So, I fell back to my contract with myself: First, do no harm; then heal.
No new patients had come into the department yet. It was a perfect time to scroll through the list of boarding patients to make sure nothing had been missed and nothing was still due.
Ms. Craig, who had been admitted last year for chest pain and had a history of a positive cardiac catheterization, which showed evidence of significant heart disease, was due for her second blood draw for her troponin level, to look for evidence of a heart attack.
Mr. Hornsby would need his third dose of antibiotics in three hours, for his cellulitis.
Ms. Grant had been admitted for renal failure and a urinary tract infection. The ceftriaxone she received would give her twenty-four hours of antibiotic coverage. We hoped she’d get a bed within six hours, so the next dose could be ordered by her admitting team.
Mr. Khan’s blood pressure was stable after the seven doses of antihypertensive medication the last two shifts had given him.
Ms. Chen was comfortable and waiting for a bed for her lower GI bleed workup, with a plan for gastroenterology to scope her today.
Mr. Clements was waiting for a bed and workup on the source of his cancer and for pain control.
The four patients on the psychiatric side of the emergency department were all well and waiting for final disposition by the psychiatrist.
After reviewing all patient information, entering orders, and updating my patient list, I was caught up, with no new patients in the waiting room.
Nurse Sean pulled up a chair next to mine. “So, where’s the next trip?” I asked him.
Sean and I had worked together years ago, at Andrew Johnson. Although he was probably twenty years my senior, our lives seemed to parallel. Back when he was leaving his marriage to be with the woman it made sense for him to marry, and I had freshly completed my divorce from the man I thought I was supposed to marry, we were both working in administrative positions. I was new to the role, and he was a seasoned veteran. Now, several years later, we had met again, in new phases of life. I had left academic medicine and administrative work to resume the clinical work I cared most about.
Sean was Irish American, with more rust-colored hair sprouting from the V-neck of his scrub top than on his head. Thanks to his wife’s Sierra Leonean heritage, he had the distinction of being the best Irish cook of West African cuisine in all Philadelphia. He had given up his lifetime of administrative work for a per diem gig that allowed him to have the schedule of his choice, so he could travel with the woman he had anointed his “queen.” It is no exaggeration to say that every several weeks, the two were on their way somewhere: Martinique, Niagara Falls, Hawaii, Tennessee. Their life together was entirely intentional and, in that way, entirely inspiring.
“Next we go to Paris,” Sean said, leaning back in the chair, arms folded behind his head and feet propped up on a stool. Before the next five patients registered to be seen, he and I had time to catch up on their plans to visit the Louvre and his desire to see General Patton’s grave.
Ten patients and two and a half hours later, the second attending should have arrived. I looked at the board and noticed that none of my patients from the night shift had been assigned to admitting physicians. One patient was waiting to be seen by my colleague—whenever he deigned to show up for his shift. Three patients were being sent to the ER for evaluation from outpatient clinics—this despite our being “on diversion,” that is, unable to accept transfers from other facilities due to our not having the capacity to care for them. One of those outpatients had even been called in from home. Four other patients were in the waiting room about to come into the ER; and now five patients were waiting for admission. The one psychiatric patient who was to go home that morning was now sober from his alcohol intoxication, but he was confused. The nurse called me to assess him; he knew only his name but had no idea of the date, place, or situation. Reviewing his records, I could tell that this was not the baseline for this otherwise healthy middle-aged white man. I started his medical workup and then made a string of phone calls to find out when the boarding patients would get inpatient beds and teams to manage their care.
Gloria, the trusty and hardworking bed coordinator, informed me that not only were there no beds available, but there were “negative beds.”
“What do you mean by negative beds?” I asked.
“I mean the OR has a full schedule, and I have no place to put all the post-op patients, nowhere to put the ER patients waiting for admission, and there are no discharges planned. Negative beds.”
“And it’s only nine a.m.,” we said in unison.
“Awesome,” I said. “Well, Gloria, please keep me posted.”
“Yeah, I’m working on it. I’m going up to the floors now to tell the docs to get people moving.”
I reached out to the ER medical director, leaving a voice mail, text, and email asking for the higher-ups to mobilize hospital beds and to continue our diversion status from transfers from other hospitals in light of this Monday morning madness. As was typical of the ER leadership in this institution, there was no answer, no return message, no help.
I asked myself: How much inpatient medicine could I safely perform while still attending to the care of the steady stream of brand-new ER patients? I knew that the new ER patients had to be seen. Could I safely leave those boarding patients to linger in the ER unattended? Even if it was safe to do so, was it ethical?
To the layperson, these may sound like silly questions, but would you expect an auto mechanic with a full schedule to stay on task with each new vehicle and at the same time help each client get directions home, coordinate vehicle pickup and child care, and schedule follow-up appointments? Of course not. Yes, these details fall under the category of “it’s not my job,” but that’s what doctors are often called to do, and it’s what makes it impossible for us to excel at what is actually our job. In emergency medicine, as in the case of the overworked mechanic, working outside one’s prescribed duties makes the work dangerous. All this, of course, doesn’t answer the most important question I was forced to answer: How many of the shortcomings of this modern health care system was I willing to put up with? Or, perhaps better, would my healing mission be better served in other ways?
