by Horner, Rob
“Monitor shows sinus tach,” Lisa said. “He’s clocking right around 140, no ectopy. Pulse ox is at 98%.”
“Help me get him undressed,” Josh said. “We need a core temp.”
“Look for sores or infections,” Tina added. “We’re assuming drugs, but it could be sepsis.”
“Cath?” Lisa asked, turning to the supply cabinets on the side of the room.
“In and out him while his pants are down,” Tina said. “UA, UDS. Start a second line off with a culture.” As she spoke, she reviewed the standard overdose labs in her head, then added in the labs needed for sepsis and blood contact. “We’ll need a CBC, CMet, ASA, APAP, EtOH. Add a lactic acid and an ammonia level—”
“Ammonia? You think there’s something wrong with his liver?” Lisa asked.
“Not specifically, but a high ammonia level can cause agitation, personality changes, confusion…it beats having to do more blood work later.”
“Amen to that,” Josh said. Using a pair of trauma shears, the male nurse cut the patient’s Polo shirt from hem to collar. “Lot of tiny puncture wounds over here,” he said.
“And don’t forget the Hep panel and the HIV,” Tina added, moving over to assist Josh. “Looks like six puncture wounds; only one is oozing.” She massaged around the wounds with her fingers. “No palpable crepitus. Chest movement is symmetric.” She took a breath and turned her head. “Whew, I didn’t notice it before but this guy smells like he might have had some diarrhea.”
“Yeah, I think it’s old or else he would smell worse,” Josh said, working the open shorts over the patient’s hips.
The smell of old feces rose up from between the patient’s legs as more flesh was exposed.
“Oh man, we got blood down here,” Josh said as Tina made a face of disgust. Eight years, and the smell of bloody stool still threatened to gag her. “A lot of it,” he added, removing the man’s shorts completely, exposing pale thighs and a flaccid penis liberally caked with dried, red-tinted stool.
Turning from the cabinets, Lisa set the catheter kit down on the counter. “Okay, let’s get him cleaned up first. Do you want a hemoccult, Tina?”
Backing away from the smell, Tina answered, “We don’t need it but do one for the record. Pull a type and cross as well. If he’s bleeding this much, we might need to transfuse.”
“Still want the in and out?”
Tina considered.
A man like this, unresponsive and bleeding out of his rectum, would certainly qualify for inpatient admission. Depending upon what they found, he may well be bed-bound and require an indwelling catheter. She couldn’t dismiss the blood dried on the side of Buck’s head though. Though he appeared quiet now, suffering through almost every indignity an emergency department could inflict on someone, that didn’t mean he might not come roaring back to an aggressive state. It was bad enough they were going to add a second IV to him. Better to not give him something else to yank on that would cause more harm.
“Stick to the in and out, Lisa,” she said. “We can always Foley him later or leave the honor for the nurses upstairs.”
“Oh, they’re gonna love us for this one,” Josh said.
Moving to the head of the bed while Lisa and Josh went to work cleaning the man’s genitals, Tina positioned her stethoscope in her ears and placed the diaphragm on his chest, moving from right to left then back, systematically listening to heart and lungs. “Breath sounds are clear and equal bilaterally; rhythm is tachycardic but regular, no murmurs, rubs, or gallops,” she said aloud, knowing one of the nurses would chart it as part of their assessment. Moving the diaphragm down to his abdomen, she heard a series of loud gurgles and pops that made her jerk away immediately.
“What the hell?”
“What is it?” John asked.
“His stomach is loud.”
“Maybe he didn’t get enough Buck to fill him up.”
“Not funny, Josh,” Lisa chided.
“Not appropriate,” he corrected, lifting the man’s scrotum so he could clean around it, “but definitely funny.”
Tina placed the diaphragm on a different part of the man’s abdomen. The same sounds came through, a near-continuous sequence of pops and crackles, gurgles and squelches. Wanting to talk through the findings, she said, “Bowel sounds are hyperactive and…um…very loud.” She moved the stethoscope through all four quadrants. “Equal throughout the abdomen.”
