The Patient in Room Nine Says He's God

by Louis Profeta

  It was early in the morning, and she was my first case of the day. Her condition was grave to the point that I needed to put her on life support. Just prior to this drastic step, her husband leaned over and gave her a gentle kiss on the lips knowing deep down it would probably be their last. Once the tube to breathe for her was placed into her lungs, she stabilized but still remained in critical condition. I spoke with the neurosurgeon, and we both felt she would be best served by being transported to our larger hospital. I arranged for an ambulance and a critical-care transport team, and sat down in my office, flipping though medical books, seeing if perhaps I was missing something. Nothing came to mind.

  Then it hit me! Post her case on the doctor’s blog, in real time, and see if any other physicians might have an idea, or have treated anything similar. Who knows, we both might get lucky.

  In order to draw as much attention as possible to this urgent plea, I opted for the attention grabbing title: I Just Had a Horrible Case. I laid out the situation as quickly and as accurately as I could: Thirty-Five years old, healthy, no significant past medical history, with multiple sites of brain hemorrhage on head CT, etc, etc. There must have been a sense of urgency and despair in the way I posted the case, because the blog exploded with suggestions from neurologists, internists, infectious disease experts, ER docs, and other specialties—all making suggestions, offering guidance, and a shoulder to lean on, a comforting cyber-hug, that said: “You are not alone, we are here with you.” So in this small ER north of the city, in the early hours of the morning when children were starting their day and coffee was being dished out in central standard time cafes, physicians from across the country were poring over books, racking their brains, digging into their case files, and trying to save a young woman whom they only knew as: “The Horrible Case”.

  About 48 hours later, after screen upon screen of comments offering insights into cerebral vasculitis, steroid management, antiviral therapy, immunosuppression, the thread was punctuated by the following . . . Pt died at 0900 . . . husband age 35 . . . 2 children.

  And while this may sound like another natural end to the story, it doesn’t stop here. A few months later, the blog had a contest for the best emergency medicine post. Well, a physician in Texas nominated my post, and around late November I was the proud, anonymous recipient of a Sermo (the blog site) choice award for the outstanding post in emergency medicine, which came with a $500 honorarium that accompanied the award. And there it sat in my home office, along with my check for $500.

  And as sure as I sit here, I gloated over that check for a solid two weeks, fingering the print, smelling the paper, and snapping it against my palm . . . 500 smackers. I had made up my mind. I was going to cash it that week. You see, anyone can ‘justify’ a wrong decision, if you think about it long enough. But as seems to be the case with me more recently, when I am faced with these moral conundrums, God tends to step in and help me resolve the issue, usually in his favor.

  We have some twenty physicians that rotate through various days and shifts at this small community ER we staff. When you take into account that fact that we see some 20,000 people each year, the chances of me working at any particular hour are only about one in twenty. Now calculate the chances of someone coming to the ER at the exact moment in time where I am thinking about how best to spend their $500—it must border on infinitesimal. But of course, that is exactly what happened.

  “Hey Profeta, get in here, someone wants to say hello,” shouted the voice of my colleague Dr. Smith. He came out of this room where he was sewing the lip of some kid that crashed sledding.

  And there he was: her husband and one of her children. “Dr. Profeta. . . remember me. . . you took care of my wife.” He held out his hand. I clutched it in both of mine.

  “Of course, I remember. How are you and your children doing?” I asked, motioning to the one with a big piece of gauze sticking out of his mouth.

  “We’re doing okay,” he said, but his eyes gave away the truth.

  I tried to flash him a smile, shuffling my feet and looking at the floor. At that moment I had a suspicion that God was laughing at my expense, like watching your child do something stupid but harmless. The check was a goner. “I’m driving the kids to Florida next week; we’ve never been on vacation before.”

  I nodded my head and shuffled my feet some more. “Uhhhh . . . I meant to call you. I have a check for $500 sitting on my desk for you.” A look of confused surprise crossed his face. “You remember how I posted your wife’s case in real time on this doctor’s blog? Well, this other doctor nominated it for an award on this blog and it won. So stop by tomorrow and I’ll give you the check.”

  The next day he stopped into the ER with his children in tow. I give him the check, and he just looked at me in bewilderment.

  “I don’t know what to say. I just . . .”

  I interrupted him and cleared my throat. “Listen . . . just go have a good time, and get something cool for Christmas, you all deserve it.”

  And with that he left.

  In all 200 doctors reached out through cyberspace and offered support for this dying woman. Nearly 200 doctors held my invisible hand, and cradled my invisible head. These doctors cried, cheered, laughed, and reflected on the sacred bond for which they were entrusted. Nearly 200 doctors bore witness to the mystical nature, the godly energy that binds us like cement to each other. And at $2.50 a pop, I’d say I got a good deal.

  Chapter Twenty-eight

  “I Treat Everyone the Same”

  “The check is in the mail”, “I promise it’s just between you and me,” and “I treat everyone the same.” These are three of the biggest falsehoods that come to mind, outside of the few that I can’t really put in print. The third pretense is the biggest lie in medicine. It is one of those nails-on-the-chalkboard proclamations, the verbal equivalent of chewing on a metal fork. And it is most often a pathetic attempt by the nurse or physician to explain either their inability or their lack of desire to relate to people from a variety of social, ethnic, and religious classes by indignantly sticking their chest out and bellowing, “I treat everyone the same!”

