The nurses have come in while we are talking. Quickly, Jenny checks his blood pressure, pulse, and respiratory rate. I unwrap the dressings over his head as she finishes. The forehead wound is long and deep. I remove the straps. “So what happened?”
He talks, I probe. “Not sure, Doc. I’ve been drinking a little wine tonight, can you tell? Just staying dry under the bridge,” he continues. “I was going to … Oh, shit! Now I remember. A couple of guys came up—wanted my bottle. I gave it to them—no trouble. One of these guys was really wild-eyed, fast talking—in Spanish. I didn’t understand what he was saying. He started waving my bottle around. Hell, Doc! I moved out from under that bridge real quick-like, down toward the river—backing up—but him and his buddy just kept coming. Next thing I know there are cops around: My head hurts. I’m wet. I’m cold. My shoes are gone.… Hey! Can’tcha give me something for this headache?”
“All right, Cal, but I gotta sew you up.”
“Go ahead, Doc. Don’t wanna ruin my good looks.” He lets out a wheezy laugh, hitting me with the fetid odor of stale cigarettes and cheap wine.
“Well, this is what I’m here for,” I grouse to myself. I put on a mask. Cal and I are going to be close for awhile. I get my gloves and prepare the instruments as Mildred scrubs off dirt and blood, exposing the raw wound edges.
Cal closes his eyes and starts humming. I numb his forehead and begin my first stitch.
“Whatcha humming, Cal?”
“Oh, nothing.”
“Sounds familiar.” I keep sewing.
“Yeah? Well, it’s from Hair. You look old enough to remember the sixties.”
“ ‘Aquarius’—right?”
“Yeah, Doc. Did you know I was in that?”
“In Hair?”
“Yeah. In San Francisco. Small part. I was studying at the Actor’s Workshop. Hell, I did directing, acting, set design, the whole thing. That’s my career. Or was my career. I got off track a little.”
“A little? I’d say you’re way off now. What happened?”
“Sort of fried my brain, I guess. You see I was making ends meet by living with chicks, sort of a gigolo type. North Beach. Played a beatnik role. The older chicks dug it—letting me stay at their pads, then kicking me out. I’d go back to drinking wine and getting sandwiches at the mission—just keeping it together enough for a little work in the theater. Then I started doing methedrine, then acid, then ludes. Meth and ludes. Up and down. Moved to the Haight, became a hippie. Lotsa free love. Lotsa free everything …” his voice fades.
I’m still sewing. His wound extends from his forehead to far above his hairline. “I lived in the Haight in sixty-eight and sixty-nine,” I tell him. “I used to eat lunch in Buena Vista Park once in a while.”
“Hell, Doc, I buried my dog in Buena Vista Park.” He opens his eyes and looks at me. “How much more you have to sew?”
“Not much,” I reply, “but I have to shave your head a little to get to the wound up here. Maybe I should shave it all, kind of give you a Buddhist monk look.”
His eyes widen further, fixing me with a penetrating look. “I am a Buddhist monk!”
“Come on, Cal …” I protest.
“Honest, Doc.” He’s not smiling. “I lived in Carmel Valley. Same retreat as Ira Sandperl, Joan Baez, the whole bunch of them. Shaved my head, wore robes, meditated …” his voice saddens. “Meditated myself right into the nut house and five years of Thorazine. Called me a paranoid schizophrenic.”
“Are you?” My question is flat, nonthreatening. I return his gaze.
“Not anymore. The shrinks now say they were wrong. Now I’m a manic depressive—a lithium and Cogentin man. Actually, I’m doing a lot better.”
“Sleeping under bridges? Rolled for wine and shoes?”
“Listen, Doc, I’ve got a girlfriend now. We’ve made plans. I think we’ll do it. She and I both got disability checks. We’re going back to the land. Maybe Mendocino.” His eyes close again. I finish the last stitch and remove my gloves. Mildred begins cleaning the remaining blood from his forehead.
I turn back to Cal. “You can go when she’s finished.”
I look up at the clock. It’s 5:30 A.M. and my back aches. My feet are sore. I’m definitely ready to call it quits for the night. I stretch and walk to the emergency room glass door. The rain has stopped and pale light is changing the sky in the east. I look down at my shoes. They’re old but sturdy. Good for someone on his feet a lot, and Mendocino’s a long way on foot. I return to Cal’s room.