“Gas?” Lisa asked.
“Maybe some of it,” Tina replied, unconsciously leaning toward the patient as if to hear better. “Mostly it sounds like…I don’t know…chewing?”
“Chewing as in what?” Josh asked. “Like in Aliens?”
“It’s like—” she struggled to put into words the recognition that the sounds gave her. “It’s the noise you hear in your own head when you’re chewing on something like a piece of watermelon.”
“Buck is a big dude,” Josh said. “Maybe his ear was just that juicy.”
“I’m serious, Josh,” Lisa said.
“All right, all right. I’m done here anyway. No visible sign of trauma, no wounds to account for the blood. Must be coming from his rectum.” He looked up at the women. “I’ll get the K-Y and do the hemoccult.”
Lisa moved up beside Tina, her own stethoscope in place on her ears. “Wow,” she said a moment later. “It really does sound like something’s eating him up on the inside.”
Wondering what she’d gotten herself into by agreeing to take this patient while the doctor handled Buck, Tina started for the nurses’ station, mentally reviewing the notes she needed to enter and the labs she had to order.
“Woah, he’s waking up!” Josh said.
The patient…Austin…screamed, eyes popping open as he fought to sit up on the bed. The second his abdominal muscles contracted, a fresh stream of fecal matter, much redder than brown, poured out of his rectum, running over the bottom of the bed to dribble onto the floor. The smell came a second later, a sickeningly sweet combination of copper and crap that filled the room and billowed out into the hallway.
“We need some help in here,” Tina called.
Chapter 6
Dr. Anil Patel casually sipped a steaming mug of Masala Chai tea, dark eyes closed in silent enjoyment, refusing to allow the chaos in the trauma room to disrupt his mood. Nothing good could happen when the staff allowed the stress of the moment to guide their actions. They should manage the situation to minimize stress. Every situation has an order of operations; every operation has an order to the steps necessary to complete it. You could break any situation down to a set of operations, and every operation to a series of steps. Follow the order. Keep calm. The situation would remain controlled and the best outcome would be achieved.
So, he kept his eyes closed and let the extraneous words, the adjectives and unnecessary adverbs, disappear from the stream of sentences coming from Tonya.
“Thirty-two-year-old white male found on the ground and unresponsive. Went ____ during EMS evaluation. Attacked Buck like ____ ____ ____, biting off a piece of his ____ ear. Piece is bagged and in the room.”
Tonya went on a little longer. Anil let her chatter, not responding until she finished with “—and Buck is in room fourteen.”
Some people reduced input and managed actions. Some liked to talk through a situation. Anil understood this, just as he understood each of his co-worker’s individual methods of coping with the job. Knowing them helped him maintain a control over the ED that many doctors never achieved. The ship never sailed so smoothly as when he was at the helm.
That kept him serene and satisfied. He took no pleasure in knowing that the department ran better when he was on-duty, only that it ran well. There was no superiority in his pride; it should run just so for every doctor.
But it was nice to be appreciated, all the same.
I need to go home for a few weeks, he thought. I’m becoming too American for my own good.
“Is he right or left-handed?” he asked, the first words
he’d spoken since the ambulance arrived.
“Excuse me?” Tonya asked.
“Which hand does he write with?”
Tonya honestly didn’t know the answer and excused herself to go find out.
Dr. Patel enjoyed a quiet sip of his tea.
“He’s right-handed, doctor.” Tonya said.
“Good. Now, is it his right or left ear?” Anil was aware he had a thick accent, so he tried to speak softly and slowly. Unlike Dr. Misha, who’d grown up in British-run schools, Anil never developed the clipped, lyrical way of speaking so many of his countrymen had. He talked slowly and remembered to pause between words, else they would run together in such a way that it became difficult for Americans to understand him.
“Um…it’s the right ear,” Tonya answered. Then, because she couldn’t help herself, “Why does it matter?”