  My response to this self-indulgent verbal pat-on-the-back is simple: Considering that everyone is different, and that our ER population is a remarkably balanced cross-section of American society, from Hispanic to African-American, white Anglo-Saxon Protestant to Jewish, from Muslim to Catholic, filthy rich to poor white trash, it is a safe bet that nurses and doctors treat most people in a manner that does not make them comfortable and in many instances they do not appreciate.

  There is a famous ancient story about Rabbi Hillel that, when challenged to teach the entire Torah (the five books of Moses) while standing on one foot, he responded, “What is hateful to you, do not do unto others; the rest is an explanation of that. Now go study.” This is an obvious predecessor of the Golden Rule, most commonly recited by our Christian brethren. But herein lay the confusion. What is hateful to one may be comforting to another. What is comforting to some may be hurtful to another. I have learned that the only way to know is by getting to know your neighbor or the people you treat.

  There have been numerous studies examining how different racial and ethnic groups perceive the attitude of medical staff in regards to their care, pain control, and the administration of healthcare services. In addition, there seems to be a range of patient expectations when it comes to discussing healthcare problems. Studies show that certain ethnic classes want and expect significantly more content when confronted with medical test results, whereas others want a more concise and to-the-point description. Some cultural groups greatly enhance the perception of pain, whereas other groups feel the request for pain relief to be a sign of weakness. One patient can find your explanation to be over their head, while the same explanation to another may be welcomed for being on their level. In many ways the ER is the Ellis Island of our time: the place where all of society congregates, waiting for a chance to pass into the promised
land of medical salvation, a cacophony of accents: from Russian, Chinese, Spanish to urban slang and rural drawl.

  Getting back to the Golden Rule, I think the implication is that God wants you to make your neighbor comfortable, to know your neighbor. How could you possibly do unto others if you have no idea how those others will respond? Over the years I have noticed rural Caucasian males, especially laborers and craftsmen of European descent, tend to be very stoical when it comes to pain medications. I have seen these jean-clad tough guys come in for kidney stones, amputated digits, and open fractures requesting nothing more than ice packs. Their high blood pressure, fast heart rates, and beads of sweat on their forehead and upper lip give away their agony from the pain they feel. I offer them morphine or something of similar strength, and they casually shoo me away, “Naw, Doc, I’m okay . . . maybe later.” That’s when I do unto them.

  “You know, if it was me on that table, I’d be crying like a baby. I had a kidney stone once and it felt like I was trying to crap out a whole beef roast with the bone in it. Now listen, let me give you some morphine to take the edge off and keep the pain from getting worse. There is no need to act tough here . . . you don’t want to be in pain, and I don’t want you to either.” I don’t wait for a reply. I just quickly turn to the nurse and ask her to bring some pain medication. And you know what? They never turn down the request.

  The easy way out would be to just tell the patient, “Let me know when you want something.” But that would be a failure on my part to get to know the patient, to do unto others, to speak their language, and to understand their fears.

  So often, nurses and medical students will be irritated by a patient who comes into the ER with a simple complaint in the middle of the night: the poison ivy at 2:00 A.M., the sore throat at 3:00 A.M., or the mild cough at 3:45 A.M. Oftentimes the nurses will roll their eyes and toss the chart with a resounding thud into the to-be-seen rack, and walk off mumbling about the absurdity of this complaint at this hour of the morning. By getting to know this population of patients—the so-called denizens of the night—and really exploring their motives, here is what I have found: Many of them are really there seeking help for drug or alcohol addiction, depression, or other emotional problems. They just don’t want to talk about it with anyone other than the doctor, so they make up a false complaint. Most of all, they don’t want to run the risk of seeing someone they know in the ER waiting room. Others are homeless and just want a place to hole up for a few hours, get a cup of coffee, some crackers, or perhaps a bed. Many of these patients just can’t sleep or get rest from their condition. They figure there is no problem just coming into the ER. There is nothing more miserable than trying to sleep with a severe sore throat or congestion. Some of these patients work night shifts, just like us, and have maybe an hour break to come into the ER. Others are single parents of limited means and small children. They sneak out of the house while the kids are asleep; this is the only time available to get medical care for them. Finally a few of them are just at the end of their rope and want their problem fixed regardless of the time. But, then again, the only way to know that is by getting to know them.

  So in the ER I try to do unto others. I try to make them all comfortable. I try to do what is best for them as an individual. I try to put my prejudices and judgments aside, but most of all: I try to treat each patient uniquely and get to know them, if just for a bit. And like most physicians and other healthcare providers, when I leave the hospital I tend to forget all of these niceties and focus on my own self-comfort and pleasure. You see, once I leave my house of god, the ER, and go home to my family and my close friends

  . . . well, I tend to treat everyone the same.

