Seven Patients

by Atul Kumar

  I defended myself by putting on another set of gloves and a face mask with shield to minimize any risk of splatter. I learned my lesson about taking personal protection very seriously.

  The blood draw went well … on my sixth attempt. James’ veins weren’t so good due to his dehydration. His BP was slowly dropping and his temperature increased by another tenth of a degree.

  I labeled the blood and logged in to the computer with Dr. Peter’s ID badge. Wow, with just a few clicks I had all the tests I wanted ordered, and many more, just because it’s so easy to click away. No wonder the cost of medical care is skyrocketing, with the ease and availability of testing, nobody has to think about what’s needed. Just order anything you want and figure it out later.

  Now the fun part. I bubble wrapped and placed the blood specimens into the little missile shaped pneumatic carrier tube and punched in the code for “blood lab.” There was a buzzing noise while the plexi-glass missile got moved into position, and with a muted “swoosh” it started its journey through the labyrinth of pneumatic tube passages concealed within the hospital walls. I must admit, it was fun to click the big red STAT LABS button too, ensuring that all the labs get done within the hour at only quadruple the standard exorbitant cost.

  The only thing left was to actually examine the patient, and that task could only be accomplished with the assistance of trauma shears. The use of trauma shears is an empowering experience for medical students. There’s something intensely personal and strangely satisfying about rapidly cutting off a complete stranger’s clothes in an effort to try and save his or her life. It’s almost like removing somebody’s identity.

  Clothes can tell you a lot about a patient, especially in a situation when the patient is so obtunded that a history cannot be obtained. James clearly spent a great deal of money on his wardrobe. Ferragamo shoes, Gucci belt, Prada shirt, custom tailored wool slacks, and pearl cufflinks … none of that stuff is cheap. His watch alone, a Piaget, might be worth upwards of ten thousand dollars—leaving me wondering about his source of income.

  I gently removed his shoes, belt, cufflinks, and watch, placing them in a bag. The slacks and shirt wouldn’t get such service because trying to wiggle him out of them could aggravate some hidden injury, resulting in more harm than good.

  The shears made easy work of his tailored slacks and revealed boxers underneath, Dolce & Gabbana. His legs were hot to the touch and extremely dry, consistent with dehydration. Before attacking his shirt, I give him another sternal rub. He moaned and quickly returned to his slumber. I tried again, this time his eyes fluttered open and he murmured something barely audible.

  “What was that James? Are you in pain?”

  He nods.

  I step back, wondering if perhaps he’s so lethargic because he’s in so much pain he physically can’t endure being awake. In addition to hanging another liter of saline, I gave him 5 mg of morphine through one of his IVs, hoping to take the edge off any pain he might be experiencing.

  In the few minutes it took me to get the saline and morphine, the bulge in his abdomen almost doubled in size. James suddenly looked like he was in his third trimester of pregnancy.

  Without wasting time I grabbed the shears and rapidly cut his shirt off down the middle.

  Involuntarily, I gagged and fell backwards. Thankfully there was a wall there, else I’d have been on my ass.

  I thought Ms. Maggots was bad, but this was on a whole new level.

  James had a bag stuck to the swollen, red, and juicy skin in the lower right quadrant of his abdomen. Except the bag was over-inflated and about to burst open, filled with a thick white-yellow discharge, like shaving cream mixed with egg yolk.

  It took me a while to figure out what it was until it suddenly dawned on me. It was a colostomy bag that was full of pus and rapidly expanding. Essentially like a popcorn bag, but instead of containing goodies, his contained some blood, colonic contents, and a shitload of pus. I’m talking half a liter here.

  The adhesive used to hold the colostomy bag to his skin was coming lose and some pus was oozing onto his skin and dripping off the side of his abdomen onto the gurney.

  His abdominal colostomy wound had the telltale signs of infection. It was warm and likely very tender; I’d check that later when he was more awake. The edge of his colostomy, a surgically created opening in which one end of his colon is connected directly to his abdominal wall (like a two inch belly button that spews out diarrhea all day) was very red and angry in appearance.

