I whisper your name (ayradyss) wrote,
I whisper your name

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The good, the bad, and the ugly...

I left the ER on a mingled note last night. The last patient I saw, at six minutes to four, needed a pelvic exam. And a quantitative HCG done. She's bleeding and cramping and six weeks pregnant. She was seen two days ago, and it was guessed then that she had a missed abortion. A note, O Best Beloved: Abortion as a medical term is the spontaneous expulsion of an embryo or foetus before twelve weeks of age, whereas miscarriage is any time after that and before the foetus is viable. We use "abortion", and it scares people. It does not mean we think they did it. So I did the pelvic, and the crevix was closed, but she was bleeding fairly well, and the HCG came back 5,000 less than it had been, and that was the diagnosis. She wanted me to stay until they'd decided whether she should go back to Canada and her husband or seek a referral here. So I didn't leave until nearly 5:30. We're referring them here.

Otherwise, the day was filled with the good:
Sent to see a 25-year-old male whose complaint was urgency (having to pee a lot) and blood in his urine. R. is a Navy Recruiter, positively delicious, and very nice. He also had no symptoms other than blood in his urine. No pain, no burning, no irritation, nothing that could tell me right off the bat that he had a UTI. So Dr. K tells me to rule out prostatitis. Why, O Best Beloved, does my very first rectal exam on a patient have to be on someone this fucking hot? And I could see it in his eyes, the same question everyone wonders about: "How old is she?" I had two more people today tell me they doubted I was older than seventeen, which would hardly make me legal to even see this guy's naked ass. I did the rectal, found nothing, didn't even elicit a yelp, so his prostate was nontender. Dr. K reminded me of the one other thing that can cause bloody urine: rhabdomyolysis. Basically, when muscle is destroyed, it releases myoglobin, which looks just like blood to the naked eye. And bingo, his CK was 2800, his dipstick test was positive for blood >250, and his micro came back with 6-15 RBC's. Rhabdo. So I explained it to him, and we sent him to the FP residents, and that was how my day began.
Then there was the boy who tried to swat a wasp and put his hand through a window. Calm as could be, not crying or bitching or anything, just waiting for it to get stitched up. He was a sweetheart.

The bad:
Little girl fell off some playground equipment and broke her arm. Both bones, same place she broke it last year. Only bad because she was so miserable.
Gentleman came in at the end of my shift. I didn't treat him; I was already late. He was bright yellow. About that shade. Obvious, unmissable liver failure. He looked like he was dying. He looked like he was going to make his last stay in the hospital ever. That was sad.
K came in after having his foot run over by a one-ton piece of equipment at the construction site. Dr. K looked over as he was brought in. "Kidney stone?" Me: No, foot run over. Dr. K: Oh, I was sure it was a kidney stone from the racket. Looks like a fracture that's going to take surgery and still maybe not turn out right.

The ugly:
When I came in, we had Dr. K, me, Dr. M, who's a new intern with FWFP and doing a rotation in the ER (I duly cultivated her, O Best Beloved), and C. One doctor to staff two students and an intern, who wasn't much more competent than I was. We rotated through the patients, more or less, until he told us to slow down a bit, as he was getting overwhelmed. Then J came in and we could pass C off to her, so it was just us two and Dr. K. But for a while, it was just a mess, and I didn't get to see as many patients as usual. Also, Dr. K, when we're busy, just automatically hands any suturing jobs over to the PA's, which meant C and J got lots, but I did none of the five jobs that came in. Sad.
And then there was the slug-lady. Bear with me, O Best Beloved, I was just most disturbed by this woman. She had bariatric surgery in September, and is now down to 350 lbs from 475 (one of the nurses raised a brow. "Slow loser. I've lost 90 since February"). She readily admits that she doesn't follow her diet, so she eats too much still, gets nauseated, and just takes Reglan. She fills to overflowing the hospital bed like some sort of oversized slug, with about the same willingness to move to enable me to do even the most basic of physical exams. She complains of spiking fevers, chills, constant nausea from eating too much, and pain in her chest and left flank. Actually, she's just sore everywhere. And she's a Software Engineer, on top of it all.
I did the exam and took her history, had her nurse take her temperature (98.3 on triage) again when she started to shake (100, then), and went back to talk to Dr. K about her. "Get a cathed urine. She sounds like she has a UTI," he says after doing his physical. And then the nurse comes back. Did either of you, she wants to know, get a look downstairs? No, we admit. We concentrated on the complaints she had. Wego back in. Grossly health-threatening obesity, while something I find a constant reminder of why I need to go out to Curves and curtail my incessant snacking, I can deal with. We're the first or second-fattest state in the nation. What I find revolting is grossly health-threatening obesity combined with stench.
On exam, this woman's entire pelvic area was covered in open or scabbed-over sores, from waist down. She had an extra lobe of fat that we had to lift out of the way to examine her vaginal area, some sort of lipoid modesty panel (she's going to see a plastic surgeon to get it removed), and it seemed to protect her vagina itself from the sort of fetid wasteland that was the rest of her regional skin. She had tissue stuffed into the folds of her fat, and it all stunk to high heaven. Maybe, Dr. K says, this is the source of her fevers. We continued.
Both legs were wrapped in bandages. One looked red, swollen, and painful. We unwrapped it. How long has your leg been like this? Oh, she says, the cellulitis? A while. Have you been seeing Dr. L about it? Yes, she says. I have a hard time believing this, O Best Beloved, because I worked with Dr. L and he was a very competent doctor. That leg should've been on IV antibiotics a month ago, not to mention the rest of her below-the-waist culture plate. So she's in the hospital now, for wound care and IV antibiotics, and I am thoroughly disgusted. Obesity I can handle, and I can respect people who are trying to do something about it and failing. Having surgery to reduce your stomach size and then still insisting on stuffing your face until it makes you sick...that bothers me.
And the Jerry-Springer-esque epilogue to her story: She is 61. Her daughter is 40. Her daughter is marrying a man, now 58, who was her mother's lover when she was a little girl, back when they were in their 20's. Mom is very happy about this, as she knows what a great man her daughter is marrying, but she isn't going to go to the ceremony because "it's very small and private". She's just thrilled that her daughter, who is a municipal judge in a well-known city in Texas, isn't going to marry one "of those cowboys", because you have to marry someone who's your intellectual and social equal. That weirded me out. And then I was talking to nurse H. You know, she tells me, she wanted me to go out and get her son from the lobby (not an uncommon request), and I told her that she should wait a bit, because we had to expose her again and get an EKG (which requires lying around naked to the waist for a bit). "No, that's fine," she says to me. "My son bathes me every day." Maybe that explains the filth of her perigenital region, but her son is in his 40's, too, and apparently has no life other than taking care of his mother. And bathing her.

I need to know, O Best Beloved. Am I being intolerably closed-minded in being revolted by this woman's story and physical condition (mind, I was as thorough on physical exam as I would be with anyone else, despite the nauseating stench of her revealed sores; I did not and do not intend to short my patients on care), or is there a point at which it is acceptable to marvel at the depths to which humanity can fall?

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