Anil smiled. These were the times when he thought about retiring from practice to become a teacher. “He’s right-handed and his right ear has been injured. Right-handed people hold their phones with their left hands to their left ears. It leaves the dominant hand free to take notes, you understand? It matters in the likelihood that he might complicate his own injury by repeatedly touching it with foreign objects, like a cell phone.”
“Oh.”
“He is an EMS, right?”
“Right, doctor. It’s Buck.”
“Ah yes. He will decline pain medication but offer him ten of Norco anyway. And bring ten mils of lidocaine, a suture kit, and two packs of five-oh Ethilon to the room, please.”
“Dr. Patel, there’s nothing to sew. The top of his ear is gone.”
“Which leaves a large opening, yes? Therefore, I have something to sew. I can’t close it completely because it was caused by a bite but leaving it wide open is even worse. Please let Tina know I’ll be in room fourteen if she needs me.”
“Am I gonna get an infection?” Buck asked while Dr. Patel pulled on an interrupted-suture knot. About a third of the paramedic’s ear was gone, ripped away at the level where the antihelix came in under the triangular fossa, leaving a jagged opening. Most the ear is space given shape by cartilage and covered with skin, therefore an opening like this could provide a superhighway for infection to set in. That the wound was caused by a human bite made the possibility more of a probability.
“You know this is likely, Buck, so why ask?”
“Just wondering what you think, Doc.”
“I think that you are lucky he went for the ear rather than the nose.”
Buck reached up his big left hand and felt at his nose. “I guess so.”
Calls for help came from the hallway outside the room. A moment later, Tonya burst in. “Doc, the patient in Trauma Two is seizing.”
Anil started another stitch. “I assume Tina is in there?”
“Well…yes, but—”
“Did she tell you to get me?” The cartilage provided some resistance to the 19-millimeter suture needle, but steady pressure got it through.
“No but—”
“Vitals stable?”
“I…um…I don’t know. Tina said they needed help—"
“If Tina needs me, she will ask for me. What she means is that you should be in there helping her, not running to find me.” He tied off the fourth stitch, shifting his hand a millimeter forward to begin the fifth. He never looked up from his work, and neither did his voice change tone or inflection.
“I just thought you’d want to kn—”
“No, Tonya, you were raised as a nurse in another state and don’t understand that in South Carolina, Nurse Practitioners can and do act independently. Even if that weren’t the case, Tina has earned my complete trust over the eight years she and I have worked together.” Anil pulled the thread through and began wrapping it around the hemostats, preparing the first throw of the new stitch. “If she needs me, she will ask for me.”
Tonya started backing out of the room, looking suitably chastised.
“If everyone else is helping in Trauma Two, please keep an eye on our friend in sixteen.”
“Yes, sir.”
“That one doesn’t want to get her hands dirty,” Buck observed.
Anil was surprised at the paramedic’s perceptiveness. “Why do you say that?”
“We see it a lot in rookies, especially the women who are more concerned with how their butts look in the uniform pants.”
“Be careful, you’re showing your sexism,” Anil said, smiling.
“Oh, not at all, Doc. I’m not saying their asses don’t look good—”
Anil chuckled.
“It’s just…the ones who want to help go help. They don’t find something else to do and try to justify it.”
Dr. Patel agreed, though he wouldn’t admit it aloud. He liked Buck. But liking a man was one thing. Airing dirty laundry said man had no reason to see was another.
“So, on the antibiotic thing?”
“We’ll do a shot of Rocephin here,” Dr. Patel said. “Try to get a little boost in case there’s something building already. I’ll write you for Augmentin for the next ten days, but you need to keep an eye on it.”
“Keep an eye on my ear, got it.”
“I mean it, Buck. This could get bad quickly. If it gets red or swells, gets hot or starts leaking pus, you come get another dose of Rocephin and let us look at it.”
“Will do.”
Tying off the fifth stitch, Anil admired his work. He’d drawn together the sides of the ragged wound, closing off 80% of the opening. He wished he could close it completely, but he needed to allow a path for infection to drain, rather than trapping it inside. “I’ll put a work note in the chart, in case you—”
“I won’t need that, Doc. There’s barely enough of us as it is.”