  I stood in shocked amazement; I’d never seen anything like this. I just watched, mesmerized, as the bag continued to dehisce from his skin, allowing more and more pus to escape.

  Soon the bag came completely loose and slid down the right side of his abdomen, bounced on the gurney, and crashed onto the floor creating a huge splatter. I tried to turn my head, but not in time. A stream of hot gooey slime splashed me across my left cheek, eye, and hair. Scared to turn back, I rushed to the sink and washed my entire head with hospital grade antibacterial soap. Thankfully my glasses protected the stuff from getting in my eye! Thoughts of Cindy filled my brain. Who knew if this guy had AIDS or Hepatitis C? With renewed vigor I scrubbed my face a fourth time, removing several superficial layers of skin.

  Hazarding a look down, through very blurry, irritated, and disinfected eyes, I discovered my scrubs, both top and bottom, were sprinkled with a healthy amount of the pus. My shoes fared even worse; they were caked with the thick yellow discharge. My outfit was destined for the hazmat container ASAP.

  Walking back to James’ room, I saw that the wall and floor to his right was quite splash-damaged from the exploding pus bag, as was the side of his gurney. This room was clearly going to require quarantine and a good decontamination before another patient could use it.

  With my hair still wet, I gowned, gloved, masked, and bouffant capped up before reentering his room.

  I looked at his colostomy site and instantly wished I hadn’t. It was spewing out pus at an alarming rate. Without a bag to contain the secretions, the pus slithered down the side of his belly and formed an expanding pool of goo on the gurney.

  As if the sight wasn’t bad enough, the odor hit me like a Mack truck. It took a while because the smell had to pass through my surgical mask. The smell was unique, very thick and repulsive, like wet rotting flesh mixed in with diarrhea and the slightly ferric smell of blood. Definitely pretty high up on the nausea scale.

  “So Raj, what do we have here … holy fucking shit!” Dr. Peters was caught off guard as she sauntered into the room expecting me to be examining our patient.

  The smell hit her so hard that she turned around and came back wearing a fitted PAPR mask.

  She didn’t expect to see James stripped down to his boxers with half his gurney covered in egg yolk like pus. To top it off, an active efflux of more pus continued to ooze through the open wound in his abdomen, not to mention the bag full of the biohazardous substance on the floor with plenty of flecks decorating the wall.

  Being the quintessential professional, Peters took it all in with one glance from afar. Then she meticulously gowned and gloved, making sure she was fully covered and protected from the potentially infectious pus, and cautiously re-entered the room to get a full report from me.

  I told her what had transpired. She nodded and gently placed a hand on his abdomen.

  “OH SHIT,” coughed James. Apparently the abdomen was very tender, because that small amount of pressure got James’ full attention. He was now wide awake.

  “Where am I?” His eyes fluttering open, James frantically scanned the room with increasing panic. He was about to look down when Peters threw a sheet on his chest and introduced herself.

  “You are in the hospital. My name is Dr. Peters. I’m in charge here. How are you doing?” She cleverly covered up the gooey mess all over his stomach and gurney with the sheet before James could comprehend what was going on and get even more frenzied.

  “Where am I?” J
ames managed to ask in a groggy sleep-laden voice before he again started to doze off.

  “Rajen, what’d you give him so far?”

  “Uhh, 2 liters of fluid and 5 mg of morphine IV.”

  “What was his response to the narcotics?”

  “Well, he was really lethargic before, and afterwards he was a little more arousable. But his fever is still like 105°F. I guess I should have given him an antipyretic.”

  “So you think he’s in so much pain that he’s almost unconscious as a result? Very out of the box thinking. But I believe you are right on. Good call. You are also correct about his fever; I think that’s adding to his lethargy significantly. If he was just a couple degrees warmer, his brain would start to literally melt, leaving him with permanent damage.”

  I must have lit up like a light bulb from the compliments. I was assuming that I’d done something wrong and she was going to get mad at me. Plus, I had pus all over me.

