by Atul Kumar
As we’re halfway down the massive hallway Jason put out his hand, “Hi Raj, I’m Jason Bates, nice to meet you.” We shake and he continues, “don’t mind Amy, she’s constantly going to harass you about your scores, she can’t stand it when somebody does better than her and she can’t rest until she knows your numbers. We both went to Hopkins together; she was lazy then, and she continues the trend here. Seriously, she’ll do anything she can to avoid work. Kelly is cool, married with a young kid. Duke is a nice guy, very decent and ethical, but not the sharpest tool in the shed.”
I’m not sure how to respond, so I just nod. The hospital is full of gossip. Jason doesn’t seem as though he’s very interested in it other than to give me a quick background on the team.
“I know you’re a bright guy, so just let me know what I can do to help make this an educational experience for you, okay?”
I already liked Jason; he seemed bright and professional but unconventional, though my ability to read people is akin to my literacy in Mandarin, namely, non-existent.
We enter the ER and Jason rushes off towards the phone, “Raj, I’ll meet you at the control desk; I forgot to get the name of the patient we’re supposed to evaluate.”
I’m well acquainted with the layout of the ER and before I even make it to the nursing station I run into Dr. Peters.
“Rajen, don’t you ever go home?”
“Same can be said about you Dr. Peters.”
“I’m guessing you’re here for the admission; I think I just paged Duke about him?”
“Yes, ma’am.”
“Well, I have to go to radiology right now. Some little girl put a bean in her ear a few days ago and now it’s started to sprout! The radiologist said he can see a stem emerging on her scan; I want to check it out personally. But your patient is a healthy 45-year old male with no past medical history who comes in because of a 72 hour history of right flank pain, fevers, and hematuria. See you in a bit.” With that she rushed off.
The ER is bustling. I catch Jason entering from the other end. “Duane Little, Bed 8.”
“Let me guess, 45-year old male with fevers and kidney pain.”
“Damn, I heard you were good, but nobody told me you were psychic.”
“I wish. I ran into Peters on the way over and she gave me the lowdown.”
“Cool, tell you what, I’ll let you run the show and I’ll just be your shadow. I’ll try not to interrupt if I don’t have to, and if you’re stuck just nod towards me and I’ll take over. Cool?”
“Sounds good.”
I enter Bed 8 and find Duane pacing around the little space with his hand on his right lower back nearly in tears. He’s a typical guy you’d see in a department store clothing catalog, about six feet tall, 170 pounds, fit, dressed in khakis and a polo with a clean shave. In other words, he doesn’t belong in an ER.
“Hi, Duane.”
“Oh thank goodness Doc, I’m so happy you got here so fast.” He tries to sit on the gurney but the pain prevents him and forces him to stand and resume his pacing.
“Name’s Rajen, and this is Dr. Bates.”
“Pleasure.” He cringes as he reaches out to shake our hands.
Sure I’m used to seeing people in distress, but never have I encountered a patient that is respectful or thankful. Usually they’re aggravated and insolent, so this was unexpected.
Sizing up the situation Jason announces, “Raj I’m going to get an IV kit and some morphine so we can get Duane here comfortable immediately. Go ahead and get a history until I return.”
Duane and I nod.
As if Duane knows exactly what I need, he starts talking as he limps about the room clutching his right flank. “Thanks again for your time. I usually only see a doc once or twice a year for a physical, and all’s been well. I have no medical history to report, no medications, only some occasional alcohol, no drugs or tobacco. Family’s healthy too, just a grandfather who died of a heart attack. I’m married with a seven year old daughter. She’s in school now, but my wife took off work and will be here soon. I drove here myself.”
He groans in pain and then moves to the sink where he dry heaves. Amazing, he told me in 15 seconds what most patients require 15 minutes of coaxing and interrogation, only to report details that are mostly incorrect.
