Seven Patients

by Atul Kumar

  Chapter Four: Myiasis

  “Yo, Doc, I bet you ain’t ever seen nothing like this!” the paramedics shouted to Peters as they wheeled in another patient into the overcrowded ER.

  We were in the midst of a heat wave with the fifth consecutive day over 100 degree weather, and the ER was packed beyond the normal bursting.

  It’s typical to have all the rooms, sans trauma bays, filled in the ER with an equal number of patients in the hallways and chairs—which is to say over 40 active patients at any moment. Today we introduced the double park.

  Most “hallway” patients are just what they sound like, a gurney filled with someone that is ill, but not critically so, that is “parked” in the hallway. Today we double parked the hallways, making it so tight that unless your BMI was less than 25, you weren’t going to make it through without getting a little too cozy with any number of the homeless derelicts littering the hallways.

  The homeless generally show up to the ER on the hottest days of the year due to the lack of air conditioning on the streets. But they aren’t dumb; they claim chest pain, not dehydration. If one is dehydrated, they get IV fluids and are out the door within the hour. The chest pain must be taken seriously and requires at least seven hours of evaluation until the labs are confirmed as negative. By that time the sun is setting, the temperature is manageable, and the liquor stores are open for business.

  The cost to evaluate somebody faking chest pain in an ER setting can range anywhere from five to ten thousand dollars, depending on the hospital. It’d be cheaper to put up the city’s homeless in the Ritz Carlton during the dog days of summer.

  “Guys, I’m a bit tied up with this chest tube right now. Just park her in the hallway over there, and I’ll meet you in a bit,” answered an overworked Dr. Peters.

  I watched in confusion as three paramedics, two firefighters, and Detective Higgs all wheeled the patient past me. Unless she was Nancy Reagan or a serial killer, this was way too big an entourage. Something was going on.

  Upon closer examination, everyone wore a smug expression, and the firefighters were giggling like schoolgirls, not acting macho like their pro-wrestler physiques resembled.

  Curiosity kicking in, I decided to follow and see what was going on. The bum who I was about to assist with the bedpan could wait. One whiff and it was obvious his clothes had been serving the bedpan’s function for some time now.

  Just as I turned the corner in pursuit of Higs, I heard the characteristic splash of fluid hitting tile floor. At least housekeeping would get paid to clean up his mess. My tuition dollars were better used to investigate what was going on elsewhere.

  The paramedics parked our mystery patient’s gurney along the wall, as Dr. Peters had ordered, and took to slapping each other on the chest and grinning stupidly. But they quickly straightening up as I approached and made eye contact. Soon they formed an impenetrable barrier around the gurney, preventing me from taking part in the excitement.

  “Hi, Detective Higgs.” Hearing my salutation to the boss only heightened everybody’s suspicions about me. They continued to stare me down, nonverbally communicating, loudly and clearly, that I was not wanted around.

  “Hey, buddy, you’re the med student from that baby shaker case, aren’t you? I’m sorry; you’re going to have to remind me of your name.” Hearing Higgs acknowledge my existence caused the five human pillars forming Hadrian’s Wall to slacken. They still wouldn’t grant me access to their patient though.

  “Rajen.”

  “That’s right. Are you still working with Dr. Peters?”

  “I finished that initial rotation. Now I’m back for my second two weeks in the ER. Then I move to the inpatient ward upstairs, but I’ll still be around the ER for admissions.”

  “You remember that case of the shaken baby a couple months ago right?”

  “Oh sure! How could I forget that? It was my first patient.”

  “Well, the legal shit is still going on … that fake father, what was his name, the dude who was nuts and thought the baby was his?”

  “John,” I offered.

  “Yeah, well, he was proven insane. Got some real trust issues, that one. He still thinks the baby is his despite a DNA test confirming with 99.99% accuracy that it isn’t. Got admitted to one of those psychiatric hospitals where he supposedly had a full breakdown. I think they’re still putting him back together. Probably will take years to fix his loose screws.”

  “What about the guy who actually shook the baby? And Juanita?”