  Compliments are a rare occurrence for a medical student, and to get one from the most prominent ER physician in Southern California just made my whole week. I felt like I could handle anything.

  “So Dr. Mok, what else did you order for our friend here and what’s our immediate plan of action?” asked Peters. Attending docs only allowed medical students to make further management decisions if they are happy with their work. Strange how medicine works in that regard; if you do good work, your reward is to get more work to do. But along with that extra work comes more autonomy and respect.

  “Well, I already sent off for an extended drug panel, noticing his tachycardia, the whitish powder in his nose, and the dilated pupils. Let’s see, what else … bacterial and fungal blood cultures, basic blood chemistries, liver function tests, thyroid studies, HIV, syphilis, and tuberculosis testing. I was just cutting off his clothes when I noticed the huge bag of pus attached to his abdomen. Just after I discovered its presence, it came off spontaneously and fell to the floor. You can see the splatter everywhere. It got all over me, so I washed up and came back to finish my exam. That’s when you arrived.”

  “Well, he’s clearly well off given his Zegna slacks and Prada shirt.” Peters muttered kicking aside the now useless and pus covered remnants of his wardrobe. “Glancing at the chart on my way over, I also noticed that he was found down next to a $150K car. Which, given his attire, I’m inclined to believe was his and not stolen.

  “Get some more microbiology lab slips and let’s send this giant bag of putrid pus for a STAT Gram stain and cultures. I think that holds the answer to why he’s sick. After that, we’ll have a look at his scalp; he’s already soaked through that pressure dressing.”

  Happy at being able to leave the room for a second, I grabbed the appropriate laboratory requisition forms and a Hazmat fluid collection bag.

  Returning to the scene, Peters was holding the now half empty pus bag at arm’s length. She was quite relieved to see me rushing over with the collection bag in which she promptly dumped the colostomy bag. After sending that through the pneumatic tube system to the lab we reconvened at James’ bedside.

  Peters was unwrapping his head dressing. A suturing set was already neatly placed on a table at her side and two nurses were at attention to immediately take care of anything she might request.

  “Good, you’re back, Rajen. I’ll need your help with his head. I had the nurses give him one gram of acetaminophen rectally. That should help with his fever. I also gave him another 20 mg of morphine to make sure he sleeps through our scalp laceration repair. I figure we can repair his head injury before thoroughly examining his abdomen. Some of your labs should be back by then as well.”

  Wow, it was the second time this year that I was being treated like a peer instead of a nuisance. This whole doctoring thing might actually be worth it after all.

  After removing his dressing, we examined his head. There were no fractures, but he had a four inch laceration extending from the edge of his hairline on the right side directly posterior to just above his ear.

  In deft movements without talking, Peters drenched the laceration in betadine and shaved off the hair on the right side of his scalp. The laceration was deep, all the way to bone in some places. It was still oozing heavily because of the highly vascular nature of the tissue there; hair requires a lot of nourishment. Which led me to wonder if bald people would bleed less.

  “Dr. Mok, have you sutured before?” The question snapped me out of my reverie. I figured this would just be yet another procedure that I would observe, resulting in daydreaming instead of learning. Caught off guard by the question, I nodded in the affirmative. Medical students were notorious for claiming they had done or seen something previously in an effort to be perceived as more experienced than we really were.

  Most physicians don’t want to be the first to teach a student a procedure, but if they were the second, that didn’t seem to be a problem. Technically I had sutured before—all those pigs in our various wet labs. She didn’t specifically ask if I’d sutured a human before.

  “Great. I’ll be your assistant and you can be primary. It’s a little bloody, so I’ll go ahead and anesthetize the area with some lidocaine 2% with high dose epinephrine; you can take over from there.” The instant she said it, one of the nurses handed her a fully loaded syringe and she began inserting the 1.5 inch needle at various points along the laceration and injecting the clear fluid. Within seconds the bleeding decreased to almost nothing, the epinephrine constricting all the blood vessels. “We must be very careful; assume he is infected with the worst communicable pathogens you can imagine, including AIDS and Hep C.” She handed the syringe back to one of the nurses and started to get up.

