I looked at Mr. Rangoon and realized suddenly that untoothing him might be cause for some concern. He was sitting on the garbage can, drooling blood and pus. His chin was much closer to his nose, and he seemed to have aged thirty years in a few minutes. He really couldn’t speak well at all, and when he did, the garbled communication was accompanied by a mist of blood and saliva that was sprayed all over the room. So I didn’t encourage much talking. He was a very sad sight indeed.
My anxiety level rose. Did I need a consent to do this procedure? Should I have used anesthesia? Do I need a dental license to do this? What would some ambulance-chasing lawyer say? Would he accuse me of wantonly and without regard for his smile, removing Mr. Rangoon’s teeth? What would Mr. Rangoon tell his family when he went home tonight? “Honey, I went to the hospital and some young doctor took out my teeth.” I was concerned. So I did what all concerned young physicians do. I called a consult. Not just a consult, a whole mess of consults. Almost every consultant in the hospital had his beeper go off. I wheeled Mr. Rangoon into the main ER. He was covered with blood and speaking incoherently. I sent the eager residents to “work up the new trauma.” In minutes he was swarmed by white coats. He had blood tests and urine tests, chest X rays, EKGs, CT scans of the head and facial bones; he was poked, prodded, pricked, swabbed, and smeared. I did a little creative writing of my own, mentioning that I had triaged a patient who reported being beat up outside the hospital, before he passed out from acute intoxication.
Several hours later, I was still disposing of the evidence, scattering teeth in trash cans and emesis basins all around the ER. A surgical intern asked me if I had seen the “bum” with the “really messed up face” in room 3. Naturally I told him “No,” but did not give up the opportunity to remind him that “bum” is a pejorative appellation, and the preferred term is “economically challenged.” Chastened, the intern reported that the “economically challenged” individual was supposed to be an eccentric carrying a shopping bag full of money when he was robbed and beaten mercilessly by some drug dealers just outside the hospital. “Really!” I exclaimed. The intern reported that Mr. Rangoon was admitted to the neuro intensive care unit to rule out cerebral trauma. I was impressed how the story had gotten so blown out of proportion, but did a quick scan of the ER for a shopping bag just in case. This place would keep a TV show in business for years.
Cathy and I are presently considering jobs in the big sandbox, aka Saudi Arabia. We are speaking to an oil company who needs doctors and nurses to take care of their employees while they are overseas. Our hope is to make enough in a year or two to pay off the student loans, and maybe have some left over for a down payment on a shack d’amore. We are flying out to Houston for an interview. They are putting us up in a nice hotel where we plan to start our towel-and-sheet collection, just in case the job doesn’t pan out. I’ll keep you abreast of any developments.
Warm regards,
Campion “Camel Jockey” Quinn
IV
Dear Larry,
It started as a regular day at St. A’s yesterday. The usual fun and games: drunks, crackheads, homeless, MIs, and lacerations (here they call them “lacs,” as in alas and alack.) Just your garden variety stuff.
Late in the afternoon, the nursing-home crowd started showing up. One of them was an elderly Hispanic man, Mr. Ortiz. He came via ambulance from the Bailey-Slavin Nursing Home, known colloquially as the Barely-Livin’ Nursing Home. He was sent over for dehydration and sepsis, a common enough problem in his peer group. Mr. Ortiz’s chart gave his main diagnosis as “severely demented” (what a surprise) and said he was a “behavior problem.” A cursory exam revealed a wasted man covered with urine and feces; bedsores gaped at his sacrum, and both his legs were red and swollen with infection. He exhibited an interesting neurological finding, a combination of echolalia and perseveration. When moving him during examinations, he shouted, “DIOS MIO, DIOS MIO, DIOS MIO, DIOS MIO” incessantly. After drawing blood he changed to, “AYUDEME, AYUDEME, AYUDEME, AYUDEME, AYUDEME, AYUDEME …” And … well, you get the idea. This shouting took on the character of Chinese water torture. Mr. Ortiz possessed a loud, clear, rather high-pitched voice, as older men sometimes do. It had a nails-on-the-chalkboard quality.