  “Well, the Mom used the age defense and they tried her as a child instead of an adult … why, I don’t know! But she got like four years of jail and some serious mandatory counseling and community service. I figure with good behavior she’ll be out in two years. Can still go to college if she gets her head on right and takes birth control.

  “The baby is a vegetable and blind, but her body’s working. Got a good 70 years ahead of her in a nursing facility that you and I will be paying for.”

  “Sad.”

  “Worse is that we could never get a lead on who actually shook the kid. Juanita only knew him as “J” which was apparently a fake street name and nobody knew who he was. Her child’s real father is still in jail, and he claims he knows nothing.”

  “So that’s it?”

  “Not completely. Mom filed an appeal, so that’s got to be dealt with before this case can be put to rest.”

  I was staring curiously at all the guys around Higgs that were listening in on our conversation.

  “I figure you’re wondering why all of us are here? And trust me; it’s not cause of the aroma. It’s amazing how the ER smells worse than an abandoned urinal once it gets over 100 degrees outside.”

  I couldn’t help but wonder how many medical student tuition dollars were given to the hospital only to participate in bedpan duty. Hell, nurses didn’t even help with bedpans anymore. They had their CNAs do the dirty work. Some CNAs even had MAs do their dirty work.

  Dr. Peters walked over to Higgs with a clearly feigned look of surprise in seeing the big man. “OH, I hardly noticed your entrance. You guys were about as stealthy and subtle as a sonic boom. The six of you blitzkrieg through the ER, cater to a single gurney, and yell out to the attending without checking in. You don’t need to be a sleuth to guess something’s up. Shit, half the ER is wondering about your cargo. I’m just going to drop off this specimen and I’ll be back in a few minutes.” She left towards the laboratory at a brisk clip.

  “Yeah, on second guess, the VIP entrance might have been better,” muttered one of the paramedics.

  “So you going to let me in on the situation or does the medical student get sent away for coffee rounds?” I asked the group.

  “I don’t think this is for medical students,” one of the paramedics volunteered. “Jack here lost his lunch on scene at the nursing home; luckily he made it to the sink. I bet they’re still cleaning it up.”

  “Gentlemen, let’s be professional here. He is going to be a doctor soon and needs to know what he will encounter in the future,” offered Higgs. Then he winked and the wall parted, allowing me a glimpse of what lay on the gurney.

  One thing was immediately certain; she didn’t command such a convoy due to her social status. Her odor was unique, like that of decaying flesh, but not of rot. Akin to raw meat that has been left out too long mixed with sweat. Overall, slightly more tolerable than the stench of stale urine permeating the rest of the ER.

  Most disconcerting was the sound … a sort of squishy-slurping, as though passing several spoons through a thick macaroni salad. I quickly localized the sound to the head of the gurney.

  I glanced quickly and noted that she was covered with a sheet all the way to her neck, and even then only the left side of her head was exposed. Her skin, or what little of it I could see, revealed that she hadn’t showered in some days, judging by the amount of caked on sweat and grease clinging to it. Her hair would have made Einstein jealous. The right side of her
face was covered with a large abdominal pad dressing taped onto her skin. This is from where the sound emanated.

  I moved closer. As soon as I realized what was going on, I fell backward onto the floor and felt my breakfast coming up. I managed to squelch the heaving, but not before some of my gastric contents escaped via my nostrils onto my sleeve. Damn, did that burn.

  Once I got to my feet, I realized that I’d drawn the attention of everybody in close vicinity. Looking around I was greeted by laughter and two of the firemen taking pictures of me with their phones. Wiping my nose and regaining my dignity I returned to our patient’s bandaged head.

  That’s when I discovered that the dressing was moving.

  And escaping from the bottom edge of the dressing near her right jaw were not-so-small white maggots. They looked like they wanted to crawl towards her eye.

  One of the medics gloved up and lifted up the dressing. I don’t know what hit me first, the stench, sound, or my partially digested breakfast. Housekeeping would certainly earn their keep today.