The severe pain subsides in another 15 seconds and I decide to resume our interview, “Dr. Bates will be here shortly and we’ll be able to get rid of that pain for you. In the mean time is it ok if I get some vital signs and ask you a few questions?”
He nods. I sit him down and we chat while I gather my data.
“Tell me what’s been going on.”
“Basically Doc, I noticed this pain on my right side, I’m guessing where my kidney is, about 3 days ago. At first it was tolerable with some ibuprofen, but it’s just gotten worse and worse. Yesterday I started getting a fever to about 101°F, but thought I could ride it out despite my wife telling me to go to the hospital. This morning right before leaving for work the pain increased and I noticed my urine looked like V-8. So here I am.”
“Any trauma, recent travel, sick contacts, drugs or medications?”
“No to all of the above. I did have seafood a couple nights ago. Do you think this could be food poisoning?”
“No, that doesn’t explain it. What do you do for a living?”
“I’m a software programmer and soccer coach. My wife’s a high school teacher. Daughter doesn’t work yet, being in second grade and all.”
We both manage a smile despite his distress.
“Duane, your BP is a little elevated. That’s likely due to your pain, but you also have a fever of 103.8°F. I suspect you have an infection.”
Jason rushes back and immediately gets to work on placing an IV in Duane’s arm. He gets it on his first try. Duane was a model patient despite another bout of colic. Jason quickly injects an entire ampoule of morphine through the IV.
“How do you feel now?”
“No different Doc … oh, wow … ok, you gave me some serious stuff, huuuuugh?”
Duane’s words slur and his eyes take on a glazed appearance as the Bell’s reflex causes them to roll upwards. Soon he’s snoozing and barely breathing.
I quickly affix an oxygen mask and crank it up to 12L/min. His oxygen saturation and other vital signs normalize almost immediately.
Satisfied with our work, Jason says, “Well, we know he’s not a drug user, seeing as how I only gave him 10 mg, a very moderate dose of morphine for a guy his size. He’s already down for the count. So you discover anything Raj? What’s your diagnosis?”
I recap what Duane told me. “Basically, I think he has a kidney stone which is stuck in the ureter somewhere and it’s been causing intermittent obstructions and hydronephrosis. Now he’s gotten infected.”
“Is that your final answer Dr. Raj? Renal calculi with secondary urosepsis?”
“It is.”
“Ding ding, I think we have a winner here folks.”
“You mean, that’s all?”
“Well, the fun part’s over, now we get to do all the paperwork, admit him, get some blood and urine cultures, along with some basic labs. We should get a CT to confirm our diagnosis. I think we should admit him for a couple days until we know what bug is causing this and get his fever under control. Then he can go back to his happy life at home.”
“So you think he’ll be alright?”
“Oh yeah, you kidding, this is what ER’s and hospitals were created for, diagnosing and treating acute illness. Not the homeless shelters, hospice facilities, and drug dispensaries they’ve become.”
“Good. He’s a super nice guy, his wife’s on her way over, and his daughter …”
“Wait, did you just say he’s a ‘super nice guy’?”
“Yeah, why?”
“Nothing. Just silly superstition that bodes poorly for him. Always remember this dictum in medicine: bad things happen to nice people. Especially in a hospital.
�
�Haven’t you ever noticed most patients are annoying, and some are complete assholes? And that it’s always the assholes who beat the odds and survive the fatal heart attack or somehow live ten years with metastatic cancer? It’s the nice guys that finish last in hospitals, probably why we don’t see many of them; they’re smart enough to stay the hell away from us.”
In medicine, the joke is that prognosis is inversely related to niceness. The nicer a patient, the worse their disease, and poorer their outcome. I certainly hoped this wasn’t the case in Duane’s situation. In fact, I was looking forward to meeting his family and informing them that he’d be good as new in a couple days.
Boy, was I wrong.
~~~~
The rest of the day was not nearly as interesting as the morning, but at least there was no further discussion about MILFs or board scores. We were back in the lounge just finishing up the paperwork from the day. We’d received three other patients after Duane; a steady but very manageable amount of work.
