“I hate people!” my co-worker declared as she stormed by me and threw herself into a chair. “My patients are all crazy!”
My facial expression let her know she had been heard, as I took off my coat and logged into my computer. But I added, “It’s been a beautiful day outside,” hoping a change of subject would deflect the black hole of negativity that can swirl in this place.
It was another day at the office in the county hospital’s emergency department, where my customers, by definition, are always unhappy. My co-worker had just been verbally abused by a patient who forgot politeness in a moment of intense pain. Pain, sickness and chronic disease do not move the afflicted to smiles and warm introductions. But this is my environment; for me, just another day at work. My job is to inject healing and relief into the traumatic experiences of human beings having health crises and experiences they would remember for the rest of their lives. I wrapped my stethoscope around my neck and went to see my first patient.
Patient 1 was crying. She was hosting her entire family for the holidays. Her recently laid-off husband offered no help cleaning the house; she did all the cooking, made all the arrangements for her demented mother and handicapped uncle, and got no thanks or sleep. She was exhausted, depressed and in need of help. In our five-minute interaction I did my best to hear her concerns, offer a sense of hope and extend a Kleenex. But I knew I could not fix her depression today or even admit her to the overpopulated psychiatric ward because she had not used the password: “Suicidal.”
I got her to speak with our counselor, who provided some resources for her to get help. After seeing some other patients, I checked back and found her more relaxed. Although I knew she needed more, I felt she was safe to go back to her chaotic home. When I told her she was being discharged, she looked up and conjured a soft, but genuine, “Thank you, doctor.”
Patient 4 was holding his finger in a bag. The burly 29-year-old construction worker had been retrieving an empty bowl from a stray dog he had graciously fed in his backyard when the canine took a bite of dessert. The man now held in a Ziploc bag the detached tip of his right ring finger, from the last knuckle to the end of the fingernail. Had the stray been a little more zealous and removed just another few centimeters of the finger, I would have been calling another hospital and sending the man to a hand surgeon to re-implant the finger. But the tip alone was not salvageable, and I broke the news to the 9¾-fingered man alongside his distraught wife and iPhone-distracted daughter.
“I guess he wanted a doggy bag,” I said, trying to cut the tension. Everyone laughed.
“I was never going to be a hand model anyway,” the man said.
The skin was difficult to pull together to cover the exposed bone and muscle. I used a ring block technique to numb the entire finger, but he continued to feel occasional stabs of my sewing needle, one causing him to jump and toss a gauze full of fresh blood onto my new shoes. After additional lidocaine to numb the pain and many carefully placed stitches, I declared the nub complete. He studied his newly designed dominant hand.
“Hey doc, you did it! Looks great!”
Patient 11 had a cough. I walked into the room and was immediately overwhelmed by the smell of smoke. There was nobody smoking in the room, just three people marinating in the toxin.
“I’ve had this cough for three weeks, and I just can’t get rid of it,” said my 33-year-old patient. “And now my ribs hurt. My primary doctor wrote me some pills, but I can’t afford them.” His parents nodded in agreement.
“He’s been taking my Vicodin, but I need it for my lung cancer,” his father chimed in.
“OK, I understand,” I said as I went through my standard questioning. It was clear that this young man, who had been smoking for almost 20 years, a life skill learned from his parents, was now well on his way to emphysema. He watched me anxiously, along with his gene pool squirming in the chairs next to his bed, as I listened to his lungs.
“Yeah, I can hear the smoke in there. I really suggest you work hard to quit smoking. Think about all the money you could save for other things.”
“I’ll quit someday, but right now I just want some antibiotics and pain meds!”
“Well, I’d be happy to give you a prescription, but I don’t have pills that I can give you for free.”
“Are you serious!?” he blurted, then turning: “Mom, why did we even come in here and wait for three hours? Let’s go.” He pulled his IV out of his hand and barked, “Thanks for nothing!” as he stormed out of the room.
Patient 16 had a hole in his chest. This gentleman, persuaded by methamphetamines, decided on this night to retrieve his stolen gun. He walked up to the home of the man he believed to be the thief, and a gunshot came through the front window and struck him in the right side of the chest. Paramedics brought him into our trauma room, and he was screaming profanities at a volume that was impressive for someone with just one lung. I knew he needed a tube put into his chest, as his right lung was deflated. After receiving large doses of my strongest drugs to control his pain, he continued to scream. His years of meth and other drug use had made him immune to my attempts to sedate him. When I thrust the tube into the incision I had made in his side, between his ribs and into his chest cavity, he gave the loudest scream yet, “Ahhhhhh!!!!” Blood instantly blew out of the tube and sprayed into my face and all over my gown as his lung inflated. He put his head back in the bed and looked at me, taking a slow, deep inhalation. “Now I can breathe,” he said calmly. I smiled and looked down at my shoes; I was standing in a pool of blood.
Patient 24 weighed 473 pounds. She had a difficult time washing, especially reaching certain parts of her body where skin folded upon skin. Bacteria would accumulate in these areas, leading to a large infection in her right groin.
“Hi, doctor . . . oh, you’re too young to be a doctor!”
“I’m so sorry to come to you with this, but I think I have another abscess. It’s on my right thigh, it’s so painful. I tried to use a warm compress, like they’ve told me before, but it didn’t work. It is really big this time, and it looks like it’s about to pop!”
I looked down and saw the ensuing natural disaster.
“This is a really large abscess,” I said. “Would you like pain medication through an IV before we open it?”
“No, thanks; I think I can handle it."
I drew up lidocaine into a 10cc syringe and had her nurse help open her legs. I started injecting the abscess, and as the pressure of the injection was added to the highly pressured infectious contents inside the abscess, the top of the volcano erupted and a mixture of pus and lidocaine exploded onto my chest.
As the numbing medicine took effect and she grimaced in pain, I took a scalpel and cut into the abscess, unleashing a creamy green and red lava. I breathed through my mouth to avoid smelling the pungent odor but coaxed the eruption until the volcano eventually turned from hill to plain. She then breathed easier.
I disposed of my sharp objects, and as I was walking out of the room she grabbed my arm and said, “Thanks, Doogie Howser. I feel so much better. I really appreciate it.”
As I walked away from my 12-hour night shift, the sun was just rising. I walked out of the ambulance bay doors, looked east at the light coming through the trees and thought about the patients who had shared their fingers, smells, depression, addiction, relief and wee hours of the morning with me. These people, often the most uneducated and impoverished around, had come to my office with a problem that had their minds and bodies spiraling downward. But together, we avoided being sucked in by a dark and beckoning affliction to live another day under the warm, persistent and positive sun. “If only every shift could be that much fun,” I thought, sitting in my car and putting on my sunglasses.
Nick Stahlschmidt is a doctor of family medicine living in Saint Louis and practicing in the emergency department at Mercy Jefferson Hospital, Crystal City, Missouri.