by SA Magnusson
I frowned, looking around. The ER wasn’t terribly busy yet, which was a good thing, but had I been the only fool to come in?
Others might have been smart enough not to answer when Dr. Locks called. That might have been my inexperience at working as an attending. Others were smart enough to know they should avoid answering calls from the hospital in their off hours. That was one of the benefits of being an ER doc; we were supposed to be off the hook when we were off, and there was no call, just as there should be no need to come in like this.
Then again, this was something of a unique situation.
“It looks like I’m going to be powering through patients. What do we have this morning?”
“Kind of the usual for a Saturday morning.”
The usual on a Saturday was a little bit different to the usual on a Sunday—which often consisted of little old ladies who fell or fainted while at church. Weekdays were a different crowd yet—most of the time in the early part of the day, there were kids who were trying to get out of going to school, sometimes parents trying to get out of going to work, and then the smattering of work compensation-related claims that came in throughout the day. But Saturdays often had a unique flavor to them. As I scanned the listing of patients, I noticed three different orthopedic-related injuries—likely all tied to sporting type activities, and then there were two patients who looked to have stomach pains; one was a teenager where it was described as a probable bladder infection, and then an older patient concerned about a bowel obstruction. When patients came in concerned about bowel obstructions, they usually had a reason to do so.
It looked like the best one to start with would be the older patient with abdominal pain. That one would require the most work-up, and if the goal was as Dr. Locks had said, naelyy to get patients through here as quickly as possible, then I figured I should do that first.
I found Mrs. Jorgenson to be a perfectly pleasant eighty-five-year-old woman. She had her hair all done up, with more makeup than I had worn last night on my date, and she was dressed in a nice dress with a necklace. She glanced up at me as I came in, not nearly in as much pain as I would’ve expected given what her presenting symptoms were.
“Mrs. Jorgenson?”
“That’s me.”
“I’m Dr. Stone. I understand you are concerned about a bowel obstruction?”
She smiled and patted her stomach. “I haven’t gone in three days.”
“Have you ever had a bowel obstruction before?”
“About a dozen times.” She still smiled at me, something I found impressive considering what a bowel obstruction would have felt like. I’d had patients suffering from them and knew how miserable they could be.
“When was the last time you had an obstruction?”
“About a month ago. I was traveling and was hospitalized in Wichita.”
“Why Wichita?”
“That was the nearest hospital,” she said.
“I understand that, but why were you traveling to Wichita?”
“I have a daughter who lives in Oklahoma City.”
“And you still drive down there?” That surprised me as much as anything. I would’ve expected her to have been the kind to fly.
“I’m not a fan of airports. Airplanes either, for that matter.”
“Why not?”
“It’s a long story, but let’s just say I prefer to drive.”
As I looked at her, I wondered if I would be as willing to drive when I was her age. I had no idea how long a drive it would be to get to Wichita from Minneapolis. Probably ten or more hours, and far enough that the road trip would be miserable. I could understand why she would have gotten an obstruction when traveling like that. Sitting, basically being immobile, was one of the risk factors for developing a bowel obstruction. It was also a risk factor for developing blood clots, which made me wonder if her abdominal pain could be something other than an obstruction.
“Have you ever had surgery for it?”
“Not yet. They tell me I’m lucky.”
I smiled. I don’t know I would consider having repeated bowel obstructions lucky, but then, maybe it was lucky she hadn’t ever had one requiring surgery.
“Well, let me take a listen, then.” I pulled my stethoscope off from around my neck, stepping toward her. “I’m sorry about the heat.”
She waved her hand. “I don’t mind the heat. I’m always cold, so the heat is not so bad. I could use a little bit less humidity, though.”
I smiled as I pressed my stethoscope down onto her stomach. When auscultating an abdomen, I was listening for typical bowel sounds, the sounds that reminded me of the way someone’s stomach would gurgle when it was hungry. In this case, as I moved the bell of my stethoscope around her stomach, pressing and listening for a little bit, I heard a few high-pitched sounds but nothing else. Pulling the stethoscope off, I pressed on her belly, feeling for any firmness or anything else that might suggest she had any masses, but didn’t find anything.
Stranger still, it didn’t seem as if she was in any pain as I examined her. Either she had a high threshold for pain, or she wasn’t nearly as uncomfortable as she should be.
“I’m going to get a few tests, and then obtain an x-ray to see what your belly looks like.”
“A regular x-ray never shows anything for me. They always have to get a CAT scan.”
“Is that right?”
“Unfortunately. I’ve had more of those things than I can count.”
I wasn’t a fan of imaging people more than was necessary. There was a real risk from radiation; regardless of the newer CT scans using lower dose radiation, there was still a danger from them.
“Why don’t we see what shows up, and then we can go from there?”