So, at 9:40 a.m., with a growing backlog of patients and still no sign of the second attending physician, I wondered what to do. First, I knew, was to do no harm: My patients were all stable, with the exception of the man with the newly altered mental state. I would evaluate him first and, if necessary, order additional labs, an EKG, a head CT, and vitamins, as he was a known alcoholic and could have a vitamin deficiency that put him at risk for permanent brain damage.
Next, I would see any new patients who were waiting.
Then, to heal: I would initiate any plans I anticipated the inpatient teams would have for the boarding patients who had been waiting the longest in the ER. While adding this to my list of tasks would make my work exponentially harder, it wasn’t the patients’ fault they were still stuck in the ER.
The best way to start, I thought, was to get another cup of coffee and then dive in.
I called Cardiology to come see the patient with chest pain, and I called GI to see my GIB (gastrointestinal bleed) patient. Both services were very confused as to why they were getting a call from me, rather than the inpatient teams, and they asked if the admitting physicians could call for the consultations once the patients were on their floors, as this was standard hospital procedure. I explained that I, too, was confused by the chronic delays in patient care in the hospital, and that I was trying to expedite these patients getting care while they waited in limbo. The departments agreed to see the patients in the ER. Similar calls followed, to Neurology and the Echocardiography Lab, and the people there were similarly accommodating.
Next, I had to decide what to do with Mr. Clements. The notes from the last two attendi
ng physicians indicated that he was being admitted for pain control and a metastatic cancer workup. He had received one dose of pain medication since last night, and his vitals were normal. I had just passed his room and saw a well-dressed, slender man walking around, speaking calmly and comfortably on the phone—not the picture of a pain-control admission. A CT of his abdomen had revealed scattered swollen lymph nodes “too numerous to quantify,” as the report read.
“Dr. Harper,” Nurse Carissa called. “I just put a young guy in Room Six. He only has a psych history of some depression and anxiety, but he comes in today with fever, tachycardia in the one-thirties, infection from shooting drugs.”
Putting my phone calls and Mr. Clements on hold again, I followed Carissa directly to Room 6.
“Good morning, Mr. Spano,” I said.
He was seated on the stretcher, looking contained and anxious. I turned to the man standing at his side, who appeared to be a carbon copy of him. “Hello. Are you two related? You must be. You look exactly alike.”
“Yeah, I’m his brother.”
I turned back to the patient. “What brings you in today?”
“An infection, ma’am.”
He had long brown hair, olive skin, and the stocky build of an ex-athlete. It was clear that before the depression and before the drugs, he had been an attractive young man. He was only twenty-nine, but with the pallid skin of a man thirty years his senior.
He grimaced as he bent his right leg, pointing to a sausage-like calf with puffy, flaking black skin that looked like charcoal. As he looked at his leg, tears rolled down his cheeks, and he wept out loud.
“How did this happen?” I asked him.
“Ma’am, I’m not gonna lie. I shot up crack. There might have been some heroin in there, too. I don’t know.”
“Hmmm,” I said, nodding as his shoulders shook under his sobs. “This is a very serious infection. We’ll need to—”
“What? What do you mean? Why do you say that?” he yelled.
“Well, you have a fever and—”
“A fever?” he interrupted again, his face twisting in agony. He covered his mouth as he whimpered and shook his head. “I didn’t have a fever before!”
I recoiled from him. It might have been the volume of his exclamations or maybe the drama unfolding before me that caused me to cringe.
“As I was saying, you have a fever here, and your heart rate is very fast. Those two things tell us your infection is significant. Do you have pain?”
“Pain? I have tremendous pain—one hundred out of ten!”
“Okay, what we’ll need to do is check your blood, get X-rays, and give you antibiotics and IV fluid. I’ll also give you medicine for fever and pain while we sort everything out. Because your infection looks quite serious, I’ll need to speak to a surgeon, in case you need an operation to fix this. No matter what, I’ll have to keep you in the hospital, because you’ll need to be continued on intravenous antibiotics for a couple of days or so.”
“Oh, no!” he shrieked, in a voice much higher than one might guess his two-hundred-pound frame would be able to produce. “Am I going to die from this? Could I die from this?”
I spoke slowly, my voice soft, my tone deliberate, as I tried to tamp down his frenzy and instill clear boundaries. “It’s too early to say. You have a very serious infection. People can die from infections like this. Most people with this are fine as long as we do everything to treat it well. That’s what we’re doing here today.”
“Pull it together, dude!” his brother interrupted, sounding intoxicated. He had a beard as scruffy as his voice and wore a black T-shirt that rolled over a loose stomach and soft silver athletic shorts.
His brother’s words only seemed to add fuel to the fire of agony in Mr. Spano, who now began to weep inconsolably. “Oh my God,” he whimpered, burying his face in his hands.
