My patients are tucked in, in X-Ray, awaiting transfer. I have brought with me a cloud of not-what-you-thought, tonight, and it has been a cloud that took my patients out of my hands in many cases. My staff is a pleasant man, with a baby face and softly greyed hair, bald on top, small and soft-voiced and smiling. The evening's staff, who went home at two but did not leave until three, was hard to read for his eternal neutrality; this night staff is hard because of his eternal pleasantness. I am not complaining. I think I am doing well; my stapling job has been complimented.
First chart off the rack had fallen down her porch steps. Notes said no loss of consciousness. How can you fall down the porch steps, bleed everywhere, and not lose consciousness? I asked again. "Well, yeah, she blacked out a bit." Off to the CT scanner. Distracting head injury means C-spine x-rays. And CT results say subdural hematoma, 7 mm, and that means we stitch rather than staple. We pry hair matted with blood from her head, reveal a sharp laceration that bleeds like crazy (scalp wounds always do), write for the techs to scrub and shave after we inject the Lidocaine. I say we, O Best Beloved. I watch as the PA (lovely piece of work that he is) demonstrates. And he stitches. Five stitches.
Why stitches? She has a subdural hematoma, a bleed in the bridging veins between the brain and the skull. She is going to $hospital for an MRI and a neurosurgery consult. I am so glad I asked.
There is a gentleman back in the holding room with a high blood sugar. After I examine him, I am called back by the nurse. He has leg cramps, chest pains, and we get a blood draw. The lab calls a panic value: Hemoglobin 5.9, potassium 2.something. ER doc looks hard at the lab values, goes in to see the patient. "Where did you draw this from?" Upstream from the IV, which is running normal saline at full open. He does an arterial stick on the other arm, and it comes back with a hemoglobin of 8.9 - still low, but bearable. Look. He shows me. Everything is low. Absolutely everything. That doesn't happen.
Our EKG shows third-degree heart block, and he goes from the holding room to a monitored bed, and from the monitored bed he will go to $heart_hospital. He would be a sweetly cantankerous old man with Alzheimer's if he were not such a stubbornly loud old man.
Schizophrenic whose chief complaint is "jumped". Seems he was in his group home and got beaten up by his best friend over a bicycle incident. I got lost in the vague pronouns and wandering tale. Dermabond to the rescue; it was a small laceration.
Chief complaint: increasing blood sugar and blood pressure. "Sounds like a medical student complaint." I see the man. He tosses off an incidental "And my back hurts." Everyone I pass today asks me for pain medication. I must have a sucker's face. Why he came to the ER for this, I don't know.
Abdominal pain - a hot gallbladder. Give her some Vicodin and send her to see a surgeon later. The infamous triad of danger signs is absent, although I did get to see a positive Murphy's sign, something I was not cruel enough to try on my Angel. You apply pressure over the gallbladder and ask the patient to take a deep breath. A positive Murphy's is when she abruptly stops inhaling because of sudden pain.
Chief complaint: insect bite. Apparently, her husband's friend got bitten by a spider and it laid eggs in his hand and he had to get it cut open. And she came to the ED at one o'clock in the morning to see if she had spider eggs in her knee. I told her not to scratch, and to put Bacitracin on it, and to come back if it got hard and hot or turned black. I did not laugh, O Best Beloved, not where she could see. Be proud of me.
The gentleman who we saw after having been hit about the head, ribs, face, arms, and other body parts with unknown objects. Looked like a boot to the ribs; my forensic skills make the 5-centimeter laceration to his scalp out to be a brick corner or other blunt object. There was tissue bridging. When asked how he came to have an unknown object applied to his head, he looked at me from behind a bushy, blood-clotted beard, and said "I'd prefer not to say." I don't need to know. Apparetly, three of four attackers were still at the scene.
What boggles the mind, O Best Beloved, is that this man is covered in tattoos from shaven scalp to dirty work boots; his entire back is a picture in full-colour whose significance I did not dare to enquire about. And yet, when I said, "I'll have to numb this up a bit," he quailed. His brother had to talk him into acquiescing. I used a 27-gauge needle, the thinnest we have; he trembled like a broken bird as I injected - he hyperventilated and blacked out at one point. He was literally terrified; to the point almost of threatening me. How did he get these gigantic tattoos?
Cleaned and scrubbed, picked clot out, talked him into allowing me to staple rather than suture - scalp wounds swell, they close much faster and easier with staples, it is better in the long run - and put in 11 skin staples, click click click. I am proud to say that my numbing medication worked, save for one staple only. We discussed staple removal. They were not eager to return to the ED; they asked if they could remove them at home. "After ten days," staff says, smiling with a hint of inner amusement, "if you have a staple remover."
The brother, who made it possible for me to work at all, thanked me profusely in his own way. He sought me out as he left to tell me that he appreciated my work. In the ER, that means something different. It means you touched someone somehow, in that brief moment.
But I still wonder what he was doing to get jumped.
Sickle cell crisis and out of Vicodin. Atypical chest pain. "Can you do me a favour" tonight means "can you do a rectal exam?" I am ashamed to say that I did one of my rectals dry, being unable to find any lubricating jelly. I did, however, remember to do the prostate as well when I did my male rectal exam. And did he ever scream. Such a loud man. And a heme-positive stool, to boot. No wonder his hemoglobin is low.
It is nearly five, now, and the low silence is most likely nearing an end. Two hours more and I can go home and sleep. And then, again, tomorrow.