  Chapter Twenty-nine

  “You Don’t Understand . . . I am Going to Die”

  I think she was about 35, slightly heavy, and had dirty-blonde hair. Her face was marked and ruddy with years of tobacco and alcohol abuse, and perhaps just a tired, strained life. She came into the ER sitting bolt upright on the gurney, grasping the side rails, and complaining that she could not breathe. She undulated and rocked back and forth on the cot in a sick symphony, calling for anyone who would listen. Her yells were palpable and disturbing to the patients on the other side of the curtain who were within an earshot.

  “Help me, I can’t breathe, I can’t breathe,” she cried, over and over again. Sweat beaded on her brow, her body strained. But her oxygen level was perfect, her chest was clear, and her EKG was normal.

  “Calm down,” I told her, “you’re going to be all right. Slow your breathing and tell me how long you’ve felt sick.” She shook her head as if shooing me away, not wanting to talk about it, not wanting to explain.

  “I can’t breathe,” she repeated over and over again. I did all I could do to get some useful information, but the locked-in fear on her face told me she was lost in another world, or perhaps another time. Nothing seemed to be helping; oxygen did nothing to alleviate her distress. Her chest X-ray was normal.

  “Did you take something, a drug . . . anything?” I pleaded.

  Again she shook her head in disgust. “I can’t breathe,” she said, but softer now.

  “Calm down,” I reassured her. “We’re going to take care of you; you’re moving air well, and the oxygen level in your blood is good.”

  Suddenly, she sat bolt upright, digging her nails deep into my arm, pulling my eyes into hers. “You don’t understand . . . I AM GOING TO DIE!” And with that exclamation, she fell back hard, let out a final sigh, and her heart simply stopped. I was dumbfounded.

  One of my colleagues, Tom, peered around the corner, hearing the commotion as did everyone in the vicinity. We immediately started CPR, placed a breathing tube in her, and injected every imaginable medication in an attempt to save this woman. But in the end her heartbeat just ran out. We were left with the sobs of other patients and their families who bore witness to this sad event.

  “What do you think happened?” Tom asked.

  “A massive blood clot in her lung, tore her aorta, or blew a hole out of her heart wall; take your pick.”

  In retrospect, I knew we would not have been able to save her in any of the above scenarios. But I still felt profoundly sad and was left with a sense of helplessness. Why had this person been allowed to come into my life for these fifteen tragic minutes? What did I really contribute to her final restless hours but a sense of my own profound frustration? She knew something in the very depths of her being: she knew that she was about to die. It was as if this were her final salvo, a way to tell the world that she was here, and that she would be remembered, if only by a stranger.

  And what of God, what was his role in this? Her time was his time, and we were simply spectators in this event. Or was it more of a lesson in mortality, our fragile existence, or that dying is always loss, and that we should grieve even for those we know only for a brief moment, or as a pleading voice on the other side of the curtain?

  Chapter Thirty

  “Stop Him”

  I don’t remember his name. He was a big guy: forty years old or so, maybe five-eleven, and weighed at least 250 pounds. That night it was catastrophically busy. We had patients in every bed in the ER, and they were overflowing into radiology and in other parts of the hospital. We were most likely in the midst of a flu season.

  As time passes, most patients just blur into a chief complaint: they aren’t Mrs. Jones with chest pain or Mr. Brown with a stroke. They become the acute MI or the CVA, as if their identity is forever tied to their illness. I do know that this gentleman has no idea of the name by which I summon him from my memory. To me he is simply . . . the voice.

  “I’m having trouble breathing, coughing a lot, that kind of stuff. I work at Ball State and went to a Med-check earlier today, and they said I had bronchitis and put me on this stuff.” He handed me an asthma inhaler, some prednisone, and I think an antibiotic.

  That’s just great, I thought to myself, exasperated: This guy comes in only twelve h
ours after a checkup and is surprised he hasn’t gotten any better. He hasn’t even given the medications a chance to take effect. And now, to top it off, I have to waste my time convincing him that the earlier diagnosis was correct, and then he’ll be angry that I’m not going to do anything else and that he wasted all his time tonight.

  Mind you, in my self-serving egocentric style, I have already pegged this guy. I have formulated all this without even laying a hand on the patient. Damn, I’m good. So I did a quick evaluation; he sounded a little wheezy perhaps, or maybe I imagined it to feel better about the time spent. I gave him a breathing treatment and then ran out to attend to a patient who was most certainly in greater need. An hour or two more went by, and I’d forgotten about my nervous doughboy who would not let his meds kick in. A nurse reminded me that he was still in the examination room and asked what we were going to do with him.

  “Tell him I’m tied up and I can’t get back there. Sign him out and reassure him it’s just bad bronchitis, and he’ll be fine in about three days. Oh, and give him a work release. That’s probably what he is here for anyway.”

  I tended to some paperwork as the gentleman passed by in front of me onto the way out of the heavy metal security doors of the ER.

  “Thank you,” he told me with a conciliatory closed-lip smile as he approached the heavy exit doors. His demeanor and walk seemed to be affected by the nurse’s comforting explanation; the doors snapped open with a loud clang. That’s when I heard it inside my head . . .