Err Freshener

“Do you have cats or dogs?” my Emergency Department attending asks. “Neither, “ I say, “I have plants” His question is somewhat rhetorical and in response to my mumbling that in addition to the chest x-ray and urinalysis I have ordered a meal tray for my homeless patient with a cough and polyuria who had her car (which she’d been living in) stolen five days earlier. He stares ahead when I say I have plants. I understand the lesson he’s trying to convey. “If you feed them, they keep coming back.”

I just don’t agree with it. The hospital has plenty of food. One less cold turkey sandwich on white bread without mayonnaise is no great feast, and does no one any good in the refrigerator where it will get thrown out if not eaten soon. And she has cried to me minutes before, “Please help me!” She pleads with me between face-reddening coughs. She needs more than the medical help I can provide. And the homeless shelter downtown is full by 7pm. My church’s shelter has closed the night before. And it’s almost Christmas Eve. I don’t know what I can do.

So I drag my feet with her medical work up, despite the senior ED resident breathing down my neck about “dispo” of patients (ie where they end up, admit v. discharge) and what is the hold up. I get to her last in my to do list. I let her sleep a little longer in the busy, but warm, hallway bed because all the other rooms are full. Maybe it isn’t a great use of medial space. The hospital cannot accept elective ambulance transfers because the ED is too full right now. There are times in the night when we don’t even have a bed held for an ambulance emergency. A 400 pound woman in respiratory failure has just been intubated and the waiting room is full.

We get most of the homeless patients at the university hospital--all the ones the cops find on the streets and think need medical care. Like last night, the police called the paramedics for the first patient I saw. A 60 something year old veteran without an honorable discharge but with a very bad attitude covered in his own feces which had leaked from his colostomy because his last bag broke when he fell after two seizures the day before. He didn’t even want to come in this time, though he’d been there the day before, drinking vodka in the waiting room. And he was there the day before that, insulting the female senior resident by saying, “Huh, they’ll make anyone a doctor these days.”

He smelled awful. The whole hallway smelled of feces. The residents in the “doc box” discussed at one point if burning incense or bringing in air fresheners might be acceptable. I thought after seeing him what a long-term disservice it had been to give him a colostomy without any means to take care of it. Of course, social workers had seen him many times, and he didn’t want help finding a place to stay. He wanted to stay on the streets in front of the Jiffy-Lube where he was proud to tell me he was the only one who had an agreement with the owner to allow him to stay there at night as long as he was gone before they opened and as long as he didn’t go to the bathroom in the parking lot. “Easy enough,” he said to me with a matter-of-fact shrug. He conversed with me because of the MD after my name. He glared at the RN when she tried to help him, then commented to me when she left the room that he liked her but she just got on his nerves. “Do your job. It’s your job to help me!” he berated her as I tried to set some ground rules about courtesy which I don’t think he heard.

I thought of the psychiatry recommendations regarding my narcissistic antisocial personality disorder patient at the VA: Don’t bargain with him. Don’t accept rudeness unless he is in imminent danger. Don’t engage him in banter. ED nurses catch a lot of flack sometimes. Most of the time their patience amazes me--especially with all of the literal shit they have to deal with.

Another of my patients had soiled himself today, also. He was embarrassed about it, but still insistent about getting his pain medications before he got cleaned up. He’s another patient well-known to the ED staff. He has spina bifida so he can’t walk and has imperfect bowel and bladder control. He has chronic wounds on his foot and his rear end. As I pulled the sodden bandages off of his feet, the smell of anerobic bacteria momentarily overrode the smell of feces. Everything smelled bad. “Maloderous” is the politically correct medical term.

I remembered Dr. Vaiyerman as I looked at his wounds and remembered how he’d smelled the culture swabs or bandages to help him characterize the infection. I followed his example when the nurse at the VA paged me, as I’d asked, in time to see the dressing on my antisocial personality disorder patient’s sacral wound deep enough to reveal the bottom of his spine. The patient tried to make me feel bad for keeping the nurse waiting because I’d shown up later than planned as I was admitting another patient at the time. The nurse was gracious and said it was fine, but my patient still glared at me as he rolled over for the dressing change. I had already learned I could not please him; he called me a rookie and often wanted to speak only to the attending. Anyway, I probed his wounds to try to find any new area of drainage to culture so we could choose the correct antibiotic. And, thinking of Dr. Vaiyerman, I gingerly smelled the dressings the nurse had removed. “Anaerobes,” I though. Maloderous. The nurse later stopped me in the hall to tell me that he’d never seen anyone do that and that he thought it was an important part of taking care of patients—using all your senses—“So I just wanted to compliment you,” he said.

In the ED, I smell urine often, too. Less diagnostically specific. My overweight homeless patient the other night had become incontinent prior to arrival and we didn’t have any extra clothes large enough to give him. When we discharged him, he had to put the pants back on. Most of the time the homeless patients don’t wear underwear; he didn’t have any either.

The drunk patient I took care of Thursday night smelled of alcohol and sand; he too is homeless and usually stays at the beach where Jane and I had gone to the wonderful farmer’s market the night before. I catch myself looking into the faces of the homeless people now, to see if I recognize them, to see if they I can see a past in their eyes. An explanation for their predicament. I ordered one of the awful turkey sandwiches for this drunk patient. He ate half of it and told me he threw it up in the bathroom. I don’t know if he did or not. The nurses and attendings didn’t believe it. The advantage of telling me this is that it would delay his discharge back to the streets if he was still vomiting. “He’s lying to you,” the nurse insisted. He probably was since later I saw him walking around easily looking for a bathroom or the door to go out and smoke. Then I discharged him. But no one knows for sure. I’d rather give them the benefit of the doubt. What does it hurt?

My attending tonight thought the homeless woman was lying about having her car stolen, too. “Convenient,” he scoffed under his breath when I told him the story. I just went on with her medical history and pretended I didn’t hear him. Thing is, he’s very medically careful with some of the patients. I actually think he admits more than he should to err on the side of caution, or to clear out the ED, or to avoid law suits, or to ensure thorough patient care. I don’t know. It’s so hard to know true motivations—of anyone. It’s hard to truly know anyone, let alone drunkards and teachers and strangers.

It’s hard to know how to help, too, particularly when you’re still close to the bottom rung of the medical hierarchy. I reluctantly canceled my homeless patient’s meal tray, with a glance at the evaluation paper he had for me beneath his computer keyboard. Looking back now, part of me wishes I hadn’t done that; wishes I had taken more of a stand; wishes I’d done more than make sure she at least got some of the emergency crackers and juice from the nurses. Or maybe it’s better I didn’t draw attention to my tray-ordering practice by objecting too loudly; next time I can just order the meal more discretely, because if I’m going to err, I choose to err on the side of kindness.


Merry Christmas Eve!