The computer in this room wouldn’t be active. Only a few were working on reserve power, which meant I had to find one of the special PCs to use. Heading out of the room, I found one at an alcove, logged in, and entered the orders quickly. As I did, I scanned through her record, something I should have done before, but fatigue had made me a little less inquisitive than I should have been. As I scrolled through, I saw she had been hospitalized before, but the last time was about a year ago, and it wasn’t for a bowel obstruction but for constipation.
I pulled open the note, scanning it. It was difficult to determine anything from the discharge summary, but it looked as if the residents taking care of her at the time thought that if anything, she had an ileus rather than an obstruction. An ileus was nothing more than the bowel essentially going to sleep. In this case, with her hypoactive sounds, that could have been what we were dealing with.
It was difficult to fake, though I couldn’t shake the sense she was pleased to be here.
Labs and an x-ray would be a good starting point, and if I didn’t see anything, then maybe I would start with an enema before moving onto anything else. I wasn’t too eager to overly image her. If we had power, I might have been more interested in trying to obtain records from the hospital she’d been to in Wichita, but I wasn’t sure we had time to do that and wasn’t sure it made a difference in my management of her.
The next patient I saw was the teenager with a bladder infection. It turned out she was sexually active, and she was mostly concerned about STDs, which involved me counseling her on safe sex and then obtaining tests.
“We can make sure you don’t have a bladder infection, but without any other symptoms, why don’t we wait and see what the rest of the tests show.”
“Will those be back today?” she asked.
I shook my head. “Unfortunately, it usually takes a few days for us to get results. As you can see, we’re in a low-power situation, so only the essential tests are being run.”
“But this is essential,” she said.
“Are you concerned you might have been exposed to something?”
She turned away. I suspected there was something she wasn’t sharing with me, but with teenagers and sexual activity, it was often difficult to know what
they were hiding.
“I just don’t want him to know.”
“Him?”
“My boyfriend. We’ve been seeing each other for the last year, and he went away for the summer to work at a church camp, and…”
I shook my head, thinking I had the idea. Pulling the stool up, I sat across from her. “You know, it’s okay for you to enjoy sex. I’m just trying to say that you need to be safe about it. In that case, it means birth control of some sort unless you are actively trying to get pregnant. It means condom use so you make sure you aren’t getting exposed to something, unless you’re in a long-term and committed relationship. And it means being honest with the people you’re with.”
“I don’t want to hurt him, and this thing with Xerxes is over. It was just a summer fling.”
I suppressed the desire to make a comment on the name Xerxes, and instead tried to smile at her. “Like I said, we will have the results at the beginning of the week, and you can go and see your primary care doctor to get them.”
“I guess I was just hoping I’d find out today.”
“When is your boyfriend getting back?”
“Tomorrow.”
“Tell him you have a bladder infection. And enjoy your time with him. You don’t have to have sex the first day he’s back.”
She nodded, and I patted her hand, though wasn’t sure I had done anything to reassure her. I suspected there was still a lot she didn’t want to tell me, but it was a good thing she had come in for testing. A seventeen-year-old coming in for such testing wasn’t terribly uncommon and coming in as an emergency room visit would at least alleviate the stigma if her parents got the bill. Depending on what relationship she had with her parents, there might be more of a stigma than there needed to be. In the ER, it was easy to explain such tests were common and a part of standard emergency protocol. I had heard from clinic friends that it was more difficult to make that same claim there. Oftentimes, people were more price-conscious and they could question the need for screening.
I left her and headed over to the computer, tapping in a few orders. When I was done, I paused at the nurses’ desk, and took a deep breath.
“They convinced you to come in, too?”
I turned and smiled at Roberts. “I thought I was the only sucker who agreed to come.”
“I don’t know that you should call yourself a sucker. I think caring and compassionate.”
“And working in a stinking ER on my day off.”
“There is that. And it does stink. At least we get bonus pay for coming in.”
“We do?”
“Didn’t you read your contract?”
“Apparently not closely enough.”
“We get bonus pay in addition to our normal shift.”
That made it marginally better. I was still coming to terms with having attending-level income after years of very little money. It was crazy to have extra money, and yet, I didn’t have anything to spend it on. I was a single woman. I was staying in my friend’s condo which was completely paid for. And all I had for expenses was food and clothing. I supposed I could buy a house, but with Kate’s condo so close to the hospital, there was no real reason for me to vacate it any time soon. It was simply easier for me to stay where I was.
“Why does it seem like there aren’t any residents around?” I asked.
“They sent most away. Figured that if we had enough attendings, we would be able to power through the patients faster. I’m sure we will have the residents make up for it later.”
“Or maybe they can just have an extra day off.”
“See? There you go thinking you are going to be too compassionate. The residents are missing out by not being here, Stone.”
“I’m not so sure they are.”
“Yeah, me neither.”
Scott, an older nurse with thinning hair, came racing from the front of the emergency room. He paused, taking a deep breath as he looked at Brad and then me, and shook his head. “We need somebody to come up to the front.”
“Why?”
“There’s an angry patient up there. He’s demanding to be seen, and he won’t leave the front desk.”