“You intend to work today?”
“It’s still my shift.”
“All right, but I am going to send some pain medication to the pharmacy.”
Buck raised his hands to protest but Anil continued, “I know you don’t want it, and I don’t want you taking it while you’re on the job, of course. But tomorrow night, when you’re lying in bed, this ear is going to have its own heartbeat. Having something to take the edge off will let you get some sleep.”
“I’ll think about it, Doc. Thank you.”
Anil began cleaning up his work area. There were many doctors who didn’t bother. They had nurses, or a housekeeping staff; why should they clean up after themselves? To Dr. Patel, it was a small courtesy, but an important one. He knew how many needles he’d used. He knew where he’d put them. It just made sense that he should be the one to put them in the Sharps container. And once you took that step, well, cleaning up the rest of the area was a simple matter of gathering everything in the blue cloth and putting it in the trashcan.
“I’ll have Tonya come give you the Rocephin and get your paperwork together for the work-related injury.”
“Okay.”
“Stay in touch so we can update you on the labs.”
“Okay, Doc. You don’t think he has anything communicable, do you?”
Having only seen a brief glimpse of the patient, Dr. Patel said, “I don’t know. But it would be best if you let your partner handle most of the patient contact until we have a better idea.”
“Okay, Doc. Thank you again.”
Chapter 7
What the hell? Austin thought, gasping as razor wire wrapped itself around his intestines, squeezing, cutting into vital parts of his anatomy, causing a pain like he’d never known existed, or even conceived.
A rumbling filled his ears as a shuddering rattled the frame of his Nissan Pathfinder, and through the fog of pain tearing through his middle he realized—Shit! I’m running off the road!—and gave a desperate twist of the steering wheel, pulling the car back to the left. The sudden movement acted against the inclination of his body to curl in on itself to the right, and a greater pain rose in his gut, as if he was trying to pull his large intestine out of a glass-lined Chi
nese finger puzzle, making it squeeze tighter and cut deeper.
Panting, panicking, he concentrated on taking his foot off the gas, easing it over to the brake pedal.
Another spasm of pain shot through him, accompanied by an internal splash felt rather than heard. A fullness entered his lower gut, that feeling that says a dam has been opened, a flood has begun, and the only thing separating it from the outside world is a thin membrane of skin and muscle called your anal sphincter, the starfish, the little hole with the big role. And if it fails in its duty, you’re gonna mess up your booty.
“Ah, hell!” he said, jerking the wheel to the right, clenching his teeth and his cheeks as the shudder hit the right tires again, then the left. His right foot pressed hard on the brake pedal. Horns started up behind him, grew louder on the left side, then receded away from him as pissed off motorists let their displeasure be known.
Without bothering to check for traffic, lucky as hell that no one took out his driver door and him with it, Austin bolted out of the Pathfinder, not hearing the clack and clatter of his smartphone tumbling out of his lap and onto the asphalt under the car. Lurching, one hand across his stomach like a knife had sliced across from hip to hip and only his hand could keep his insides from becoming his outsides, and the other pressed edgewise into the crack between his cheeks, trying to hold back a waterfall with an umbrella, Austin made it around the back of the SUV and to the passenger side.
One hand fumbled with the button on his shorts while the other grabbed the front and back passenger doors, jerking them open to provide a small measure of privacy as he tried to aim his ass away from the pooled cloth around his ankles.
Sometime later, minutes, maybe an hour—the sky had darkened from late afternoon to early evening, but it wasn’t full dark yet—Austin awoke. His stomach still hurt but it was a dull fire compared to the nuclear blaze from before. His thighs and calves positively screamed, having locked in a cramped, compressed position while he emptied out a foul-smelling river of liquid crap. Somehow, he’d stayed upright while his mind retreated from the pain in his gut. Looking down, seeing the creeping molasses of shit only a little darker than the dirty concrete of the feeder lane making its slow way toward his clothes, all he could do was be thankful he’d woken up before that stuff got on him.