  “Alright then, he’s all yours. Let’s switch places and I’ll hand you whatever you ask for.”

  Uh oh, open mouth and insert foot; that’s how I felt.

  With a surge of adrenaline my heart rate jumped up to match that of James’ and beads of sweat soaked my brow and armpits. Thankfully the cap and gown hid my sweat stains from public view.

  On cue, my Parkinson’s kicked in and my hands began to tremble uncontrollably immediately after Peters handed me the needle holder with a loaded suture. Great, I probably already blew it and was going to be reprimanded any second.

  “It’s normal to be nervous. Don’t worry, I’m here to help you, not judge you,” whispered Peters.

  “Thanks.”

  “I think you should start in the middle with a couple buried sutures to bring the edges of the laceration together. Then we can run a buried subcuticular suture to close the wound with a dissolvable suture. Normally I’d use a permanent suture, but that requires removal, but I’m not sure if he’s going to follow-up.”

  Astonished that an attending, and not just any, but the famed Dr. Peters, head of ER and all things televised, was giving up her valuable time to help an insignificant med student learn to suture was more than I’d bargained for. Taking a deep breath, I slowly did exactly as she instructed.

  I placed three buried stitches and the wound came together nicely.

  “Ok, the easy part’s done. Now we have to do the buried running stitch that is going to completely close this wound and make it look like he was never cut in the first place. I like to hold the forceps on one edge to create tension and place the first bite like this.” Peters was mimicking what I should be doing just above the laceration. Then she handed me the equipment and stepped back to observe.

  “Just take your time, Raj; you’re doing great.”

  About half way through the laborious process Peters’ pager went off and she slipped away leaving me alone, but giving me permission to finish.

  Seconds turned into minutes and minutes into half an hour of intense concentration while I sutured the final inch of the laceration. I just finished tying off the stitch when I felt a bump on my shoulder.

  “Hey hey, not bad for your first time on a human,” announced Peters winking. Guess she wasn’t the only one who knew I was bluffing.

>   We both stared at the scalp and nodded in approval. Wiping away the residual crusty dried blood we placed some Steri-strips and a piece of gauze over the cut and had the nurses clear away all the detritus that had accumulated during the procedure. The waste managed to fill up an entire garbage can; no wonder medical care costs so much. Everything is disposable, sterile, and frequently requires proper disposal.

  “So Dr. Peters, what do you think …” I was cut off by somebody rushing down the corridor headed straight for us. She drew attention not so much because she was running, as that was common in the ER, but because of how she ran with an awkward hobble. My guess was she hadn’t run in years.

  Her name badge read Urmila Franks. While she wore a long white coat, she wasn’t comfortable in the ER. Then I realized she was from microbiology.

  “Dr. Peters, I just got the results of the Gram stain you sent off from the colostomy secretions. I tried calling but they said you were busy with a procedure so I came up personally. You’re not going to believe what showed up.”

  I could start to see a smile forming on Peters’ lips; she loved it. The thrill of making a diagnosis and saving this young man’s life was just moments away.

  “You’re going to make me guess, aren’t you?”

  “No, that wouldn’t be fair, I’ll tell you: gram-negative diplococci. And not just a few, the whole sample is chalk full of them!”

  Both our jaws dropped as we turned to look at James and the pus splatter that was still on the floor and wall.

  Turning to me Dr. Peters was dead serious, “Rajen, I think you should go to HazMat immediately for a full decontamination. I’m going to quarantine this room. Come back when you’re clean and I’ll give you some Ceftriaxone prophylactically. Just go to them in the basement; I’ll call and make sure they know you are arriving.”

  “Fucking shit,” I murmured inaudibly as I took off running down the hallway to the emergency elevator. I couldn’t believe that the bag of pus was really a biological bomb of actively replicating gonorrhea! And I got it all over my face, glasses, hair, and clothes.