An hour and a half later, I slosh out the back door of the ER, headed for my car. The pavement is cold and wet under my bare toes. To me, it feels good. It’s no longer night. It’s morning.
KENT BENEDICT, M.D.
Aptos, California
COMMUNICATING IN THE ER
Communication in the Emergency Department is a vague art, taught (ad nauseam) in school, mastered only in practice. Medical personnel can write an entire history and physical without using a single word, symbol, or initial recognizable to the average layperson. In the ER, it’s not only what we write and say, it’s what we really mean when we write or say it.
Picture an eleven-bed emergency room on a moderately busy afternoon. Mr. Patient in bed 5 has a lacerated arm. I am the trusty physician’s assistant assigned to deal with bed 5, but as I survey the room, I notice there is no place for me to sit as I repair the laceration. I have been on my feet since early this morning and getting to sit down is one of my favorite reasons for repairing lacerations, so as I hastily assess Mr. Patient and move on to bed 6, I tell a nearby volunteer: “I need a stool in bed five.”
Now, the volunteer is fairly new to the department, and eager to do a good job. She has not yet caught on to the standard reply to a request from a physician’s assistant, which is usually “Get it yourself.” But she has been exposed to the art of ER communication; she knows the SOB in bed 1 is not a bad person but “short of breath,” and she knows “bed four needs a chest” is not a physique appraisal but an X-ray appraisal. So, when she hears my request, she approaches the treatment room nurse and says:
“The P.A. needs a stool in bed five.”
The volunteer looks a little embarrassed. The nurse looks at me and asks: “You need a stool in five?”
I answer: “Yeah.”
If communication is an art, we begin to create a masterpiece.
The nurse asks the nurse’s aide to get a stool specimen container and instruct the patient in bed 5 while she makes the requisition.
The N.A. approaches bed 5. Mr. Patient is wearing a hospital gown. His laceration is not readily visible. The N.A. shows the specimen container to Mr. Patient and tells him he must provide a bowel movement in the little bowl. Mr. Patient tells her she must surely be mistaken, and refuses. What to do?
The nurse’s aide approaches Dr. Hart. Dr. Hart is the supervising physician on duty. He does not know Mr. Patient in bed 5 from Adam, but he trusts his faithful physician’s assistant. The N.A. tells him: “The patient in bed five won’t give a stool specimen.”
Dr. Hart gives sound advice: “If it is just for a stool culture, we can get by with a rectal swab. Check with the P.A.”
The N.A. approaches me and says: “Can I get a culture swab on bed five?”
I am confused. I ask: “Who suggested a culture?”
She replies: “Dr. Hart.”
Well, I was not aware that bed 5 needed a culture, but I respect my omnipotent supervising physician. Perhaps he knows something about the patient that I missed. A weakened immune system? Contaminated wound? I decide I will investigate further before the specimen is sent to the lab. In the meantime, so as not to look foolish, I answer: “Sure, go ahead.”
She goes to bed 5 with her culture swab. We can only imagine what transpires. What did not transpire was the obtaining of a rectal culture. She tells the treatment nurse: “Bed five is refusing his culture.”
Refusing? She has been busy with other patients, but cou
ld it be that bed 5 was becoming a problem patient? (Now, everyone knows, once an ER nurse has labeled someone a problem patient, then that is what he is. Period. If you cross that bridge, buddy, there is no going back.) The treatment nurse, of course, knows the role of a physician’s assistant. She approaches me and says: “Bed five is a problem. He is refusing his culture. You’ll have to get it yourself.”
Refusing his culture? A problem patient? What news is this? Did he read some Reader’s Digest book titled I Am Joe’s Wound? Some magazine article on how doctors are getting rich off of unnecessary lab tests? Well, I would speak to him. I approach Mr. Problem Patient.
“I understand you don’t want your culture.” I go on to wax poetically about the dangers of undiagnosed infections, the need to discover what type of bacteria he may be harboring, and the importance of cultures in general. I am getting nowhere. Mr. Problem Patient is adamant. And I’m not sure, but does he look a little confused? Apprehensive, maybe? Of course! Not to worry. I try another approach.