The AYUDEME doggerel continued for several hours. Tension was building. It became increasingly difficult to think or talk or do anything in a nice way with the constant shouting. Finally, I walked over to the stretcher, leaned in Mr. Ortiz’s ear, and shouted “SHUT YOUR FACE!” He took this lapse of mine very well and was quiet for several seconds. The silence began to settle. Everyone in the ER seemed relieved, and I was halfway back to the counter when I heard, “SHUT YOUR FACE, SHUT YOUR FACE, SHUT YOUR FACE …” This got great yuks from the worker bees. It was not long before members of the staff had Mr. Ortiz repeating their favorite expressions: EAT ME, SHITHEAD, FUCK DOCTOR—–(place the name of your favorite attending here), and the immortal FRANK BURNS EATS WORMS. Despite this feast of the intellect and flow of the soul, I was becoming unglued. It is very difficult to compose even a minor chart note while someone is shouting, “EAT ME, EAT ME, EAT ME …”
In the midst of all this din, Mr. Rios arrived. While smoking crack and drinking to excess, he had neglected to take his Dilantin. He was seizing with considerable vim and vigor, and these seizures were not responsive to my ministrations of Valium and magnesium. He eventually responded after I added a gram of phenytoin intravenously to the mixture. It was good that it worked, since he showed no signs of tiring. Mr. Rios was a stocky man whose arms were covered with homemade tattoos of snakes and skulls. His chin sported a goatee, and there was a livid scar under his right eye. Two earrings in his right ear and a “rattail” at the nape of his neck completed his fashion statement. All in all, he was the very flower of urban youth. He had no doubt lived a hard life. When he began to get agitated we gave him a little more Valium, for fear of him seizing again. He began to snore and slept peacefully, oblivious to Mr. O’s vocalizations.
Several hours passed and Mr. Rios awoke suddenly and became quite demanding. He requested food, scotch, and “my fucking money.” Since there were no bank tellers or barmaids immediately available, his requests went unheeded. This did not stop him from asking for it, though. His shouting went on and on, blending with “EAT ME, EAT ME, EAT ME …” The volume in the ER was becoming unbearable. Mr. Rios, no doubt an honors graduate of some assertiveness-training course, called out to whomever was in earshot for his food, scotch, and money. When they didn’t comply he would castigate them in a ferocious manner. To a nurse, “You cunt! I’ll fuck your daughters and strangle your infant sons!” To a transporter, “You faggot! You pussy! Come over here and suck my cock!” And on and on in this manner. I found it hard to relegate this to purely background noise. When Mr. Congeniality got up off his stretcher and shoved a nurse who was trying to quiet him, I was ready to do my all to shut him up. I was joined by several other members of the staff. We grabbed him and threw him onto the gurney. Our intention was to hold him there while a nurse drew up another dose of Valium to quiet him. (Although it is strictly against hospital policy to use “chemical restraints” on a patient just for the convenience of the staff.) This upset him to no end. He was mortally offended, as if we were old friends who had just betrayed him. Whatever decorum he had been observing was completely gone now. He sprang from the gurney, snarling, and tossed me into a wall. Dr. Bernstein and several other staff members entered the fray, Mr. Rios holding his own, kicking and biting anyone who came near him. I tackled him and forced him backward into a wheelchair. The security guards arrived with the leather restraints. I stood in front of the chair and pinned his arms to the chair’s armrest. The guards tried to put on the restraints. Now Mr. Rios was looking directly into my face. He was struggling mightily, and was lifting me and the chair off the ground. I was terrified of his strength and what would happen if he got loose. I could smell his fetid breath as he cursed me, then he spat in my face. Just as I
was thinking how disgusting this was, and how he probably had some lethal form of TB, he kicked me squarely in the testicles. I didn’t think of much then at all. I was both trying to get away and yet not let go of his arms, very difficult indeed. He half stood from the chair and was trying to bite my nose when I butted his face with my forehead. He slumped down in the chair, a four-centimeter laceration across the bridge of his nose.
