County

 

I'm a medical resident at County Hospital.

I live on an island off the coast of Miami. To get to work each day I have to drive across a long bridge that connects the island and the mainland.  It's usually dark when I leave home. Everything begins early at County Hospital. Do you know why?

Please tell me.

When I drive in I like to listen to Haitian music on the radio. It's very melodic and gentle to the ear. It relaxes me. But then again, as with all things Haitian, it carries with it a certain element of mystery and voodoo.

As I drove in this morning I looked across the water. Off in the distance I could see a full moon hanging over County Hospital. Its reflection rippled on the bay water.

I shuddered.

 

We had a good take down last night in the ER.

He was about thirty and big. He had been sleeping when the meals had been passed out but now he was wide awake and he was hungry.

The nurses were busy and they told him he'd get fed at dinner time.

The guy was an idiot. He started accusing the nurses of eating his meal. I was writing some orders in a chart about five feet from the guy doing my best to ignore him. I heard a nurse tell the guy to stay on his stretcher but he was moving.

A couple of security guards appeared out of nowhere.

The guy stood up and there was that moment when the security guards placed their hands on him..

The guy went at them with his teeth. He bit square on one of the guard’s arms and all mayhem broke loose. They tried to hold him but the guy was crazy and his head was moving so fast. He bit and bit and bit.

The ER was packed so I played a supportive role in that I made sure there was a big desk between me and the action.

Fifteen minutes later the ER was back to its usual tempo like nothing had happened.

The guy was now among the disappeared.

I saw one nurse giving a report to a police officer. That was about it. I went back to the chart to finish my order. There was a wicked string of blood droplets across the order sheet. That took me back a moment.

I looked over and saw a nurse rinsing his hand off in the sink. There was blood going down the drain.

I looked down on the floor and saw several pools of blood. I heard one person say, "Shit, he'll be back on the street in 2 hours." Then another say, "Maybe not, assaulting a security guard in a hospital is a felony."

I didn't know that.

Something to remember.

About then I heard the ER attending talking. "That patient over there is holding his chest." he said, "I hate that."

I had finished writing my orders and I would have enjoyed a few moments with my eyes closed but the attending was looking at me. He handed me a yellow flow sheet. "Here's your new patient."

"The guy holding his chest?" I asked.

"No, this is a little different."

I checked out the vital signs on the chart and they were OK. I went to meet the guy. He was an older Hispanic male and he only spoke Spanish so I called for the Spanish interpreter.

While I was waiting for the interpreter, I checked out the patient's medical history.

Schizophrenia, paranoid type. Alcohol dependence. Non-compliant with his antipsychotic meds. His last hospitalization was last month. Apparently he had walked up to a car and punched out the driver accusing him of being in the mafia.

Okey.

The Spanish interpreter showed up and we walked over to the patient.

Through the interpreter I asked the guy why he had come to the ER. He started talking in Spanish.

The interpreter said. "He has an infection on his testicles"

The guy continued in Spanish.

"He says he went to a doctor and the doctor gave him some cream to apply to his testicles."

I heard the guy say, "Mucho! Mucho! Crema!"

"He says he applied a lot of cream to his testicles but it hasn't helped."

"He says the sores have gotten worse and that it smells very bad."

The patient and the interpreter talked back and forth in Spanish but I did hear the guy say, "Terrible!" in English.

"He says it smells terrible."

For a moment I just looked at the interpreter.

"Doctor, I am glad I am the interpreter." said the interpreter.

Okey.

We went on with the interview. The big question was this:

"Sir, this problem has been going on for a while. What is it that brought you to the emergency room TONIGHT?"

"He says his legs hurt. They've been hurting for about a week and today he just figured he should come to the hospital."

The interpreter left and I started my exam. His lungs were clear thank you Jesus. Heart sounded good. In general he was filthy but his abdomen was benign which almost made me weep for joy.

I figured I'd jump on down to the legs and postpone the inevitable.

I lifted up the covers to look at his legs and was surprised to see that he didn't have any feet.

Both legs ended cleanly at the ankles in what appeared to be well healed post-amputation stumps.

Luckily the interpreter was still nearby so I grabbed him and through him asked the guy how he had lost his feet.

"Circulation problems."

An attending once told me that patients can have as many medical problems as they want.

Above the stumps both legs were swollen and angry red. I felt them and they were warm. I pressed with my thumb to assess for edema and the guy got bug eyed and yelled. "ARRRGGGG!!!"

I backed up with visions of a motorist being punched out.

The guy said something angry in Spanish. I let him cool down for a second and then said.

"OK, down with the pants." I motioned and he started to pull down his drawers.

He had described his testicles pretty well. I got my pen light out and made a quick assessment and then walked ten feet away and started breathing again.

Good God.

I told him to pull his pants back up and I went to the attending to present the patient.

This is a 65 year old Hispanic male with a past medical history significant for schizophrenia, peripheral vascular disease and bilateral foot amputation.

"Yah," said the attending, "He's been here before. Now and then he gets up and walks around on his stumps. It scares everyone."

I had visions of him striding headlong across a parking lot to confront the Mafia.

Here's the beauty of the ER. The rash on his balls was being dealt with already by an outside physician so we weren't going to do anything about that tonight. Thank you Jesus. He can go back and get more crema. The red swollen legs were cellulites vs DVT. I gave him two grams of Rocephin and ordered an ultrasound and looked up at the clock. It was 7:00 am and I sign out at 7:30 am so I had things to do.

I wrote discharge orders on the two asthma patients I was treating. I checked an x-ray on a guy with abdominal pain and wrote his discharge. Then I presented my other cases to the incoming attending and I was going home.

To get out of the ER I had to walk through the holding area. The County ER holding area is a sight to behold. There are about 30 stretchers with patients lying on them waiting to be seen. Some of the patients are moaning, some are sleeping, and some are just lying there bored. The wait in the holding area can be up to 24 hours depending.

I had to squeeze by one of the stretchers to get through.

"Excuse me" I said.

"Doc, Doc, I'm in pain. Bullet wound." I looked at the guy. I swear he looked like he had just stepped out of “Pirates from the Caribbean”.

"Mmmm.." I said, "Well, I gotta go.."

I looked up at the exit door and made a beeline.

 

Miami 2007