  Her entire right eye was missing. Her orbital cavity was instead filled with dozens of crawling maggots where her eye once used to be. The squishing sound was even louder with the dressing removed. The light must have scared them because they all seemed to want to take shelter within her orbit and down her right nostril.

  “Alright guys, you had your fun, cover her up until Peters gets back. I’m gonna love to see her expression when she sees this,” boomed Higgs from behind me, handing me a towel to clean up.

  “What the hell is going on??” I asked nobody in particular. “That was the most disgusting thing I’ve ever seen in my life.”

  Just then Dr. Peters arrived and took in the scene: two paramedics standing at the head of the gurney laughing, me cleaning up my sleeve, Higgs shaking his head in amused dismay, and the firefighters standing against the wall trying to look professional.

  “Raj, you ok? What the hell happened?”

  “Nothing, breakfast didn’t sit too well with me.”

  “Higgs, what did I tell you about picking on my students?”

  “I warned him, Doc, but he insisted on being part of the team. Handled it better than I thought. Jack over there lost his lunch and Sam had to leave the room. The medics have been having a field day with their damn camera phones.”

  “Ok, guys, what have we got here?”

  One of the medics came over, “59 year old female, history of squamous cell cancer of her right eye. She refused treatment on two separate occasions. Her nursing home called us to report a ‘moving dressing’ over her right eye, not specifying any further and requested immediate transfer to the ER. And here we are.”

  Peters gave the patient a once over and quickly gloved up and walked closer. She was immediately drawn to the dressing on the right side of the patient’s face. Of course now it wasn’t moving, guess all the maggots were trying to hide from the recent light exposure.

  “Ma’am my name is Dr. Peters, what is your name?”

  “Be … Be … B … Beatrice,” she whispered. “Are you going to give me more milk for my eye?”

  I had forgotten that there was a patient under there. I hadn’t even attempted to talk to her or try to build any rapport.

  Peters was now surrounded by the whole team, everyone just waiting to catch her expression when she realized what was going on.

  “Do you know where you are, Beatrice?”

  “Yes, at the hotel. I was told if I leave the nursing home I’d get more milk. You know I have cancer on my right eye. But I’ve been giving it milk for the last three months and its getting better I’m sure.”

  “Well, I’m going to examine your right eye now. Please don’t move.”

  Beatrice nodded and a small maggot fell out from under the gauze just as Peters was about to un-tape it. It bounced on the floor and began to writhe away. Peters knelt down to examine it and stood up to face Higgs.

  “What did I ever do to you to deserve this? I bet she has a raging myiasis, probably even lost her right eye, huh? That’s why the dressing was moving? Let me guess. She stays in some shithole nursing home where they didn’t properly care for her wound. The heat wave and invasive cancer were perfect for the flies to lay their eggs and PRESTO. Do I even want to take a look?”

  Everyone was amazed at how she put the entire story together without even removing the dressing, but they were also sad that they didn’t get the look of shock they were waiting for. Higgs broke the silence. “Damn, see, that’s why she’s the Boss. You know you do, Doc, you like the sick shit.”

  “Higgs, I’m gonna get you for this, don’t you forget it.” The gleam in Peters’ eyes was real, and the cogs were turning. This was not going to be forgotten and Higgs would repay with ample interest. I secretly hoped I’d get to be there; not much shook the behemoth.

  Peters quickly lifted up the dressing and moaned in disgust as three of the dozens of maggots fell off Beatrice’s face and plopped onto the gurney. One bounced and continued its descent, writhing in mid air, only to splat smack onto Peters’ new Ferragamos.

  She managed to keep down her breakfast. Glancing down and assessing the irreparable damage to the costly suede pumps, she threw Higgs the coldest of stares I’d ever seen. Peters then promptly reapplied the dressing to cover the maggot farm, and swiftly excused herself, exuding nothing but the highest degree of professionalism and aplomb to all around. Managing to shout as she turned the corner, she yelled, “Rajen, get her a STAT head CT scan and call the ophthalmologist … and get psych involved too.”