“Don’t worry about any pain during the procedure. I will numb the area first with some Xylocaine.” I then lay the syringe in full view on the counter and go in search of a stool on which to sit as I close the wound. Didn’t I ask the volunteer to find me one?
As I culture, clean, and close the laceration, Mr. Problem Patient is very quiet. He has tucked the blanket tightly around his waist. He looks a little pale. I’m not surprised—many a strong man has gotten woozy at the sight of blood. When I finish putting on the dressing, he practically runs from the exam room.
As I dictate the note, I see there is a requisition for a stool culture clipped to the chart. The story unfolds.
Bed 5 never did return for his follow-up. Not surprising. After all, he was a problem patient.
RHONDA L. PERRY, P.A.
Honolulu, Hawaii
DOWN THERE
The GYN nurse put another patient in the next available stirrups and called me. “A four-hundred-pound fourteen-year-old with severe, generalized abdominal pain. LMP now. Never sexually active,” she informed me.
I went into the GYN room and introduced myself. The patient was extremely obese, sweaty, and screamed with pain intermittently. My first thought from about four feet from the GYN examining table was that the patient had a ruptured appendix.
The patient told me that she had been in pain for twelve hours, was nauseated, and had vomited. She had never been pregnant and had never been sexually active. Her menses had begun two years previously and had been irregular. The patient’s mother, a woman of similar body size, told me that the patient had become irregular after gaining 150 pounds during the last eighteen months.
The patient’s exam was not remarkable. The pain was in remission during my abdominal exam. The patient’s gut was enormous and prevented an adequate abdominal exam. I ordered blood. While the blood was being drawn, I asked the patient in private if she had ever been sexually active. She said no. Furthermore, she said no one had ever touched her “down there,” and she refused to have a pelvic exam.
I talked to the patient and to the patient’s mother about the necessity of the exam. The nurse also talked to both of them. I returned in fifteen minutes. The patient’s pain had increased. She writhed and screamed periodically, her pain now severe enough to persuade her to allow the pelvic.
I inserted the speculum into her vagina and saw a smooth, bloody, shiny mass covered with hair. She screamed and it shot out at me and into my lap, nearly sliding down my legs onto the floor. I wrangled the slippery mass back within my grasp. The mass wriggled. It screamed. I clamped and cut its umbilical cord. We broke open the emergency delivery bag and suctioned the eight pound baby. I placed the baby cautiously upon the mother’s abdomen and held it there.
“Aaaaaah,” she screamed. “That didn’t come out of me!”
“That didn’t come out of her!” yelled the mother.
“Well it certainly didn’t come out of me,” I said quickly, impulsively.
“I’m fixed. Hysterectomy,” the nurse said.
We called the obstetrician, the pediatrician, and social services, then moved along to the next patient.
MICHAEL ERICKSEN, M.D.
Los Gatos, California
KEEP ON SMILING
We receive many letters in the Emergency Department. Some express gratitude, others do not.
An elderly, female patient was brought to the emergency room and pronounced dead on arrival. Some weeks later, a letter arrived from her family thanking the ER personnel for the kindness shown to their aunt. The family was particularly appreciative that the staff had donated a set of false teeth, making the patient look especially beautiful at the wake. The letter also related how the deceased had always wanted to get false teeth but had been unable to afford such a purchase.
The hospital wrote back thanking the family for their kind remarks, but everyone remained perplexed by the comments about the teeth.
The mystery was solved with the receipt of another letter. This one was from a former patient complaining that she had been made to wait in the ER for three hours before being admitted to a hospital room. She was most disgruntled by the fact that the hospital had lost her false teeth and caused her a great deal of stress and inconvenience.
Thinking it best not to explain, the hospital sent a letter of apology and agreed to reimburse the cost of new dentures.
JOHN DENTE, M.D.
Wilmington, Delaware
JUST BEING THOROUGH
Three men walked through the entrance door that was immediately beside the triage desk. Sharon, an excellent nurse, could tell at a glance the one in the middle was in trouble. He was being assisted by the men on each side. He had on a bicyclist outfit—jacket over tight, light blue shorts and bike shoes. He had one hand loosely over his groin, which was covered with blood. Sharon was told he had fallen.