I retired to the washroom to rinse the sputum off my face. A lump was rising on my forehead, a pain was raging behind my eyes. I sat down in a back room to compose a note that looked favorably upon this occurrence. Even from the back room I could hear the strident voice of the intern trying to calm Mr. Rios enough to suture his laceration. Mr. Rios was winning this encounter. Mr. Ortiz was now echoing Mr. Rios’s “FUCK YOU, FUCK YOU, FUCK YOU, FUCK YOU …”
Later in the evening, Mr. Rios took on a cop who was standing near. The cop was one of the many that keep an eye on patients that are handcuffed and in police custody. Mr. Rios continued in his usual MO—“Suck my cock,” etc., etc. I sat behind the counter admiring how this cop could take such abuse without comment. He did not tell Mr. Rios to shut up or quiet down. He did not threaten him with arrest, or physical harm. His refusal to acknowledge the abuse only enraged Mr. Rios more. I wondered if they give the police a special course in this technique. Maybe he is so used to street crime and physical violence that this abuse does not bother him. Maybe he is deaf? I was feeling less of a man for overreacting to Mr. Rios’s abuse. I was about to get up and offer the cop a cup of coffee when I noticed him looking from right to left, down the hall. He took two quick steps to the wheelchair, and when he thought no one was looking, gave Mr. Rios a left hook that snapped his head backward. He slumped in the wheelchair again, his right eye closing with a hematoma.
Two new injuries and a significant amount of Valium were not enough to chasten Mr. R. Within minutes he was awake and abusing staff members. Despite the fact that there were more tests pending, I discharged him onto the street, escorted by our biggest security guards, before someone put a bullet in his head. I wonder how this guy lived to be twenty-six-years old.
Mr. Ortiz was admitted upstairs. His final comments to the ER he had entertained for seven hours were, “BED 9 WINDOW, BED 9 WINDOW, BED 9 WINDOW,” so we all knew the bed he was going to.
Cathy is pregnant. Suffice to say, I am pleased. Last week I went on an interview at TELOS Laboratory Associates, a pharmaceutical research firm. I listened a long time to their spiel, then told them I was morally opposed to human experimentation if I was paid only sixty-five thousand dolla a year. I can’t believe I’ve even considered a research job! I hope your wee man is doing well and that you have not demented his mind with hospital stories.
Warm regards,
Campion
V
Dear Larry,
Today I took care of a young professional couple. They were minding their own business, watching a video in their swanky Village apartment, when a ring at the door announced a persistent solicitor. Mr. Smith opened the door and was smashed in the face with a gun butt. Two men entered the apartment, drew pistols, and threatened to kill the couple if they screamed. The assailants calmly and methodically ransacked the apartment, looking for money and valuables. Satisfied that they had everything they could carry in their bags, they turned their attention to the Smiths. Mr. Smith was beaten unmercifully, and with a gun to his head, his wife was forced to perform oral sex on the other perpetrator. Next she was raped and sodomized by both intruders as her husband watched. The Smiths were bound and gagged, as the burglars made several trips to empty the apartment. The couple was found by neighbors in the morning when their door was noted to be open, and they were brought to the ER.
Mrs. Smith had the vitreous look of those involved in major trauma. She spoke little, and then in monosyllables. She gave an eerily calm monotone description of the attack. Mr. Smith wasn’t much better, with his facial-bone fractures and scalp lacerations. He didn’t answer most questions, nor did he react when injected with tetanus toxoid or lidocaine when suturing his wounds.
I had a strange feeling of guilt while examining Mrs. Smith. The exam is intrusive. During the interview, the doctor is in charge of gathering information and evidence. One must ask all the unpleasant details of Who?… How many times?… How many attackers?… Orally?… Rectally?… The examination involves a pelvic and rectal exam. We are looking for trauma, semen, blood, and saliva. Hair samples are pulled from her head and pubic area; the pubic hair is combed for stray hairs of her assailant, which may be matched with the assailant’s if he is caught. Bite wounds are swabbed for traces of saliva, which also may be matched with the assailant’s. The exam is a significant invasion of a patient who does not need any more stress. All during the exam, Mrs. Smith was staring blankly into the ceiling as I and two nurses discussed the wounds, documented findings, bagged evidence. I was happy to turn the case over to the rape-crisis counselor. There was no counselor for Mr. Smith. He was sent to the head and neck service for repair of his fractures. Mrs. Smith went home with her sister. As usual, the police were all over the ER, hogging the phones and writing space. I asked the sergeant what the chances were of the assailants being caught. He laughed and said something sarcastic about them feeling guilty and turning themselves in later today.