Adam and Amy seemed to get along fabulously, judging by their constant giggling and newfound BFF behavior—not to mention their mutual penchant for avoiding any type of work.
It was a pleasure to work with Jason; he was diligent, thoughtful, caring, and never said no to more work. Right on time, just as I thought about more work, Amy sauntered over to Jason with puppy dog eyes. A request for a favor was sure to follow, which likely involved more work for us.
She just stood next to Jason. He was first to break the silence. “Can I help you with something Amy?”
“Well, since you asked … I just got this admission from the ER, and I was wondering if you wouldn’t mind taking the hit, given you’re all done with your work and we’re still working on our last patient.”
“Not sure how that makes it my responsibility.”
Way to go Jason! Perhaps his reputation for being a “black cloud,” someone who always has bad luck and more work than anybody else on the team, was incorrect.
Nope, I was wrong.
“Yeah, you’re right technically, but remember the time I signed you in for lecture and you didn’t attend?”
“Sure do, I had a dislocated shoulder and was getting it repositioned.”
“Fact is that you weren’t there and I still signed you in, so this would make it even.” She even batted her lashes to emphasize the point. “And I really need to get done early tomorrow. I got a date with this venture capitalist who’s taking me to Urasawa and I don’t want bags under my eyes.”
Nooooo! I could sense Jason wavering, and he was doing so well, too. I knew he was going to cave in to Amy’s assault to pawn off her work.
“Fine, what you got?”
She yelped for joy and handed him a card and rushed out of the lounge with Adam in tow before Jason had a chance to renege on his offer.
“So this is how you got your black cloud, huh? By doing others’ work?” I asked Jason.
“You ever heard of the mantra of old school surgeons?”
“Nope.”
“What’s the problem with being on call every other day?”
“I don’t know.”
“You miss half of the cases.”
“Nobody thinks that way nowadays.”
“Agreed. But there is some truth to the saying; the more we work, see, and do now, the better we’ll be in the future when it really counts. Thus, while it’s more work for us today, I think it’s an investment in the future and an opportunity to learn now. Besides, right now, we have operational immunity, we’re covered for over $10 million in malpractice, and everybody who comes through the door signs a waiver that they are willingly entering a teaching institution. Unless we perform ‘egregious negligence’ we won’t be fired or lose our license. In the real world, if you so much as make a bad joke, you can get a formal complaint against your personal medical license. Two of those infarctions and you might lose your hospital privileges if you’re in a desirable location or top hospital.”
He had a point. “You’re the boss.” Pay now, earn dividends later.
“Let’s see what she dumped on us.” He read off of the blue card she had handed him. “Appears to be a 96 year old female with altered mental status in ER Bed 9.”
We both looked at each other, “GOMER.”
The infamous ‘Get Out of My ER’ acronym is used to describe patients that the ER wants nothing more than to get rid of ASAP; typically your homeless, psychotic, nonagenarian, or liver bomb.
“Raj, why don’t you get started on,” he squinted to make out our patient’s name, “Matilda Margaret Maude, while I go check up on Duane? I’ll make sure he’s doing well and meet you in the ER, with any luck we can hit the sac by midnight.”
“Sounds great,” I lied. Dinner sounded great, not interviewing a patient who was bound to smell like urine and have advanced dementia.
As I made my way to the ER I recalled an interesting factoid I’d read recently. Something like greater than 40% of annual Medicare spending is utilized during the final six months of peoples’ lives. Even worse, the quality of these final days are usually terrible, given they’re spent mainly inside hospitals fighting off one infection or another. Just as I started daydreaming of what other uses this $180 billion could be put towards, I entered the ER.
I was secretly hoping it’d be jam packed so that Amy and Adam would be up all night. To my chagrin it was a ghost town with about four patients and nobody in the waiting room. Perhaps the calm before the storm I hoped.