  This sure beat bedpan duty and homeless usher. I called the consults, got Beatrice ready for her CT scan, and decided to help with her transport to escape the odor of the ER. The stench of maggots gnawing on cancer still beat the stench of homeless in a heat wave.

  Upon her return from Radiology, Beatrice was placed in a private room. Apparently a face full of maggots, or vaginal bleeding (the other, more common diagnosis that was not evaluated in a hallway), was what one needed to get out of the hallway and into an actual room.

  Higgs and his buddies had apparently moved on to other duties. They were no longer around when I returned, and Peters was busy with a minor trauma from a motor vehicle accident that had just come in.

  Before I could find something else with which to occupy myself I saw an overly energetic resident rushing to the central ER desk, taking care to skirt hallway obstacles and avoid stepping in an undesirable puddle which was still present. I heard him ask the charge nurse for the eye patient.

  She pointed in my direction and he headed off towards me. As he approached all I could make out on his badge was that it said “Ophthalmology,” which made sense given he was asking for the eye patient.

  “Hi, Dr. Sun, I’m …”

  “Call me S. We’re on the same team; the doctor stuff is for egos and patients. You the med student on this case?”

  I nodded, “Rajen.” Declaring his nickname odd, I decided to stick with Dr. Sun.

  He nodded back and proceeded straight to Beatrice, gloved up, and removed her dressing.

  “HOLY FUCKING SHIT … what did you get yourself into this time, Beatrice?”

  I stood in shock; this wasn’t how a physician spoke to a patient. Or at least not how we were taught to speak to patients. I’d never encountered other physicians speaking to patients in such a casual manner, but I’d also just come off a surgical rotation in which I had to refer to my colleagues as ‘Doctor.’

  This was the moment in my training marking my initiation into the dark side of medicine. The side that only practitioners know of, well hidden from the public eye. I didn’t know it yet, but I soon learned that physicians used profanity in ways that would make sailors proud. Only makes sense given the stresses of making life or death decisions on a daily basis.

  “Is that Dr. Sun? I’ve been using my milk like I told you; I think I can see better now and the cancer is almost gone, isn’t it?” She spoke with marked lucidity in a nonp
lussed way given that her eye was missing and a maggot just fell out of her right nostril.

  “Dude, Rajen, did you get a look at this? This is the nastiest thing I’ve ever seen! Get your camera.

  “Beatrice, I’m going to take some photos of your face if that’s ok with you? I just need you to sign these forms.” Dr. Sun thrust some forms for Beatrice to sign and proceeded to take videos and photos of Beatrice from all angles.

  “Rajen, I’m telling you, this will make for a fucking awesome grand rounds or medical student case presentation. Hell, if you’re interested we can probably publish it. I’ve never heard of a case of such fulminant orbital myiasis in the developed world.”

  I wasn’t sure what to do. Nobody had treated me as a colleague before and never had I witnessed the use of such colloquial language in front of a patient. I just stood and took it all in. But he seemed competent and involved in her care despite his language and laissez-faire attitude.

  “Myiasis?” I finally asked.

  “Oh, sorry for the jargon. Just the twenty dollar way of describing an infestation due to maggots.” He continued to snap some pictures and videos.

  “Well, Beatrice, thanks for the photo shoot. Now we should get you cleaned up and see what’s going on here. Do you know how this happened?”

  “What’s happened, Dr. Sun? Can I have some milk?”

  “Haha … okay, Beatrice, I guess I’m not going to get much of a history from you. Can you read these itty bitty letters for me with your eye?”

  Remarkably she read the 20/20 line with her left eye and followed commands just fine, never arguing or causing trouble. The joys of the pleasantly demented.

  “Alright, Rajen, let’s get this mess cleaned up and see what we got here. Can you get me a Yankauer suction setup? I’ll get us some gowns and forceps and all the specimen collection shit the pathologists want. Meet you back here in five minutes?”

  “Sure.”

  With a mission, I took off immediately in no apparent direction, with the only problem being I had no idea what a Yankauer was. Luckily, I ran into the charge nurse around the corner and asked her.