“Call security,” Brad said.
“We have, but…”
Security was stretched thin today, the same way that all staff were stretched thin. And even if they called security, it wasn’t a guarantee there would be anything they could do.
I shared a glance with Brad. “I’ll go,” he said.
I pushed him gently to the side. “Take a seat. You aren’t going to go deal with some angry patient in your current shape.”
“Is that a knock on my fitness?”
“That’s a knock on your recent surgery. Let me deal with this.”
“Just call security, Stone.”
“I’ve dealt with enough unruly patients that I’m not too worried. If he just wants to be seen, I’m going to take care of it so we can avoid any other drama.”
“I doubt you’ll avoid any other drama,” Brad started, “but good luck.”
I flashed a smile, and when I did, I followed Scott back to the front desk area. The secretaries had scooted back along the wall, the glass partition protecting them, but I could tell they were uncomfortable.
As soon as I saw the man, I understood why they would be ill at ease.
It probably had nothing to do with the tattoos worked along both arms, or that his shirt appeared to be dirty and covered in stains I hoped weren’t feces, and nothing to do with the way he leaned on the glass, almost as if he was trying to push his way through it. More likely than not, it had everything to do with him having a wide-eyed stare. His pupils were completely constricted and his eyes were otherwise bloodshot. Despite the heat, he didn’t appear to be sweating.
He was on drugs, and someone like this could be nearly ready to overdose. I had no idea what he had taken, but I had seen enough reactions to remind me of this, and enough to make me concerned to get him the care he needed, and fast.
I glanced over to Scott. “We need two strong nurses,” I started.
Scott shook his head. “You can’t be serious.”
“I am serious. I’m not going to leave this guy out here. Look at him. He needs help.”
“Dr. Stone—"
“Call security if you need to, and have them escort him back, but he’s on something, and he’s reacting. We need to get him back, get him hydrated, and figure out what he took.”
As I said it, the man began beating on the glass window. I was tempted to ignore this guy and simply let security deal with him, but I knew that wasn’t the right answer. He needed help, and if we didn’t provide it to him, something might happen.
He continued to smack on the glass window. It was thick. As far as I knew, the glass was designed to withstand a bullet, which meant it should be able to withstand some guy high on an unknown substance, but as he pounded on it, I couldn’t shake the fact that I was concerned it might not be strong enough.
As he continued to beat on the glass, I waited for Scott to find a pair of nurses. While waiting, the man continued to bang on the door.
All of a sudden, he collapsed.
5
I leaped into action, my ER training taking over, and no longer fearful this guy might do something crazy. Anything he might do had already taken place. He had ingested something, and whatever it was happened to be enough to render him unconscious on the floor in front of us.
I lunged for the door leading out into the lobby, quickly prying it open and stepping out there. The man lay with one leg flexed behind him, and didn’t move.
The first thing I did was check to see if he had a pulse. Not having any idea what he might have ingested, I was concerned that he might be dead. With the wild-eyed way he’d been looking before he went down, there was a real possibility he might have arrested and we needed to call a code blue. Which I ought to do anyway.
“Call a code,” I said to Rhonda, the gray-haired secretary who had today’s shift.
She didn’t seem to be bothered by the heat, either.
The alert sounded overhead. Most of the time, we didn’t call codes overhead, at least not out in the lobby, but with the power out, the systems were all screwed up and alerts went out everywhere.
I found his pulse, thready and weak, but thankfully still there.
Scott arrived with two nurses—James and Benjamin—and they scooped the man off the floor, rolling him onto a transport cart.
I raced with them, heading back into the main part of the emergency room.
We got him into room three, and the nurses quickly beginning to cut his clothing off. They got his shirt off when the man suddenly screamed, sat up, and swung both fists wildly.
“Call security!” I said to Scott.
“I already did, but they haven’t answered. I don’t know if they will or if they even can.”
I didn’t like the idea of dealing with this guy without having help. If he was already violent, we had to give him something to calm him down.
“Hey, buddy,” I said, stepping toward him. “We’re just here to help. I’m Dr. Stone, and I need you to sit back.”
He continued to thrash his arms, flinging them wildly from side to side, and as he did, I wondered whether we would be able to get close enough to give him anything to sedate him. I didn’t know what it would take. Haldol and Ativan were typically what we would administer, but even those depended upon how he might react.
As he screamed, thrashing, Benjamin and James shared a look, and they jumped forward, seizing the man under the arm, and pinning him down.
I looked to Scott. “Give him two milligrams of Ativan and five milligrams of Haldol.”
“Dr. Stone?”
“Do it.”
Scott went running, and I wished I had a more competent nurse. Scott was fine, but he was older and not nearly as detail-oriented as other old nurses like Joan. In his case, I had to coax him into doing what I needed, and even if he did, I wasn’t sure he would do it as quickly as required. The patient continued to thrash, thrusting his pelvis up, twisting, but thankfully, James and Benjamin were strong enough to hold him down.