Before entering the room to meet Ms. Matilda Margaret Maude, I had to do a double take at what I was looking at. Ms. Maude was essentially rice paper thin skin draped over a skeleton covered with liver spots and missing dentures, making her mouth look like a black sinkhole with her lips pointed inward. She lay supine in bed but was so kyphotic that the roll in her back prevented her head from touching the two pillows under her. Her fingers were so thin and frail I was afraid that if I shook her hand they might just turn to dust.
“Ms. Maude.” No response. I tried again louder, nothing. “MS. MAUDE,” I shouted.
She opened her eyes, and whispered, “Abigail?” This was followed immediately with a return to her somnolent state, with mouth gaping open and spittle dripping down the corner of her sinkhole, er mouth.
I tried gently rubbing her sternum, but she didn’t seem to notice. I tried again harder and felt a soft crack. I recoiled in fear of having possibly just fractured one of her ribs. Thankfully she still didn’t seem to take notice. An incidental finding on a later x-ray would tell all.
She started smacking her lips and again asked for Abigail.
Nobody had bothered to check her BP, likely for fear that placing and insufflating a cuff on her arm might destroy her humerus. No wonder the ER wanted her out of here. I didn’t even know how I’d start an IV line on her; she was so covered with age and liver spots and redundant skin that I couldn’t see any veins on her arms.
She clearly wasn’t going to be of much use in giving me a history. Thus, I’d do the next best thing, research her old medical records, known as a chart biopsy.
Of course I came up with nothing; apparently she’d never been here before. So far all I knew was her name, that she was breathing, and might have a broken rib.
“Who’s in charge here?!”
I looked up from the work station to see a well-dressed forty-something gentleman yelling in my general direction from Ms. Maude’s room.
“Uh, hi. I’m Rajen, who might you be?”
“Are you her doctor? I want to know why nobody is taking care of my Grandmother.”
“I’m the medical student on the team who is going to be admitting Ms. Maude.”
He cut me off and berated me, “MEDICAL STUDENT?! What kind of nonsense is this? When I called I told them I wanted the Chief of Medicine to see her, she’s critically ill. This is nonsense. I’ll report this to the Board of Directors!”
Just what I needed, an irate family member who had no idea what he was even
upset over.
“And you are?”
No response. So I went on, “this is a teaching hospital and the admitting doctor is on his way over. He just had to check in on another patient. Can I ask you some questions so we can take the best care of your grandmother?”
“Fuck. Is this where healthcare dollars are going these days, to have medical students see patients while the real doctors can go golfing?”
“I assure you that no doctors are golfing at this hour.” It being 10:20 p.m. and all.
“I don’t approve of your insolent tone MISTER.”
“My tone? You were the one that was using profanity and raising your voice.”
“Fine, I’ll answer your questions, but make it quick, I need to get home.”
“Great, thanks. And you are?”
“Richard, her grandson. Most of the family will be in later tonight. We all live around here.”
He again ignored me to answer his cell phone, right next to the sign stating ‘NO CELLULAR PHONE USE IN THE EMERGENCY ROOM.’ “Yeah, just wait by the ER entrance, next to the ambulances; I’ll be out there as soon as I talk to a real doctor.”
I assume he was talking to his driver, but I had no way of knowing and didn’t want to indulge him.
“What brings your grandmother to the ER today?”
“You’re the doctor, isn’t that what you should be telling me?”
“Look Richard, you can be a smart ass or you can help me out here. I’m not an oracle who knows her entire medical history. If you could provide that, in addition to all her current medications, doses, and allergies it would be a good start.”
“Bernard knows that information, not me. He should be in shortly, I sent the other driver to pick him up immediately. They said there wasn’t enough room in the ambulance for him to ride along because two paramedics were in the back with her.”
“Who’s Bernard?”
“He’s the live-in butler and caretaker. Grandmother lives alone next door, and he looks after her. She also has a nurse during the day; she’ll be here tomorrow; I’m sure they can answer all your questions.”