I can only imagine the tremendous feeling of paranoia one must have after an incident like this, knowing one’s home is not safe. Wondering every time someone rings the doorbell, Is this another rapist, burglar, or worse?
This case really hit close to home. I’ve reminded myself to add a deadbolt to our door at home, and am thinking again about purchasing a handgun. That couple had so much in common with us. I don’t know if I can tell Cathy about it. She’s going off to St. Thomas in the Virgin Islands to get some sun with her sisters before the baby comes. Maybe when she gets back I will.
Be safe,
Campion
VI
Dear Larry,
Yesterday morning when I left for work I felt like I was getting the flu. I had slept poorly the night before and hoped for a calm day. It was not to be. The day was filled with the usual amount of inner-city nonsense. I became preoccupied with watching the clock and how slowly it seemed to move. I know it’s a bad day when I start by saying, “Only eleven and a half hours to go!” The day dragged on without a chance to sit down or eat.
Needless to say, I was very happy when Patty Flanagan arrived to replace me. Patty and I went to medical school together. She’s now a pulmonary fellow and works one or two nights a week to supplement her salary. She’s an extremely bright, hardworking physician, and usually takes up all the slack in the ER when she’s here. I was looking forward to a trip to the gym for a quick workout and a simmer in the Jacuzzi. While signing over cases on rounds I noted that Patty was quiet and appeared pale. I tried to ignore it, but when she left rounds to vomit in a wastebasket, it became difficult. Everyone was uncomfortably looking at one another, then down at their shoes. We all knew that the ER could not be left unmanned, but no one was interested in staying. Patty returned to rounds, said she was “OK,” and we continued. When rounds were finished there was a general rush for the door by the attending staff. I was left with Patty, and in my medical opinion she looked like shit. I suggested that she take some Tylenol and Compazine and rest for a couple of hours while I covered things for her. I felt bad for her since she would have to be on duty the next day, sick and without any sleep, to work with the cancer patients. It seemed like that job was depressing enough without the added burden of being sick and exhausted.
The evening traffic was picking up and I was getting more weary. I had not eaten since morning. It was now 10 P.M. and the Jacuzzi closed at eleven. I decided to call it a night and went to look for Dr. Flanagan. I found her lying on the floor of the coffee room, looking even more pale and sweaty. I picked her up, hoping against hope that she was practicing an unusual form of meditation, but it was not to be. S
he was febrile, very ill, and could barely move. I toyed with the idea of having the patients come into the coffee room and tell her their problems as she lay on the floor, but I didn’t think it would really work. I was screwed.
I called my boss, Dr. Kleiner, looking for help. He told me that he would make some inquiries to see who was interested in coming in at midnight. I thought of someone calling me at 11 P.M. to ask if I wanted to work all night in the ER, and knew no one would even pick up the phone at this hour. I also knew Kleiner wasn’t about to come in, but I called him back at midnight anyway, just to let him know how I was doing. He told me he was concerned, and that if I left the hospital unmanned I would be liable for a patient abandonment suit. I thanked him for his concern and assured him I would call again at 3 A.M. to let him know how the night was going.
The night turned hellish. I saw a young man come into the main ER flanked by nurses from triage. He was covered with blood—not all that unusual, but triage nurses never come into the ER so I was concerned. I walked over to him and introduced myself. He was holding his abdomen and in a very calm voice stated that he had been robbed and stabbed. I asked him if I could look at the wound, he released his hand from his abdomen and his intestines fell to his knees like a bloody apron. “I think we need the trauma team!” someone yelled. In the trauma room I started a few big lines, pushed in fluid, ordered some O-negative blood, and put a wet dressing on his abdomen. When the trauma team arrived, the surgical residents looked at his wound, then grabbed the stretcher and ran for the OR with smiles on their faces. Ordinarily they hang around the sickest ER patients, asking for different X-ray views and clotting profiles while discussing how you are mismanaging the case. But when there is a true emergency, they really can hotfoot it to the OR. They love to operate. Mr. Intestines did well, according to an intern who scrubbed on the case. He said that despite the dramatic appearance of the wound, no vital organs had been violated. He sounded disappointed.
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