Carissa and I looked at each other and tried not to raise our eyebrows. His reactions were so far out of proportion to what was going on. Patients who are struck by cars or who receive new diagnoses of cancer demonstrate more composure than this young man was showing. Sure, he was ill, but the odds were that he would rapidly improve after a couple of days of intravenous antibiotics before switching over to antibiotic pills.
Carissa placed an IV in him and drew blood. I completed my physical exam. He was awake and alert throughout—no lethargy. His heart sounds were fast but regular, with no murmur. It seemed that his drug use hadn’t damaged his heart. He had no rash. Good blood flow to his skin. His right leg was normal down to the shin. The area between the knee and the ankle was swollen but soft. While the leg was markedly swollen, red, and warm to the touch, his tenderness was greater than his physical exam suggested. When I pressed the tissue of his calf, I didn’t feel the crackling that would have indicated necrotizing fasciitis, what the media had taken to calling “flesh-eating bacteria.” The inner aspect of his calf had a necrotic abscess about the size of a silver dollar, though. I couldn’t feel a collection of pus anywhere else, and yet, given the extent of his pain, and the swelling and tachycardia, I couldn’t be sure there wasn’t a deeper area of abscess or gas formation in the leg.
I explained to the patient and his brother that I was leaving the room to enter all his orders and call the surgeon. I informed them that this was time sensitive, so we needed to start his treatment quickly, but first I looked the patient squarely in the eye.
“Do you have any questions before I go?”
Mr. Spano shook his head, and I proceeded to leave. Just as I approached the door, his brother stopped me and asked, “How could this have happened?”
“Your brother injected drugs into his leg. That is the way this infection happened.”
The contemptuous expression on his face upon receiving my answer was the same one I might have made after being awakened from a deep sleep by a phone call from a telemarketer.
Mr. Spano said nothing. Then he whimpered softly, “No, no, further questions. Thank you for helping me.”
“You’re welcome. I’ll go get all those orders in for you,” I said, turning to leave.
His brother stopped me again. “Can’t we get him somewhere better? I’m sure there is a better hospital with better doctors to take care of this.”
I paused before I spoke, narrowing my eyes as I felt the back of my throat constrict and my upper chest tighten. I knew there was no point in saying the first thing that came to mind: How dare you? Instead, I replied, “The treatment of this is very standard and is the same no matter if he’s treated here or anywhere in the world. It would be the same if he were in Timbuktu, Yale New Haven Hospital, or the middle of a medical campground. It’s all the same medicine.”
“Okay, well, let’s just do it, then,” the brother said, as if granting me permission.
“Yeah,” I said. Then I left, letting the curtain flap closed behind me.
My contract stipulated that I was to help this man, to heal him no matter what. I did not like him or his brother. I did not like that they were rude and histrionic. I did not like that they seemed not to take personal accountability for what was happening to them. I felt drained by the patient’s hysteria and his brother’s condescension and demands. But I was there to help.
I quickly entered the orders—monitor, fluids, medications, EKG, labs, cultures, X-rays, and ultrasound—then put a page out to General Surgery, who quickly called back and told me that extremity infection concerns were covered by the orthopedic service. I paged Orthopedic Surgery and waited, and waited. Finally, I called the hospital operator and asked her to notify the ultrasound tech on call, only to be told that there was no ultrasound tech on call this holiday weekend, so we wouldn’t be able to evaluate the dimensions of the abscess in that way. I was well aware that the orthopedic surgeon would need to know the size and depth of the abscess in addition to looking for deeper gas collections in the
tissues to determine the appropriate treatment plan.
While I was working on behalf of the Spanos, the ER had been backing up with patients. There was still no answer from Orthopedics, so I picked up the phone again to page the on-call attending orthopedic surgeon myself. It was both a blessing and a curse that our surgical attendings were also faculty at the nearby teaching hospital. The blessing was that it meant more staff, both attending and resident physicians, to care for patients. The curse was that nine times out of ten, they called back angry and affronted because, unlike in the community, academic faculty typically did not have the same incentives to build relationships as the private practice providers who welcomed our calls to be involved in patient care. But still, additional financial incentive or not, it always struck me as strange that a person on schedule to work in his chosen field should be angry when called to do the work he signed up to do.
As I waited, documenting the patient’s condition on his chart, Nurse Jen showed up at my side and asked me to please speak with Mr. Clements.
Yes, I had meant to get back to Mr. Clements! “Sure thing, Jen. He’s next on my list. I just have to speak to Orthopedics, and I’ll be right in.”
“Thank you, because he’s asking for pain medication, but he looks fine. I think he really just wants to speak to a doctor.”
“I’ll be right there. Sorry ’bout the delay.”
Fortunately, the orthopedic resident called back and said he would come to the ER after rounds and after seeing a patient at another hospital. Meanwhile, he requested a CT of Mr. Spano’s leg, as there was no way to complete an ultrasound.
The Beauty in Breaking Page 15