She quickly got him onto a stretcher with his friends helping on either side. With rapid precision, she pulled down his shorts, removed the athletic supporter, spread his legs, and elevated his testicles, looking for the source of the bleeding. “What are you doing?” asked one of his friends.
“Trying to see where he’s bleeding,” she responded.
“It’s my shoulder that’s hurt,” said the startled patient.
Under his waterproof jacket, the patient had a compound clavicle fracture that had bled down his chest and abdomen and covered his pants with blood. The hand that appeared to be protecting his groin was actually his injured arm being held by his other arm to protect it from movement.
The nurse won the award for the most thorough physical exam performed for a shoulder injury.
MARILYN J. GIFFORD, M.D.
Colorado Springs, Colorado
BRIAN’S STORY
The ER day shift started out as usual, somewhat slow and under control. The staff was chatting about things going on with their home lives when the radio alarm went off. “AV Hospital, this is Hall Ambulance 242 with a pediatric full arrest.” I handled the call, thinking, “Probably another SIDS baby.” After twelve years as an ER nurse I know that not many of these kids survive. I thought of the parents and, as I was a new father, I felt especially bad.
I went outside to make sure the door was held open for the paramedics. My coworkers prepared the room for the patient. When the ambulance arrived, a paramedic came out of the back holding the child in one arm, doing compressions on the lifeless little body with the other.
As he hurried past me I looked at the child’s face. A lump formed in my throat as I thought, He looks just like my baby. I realized this was the first dead baby I’d seen since my child was born. I followed the paramedics into the ER, dazed and dizzy. As I entered the room, one of the nurses looked at me and said, “Don’t even come in here. We’ll take care of this.”
I mumbled, “Thanks,” walked into the radio room, shut the door, and fought back the tears.
The child didn’t survive. The parents arrived and were told of the
outcome. Their screams and cries tore a hole right through me. I wanted to go to them, hug them, and cry with them, but I couldn’t lose control of myself.
I fought my feelings hard, kept myself semicomposed, and yearned for my son. I wanted to see him and hold him. Now! The time passed slowly. I felt like I was in a different body. I spoke to my wife a couple of times over the phone throughout the rest of the day. I never mentioned to her what had happened for fear of losing control. She worries about our baby enough as it is.
The shift finally ended, and as I drove home, the knot in my throat began to disappear. I walked in the door, said hi to my wife, and gave her a kiss. I walked over to my son, Nathan. He was sleeping in his playpen. As I looked to make sure he was breathing, the tears welled up in my eyes again. I turned to look at my wife. She saw my face just as I said, “I had a SIDS baby today.” We embraced, crying out loud, each other’s necks wet with tears. I don’t remember ever crying that hard in my life.
We calmed down a bit after about ten minutes, and I explained what had happened. I went to the sink to get a drink of water. The image of the lifeless baby came back. I thought of the parents and began crying again.
My son woke up and I held him close.
BRIAN COAKLEY, R.N.
Lancaster, California
OPEN LETTER TO THE ER
STAFF
There aren’t many times that I hate to go to work, but Christmas is one of them. It’s hard to be in the ER knowing that my family is home enjoying companionship, good food, and the joys of the holiday.
I was really feeling sorry for myself and quite resentful as I drove in to work following your plea for help. I’d already worked most of Christmas Eve, and had returned for a while on Christmas morning. And now you want me to come back Christmas night? But you’d sounded desperate, so I came.
Actually, I felt a little guilty. I thought back a few hours to Christmas morning and remembered noticing how you cheerfully greeted the patients as they streamed in. (Didn’t they know what day it was?) I remembered noticing how you hid your own distress as you comforted the parents of the baby that had coded and died. I remembered noticing the caring support you gave on Christmas Eve to the husband and children of the woman dying of leukemia, not knowing if she would live through the night. I remembered noticing all these things and never complimenting you for them. By the time I arrived in the ER on Christmas night, my resentment was fading. The waiting room was crowded and the chart rack was full, but when I saw your tired faces and felt your welcome smiles, my resentment was gone. I slipped into my ER role and felt the energy that comes with true collaboration.
Emergency! Page 17