonight.

S

The Aging Doctor

She was a disheveled, frumpy little thing, with wild eyes and stringy white hair. Slumped on her bed, she was labeled as a psychiatric consult patient, which generally means she was medically low maintenance/priority for our staff unless she causes a disturbance.  However, because her advanced age, the doctors decided to make sure she had no underlying medical problems. And of course, I was asked to draw blood from her with the distinct undertone that she would probably refuse.

She stared at my face as I approached, bloodshot eyes suspicious, lip snarled. "Well what do you want now?"
"Hi, I am S, a technician working in this area. The doctor would like me to draw some blood work...'
"He doesn't know what he's doing.  I'm fine."
I usually like to hear "no" three times before I stop trying, so I tried again.
"Well, he just wants to make sure you're OK since you are in the ER, you know... I see you've brought your veins here with you today and I will be very quick with the needle."
"These young doctors keep ordering all these unnecessary tests. Look at me, I'm fine. I don't even know why I'm here."
"Well, you had said you want to hurt yourself to somebody and they called the ambulance.  How do you know they're unnecessary, ma'am?"
"Where is this place? Am I at ____? (I nodded) I was trained here, you know. I worked here for decades. What do they know?"
I eyed her in a new light; the looks, smart little shoes, haughty dismissals made sense now.
"I guess I ought to call you doctor!"
"Yeah, well, I'm retired many years," she replied, slightly mollified. Then, as if she suspected me, she added defiantly, "and if I wanted to hurt myself, there is nothing you or anyone could do about it."
"I wouldn't say that... that will make you stay even longer. But if you let me draw blood and we have evidence you have nothing going on, then the psychiatrist will see you faster and you could potentially go home sooner."
She considered this. "Fine." She gave me her arm and refused to look at me.

My patient had threatened to put a violent end to her life by taking a metal statue and thrusting a part of it into a light socket.  Alarmed, her facility called an ambulance and she was transported to us.  Looking at her 80+ year old frame in mismatched sweats, one would never guess she was once a pioneer of medicine.  I stayed with her and slowly, I gathered the pieces of her story.  One of the first female physicians, she underwent unbelievable hardships and prejudice what was once the gentleman's exclusive club of medicine.  She told me haughtily that back in the day, there was little distinction between the fields. Your primary care physician could also be your surgeon who could also do your autopsy.  She scoffed at 80 hour residency work weeks, stating that the residents today miss out on so much, which is why they don't know how to put their hands on a patient anymore.  She decried her treatment in her facility, then mused the potential benefits of new technology. Fired up about her passion, she burst temporarily from her depressed cocoon of stained sweatshirts and dementia, and suddenly I caught a vision of the timelessly beautiful and viciously ambitious young physician she was.

Then, she remembered her current state and fell silent. The sharp-eyed girl became again an old woman. I felt the sinking feeling of an elevator descending too fast. What it is like to be at the top of the world, then falling slowly, piece-by-piece, day-by-day, year-by-year into the abyss of dementia, I shudder to think.  Soon, mercifully, the helping hand of dementia and sundown-ing helped her out of her gloom and returned her to the daily distraction of confusion.

S

Overheard

"Hi, may I speak to Mr. Rash? This is RN Experienced here at the hospital and I just wanted to talk to him about his trip to the ER here yesterday. I see that he came in for a rash... is he feeling any better?

...

Oh, I'm sorry he can't come to the phone, wait... WHAT is he doing?

....

He's bathing in bleach?!... Who told him to do that?

...

Well it's definitely not a good idea to bathe in bleach.

...

Yes, well, what kind of cream was he prescribed? Yes, you need to take that prescription and fill it and it will make him feel a lot better.

...

Please, that would be a great idea. Please tell him to drain the bathtub right now.

...

Well bleach could burn your skin, it's really not a good idea to bathe in it.

...

Yes, but I strongly recommend he get out of that bathtub right now. Thanks and please call us if you have any questions. Go drain it right now. You have a good day."

True story.

S

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