Ask any healthcare worker if they have interesting stories from their job, and you will be bountifully rewarded. This is especially true if said person works in an emergency department or hospital. The main reason for this effect is relatively simple: the more people you interact with, the crazier the world seems. The ED is a melting pot, with people of all demographics (though predominantly low SES) represented. Bringing such a diverse group together tends to give you interesting results.
The Ugly
ED stands for "Emergency Department," but it could also just as easily stand for "Elected to Display." What I mean by this is, people often have no shame in showing you exactly what ails them. As a volunteer, one of my jobs was to help people fill out a form so they could be triaged. We had several signs pointing to the forms, indicating they should be filled out first, but people often walked up to the window anyways. The conversation usually goes like this:
Me: Can I help you?
Patient: I need to be seen. I have this huge rash (reaches for shirt).
Me: (Quickly) Ok, I need y...
Patient: (Pulls up shirt revealing a large rash, fully in view of everyone in the room.)
Me: (To myself) Thanks for that.
Me: Ok, please fill out that form for me and we'll get you looked at. Sigh...
The probability of me being shown an ailment is proportional to how bad/disgusting it looks. If blood is involved, the chance jumps to 100%. Traumatic wounds need to be checked of course, so I don't fault people for that. It's the absurdity that gets me. You would not say, show your bulging abscess at a dinner party as part of your introduction (if it comes up in conversation, well, that's fair game). But in an ED, you'll walk up, lift your shirt triumphantly, and share with myself and others your pathological achievement.
The other common presentation is the "waited too long" patient. A couple of instances stand out in my mind. One was a woman who was extremely lethargic. She could barely even speak or hold her posture while sitting. A history revealed that she had hypothyroidism and had either run out of medication or just didn't take it for a while. Without treatment, she surely would have fallen into a myxedema coma. I remember the nurse blatantly scolding the woman and her family for not coming in sooner. The other case involved an older man who may well have set a hospital record for highest temperature in a living person. He arrived (astoundingly) by personal vehicle, driven by his daughter. He was a bigger guy, so I called the paramedic to help get him out of the van. He gave me a ribbing for not doing it myself. After a few minutes, he came back in sweating and out of breath with the patient slumped over unconscious in a wheelchair. "He was complete dead weight" the medic said (I should have gone out to help him, which I apologized for afterwards). I don't know how in hell his family got him into the car. The nurse took his temperature, which read 106.7 F (41.5 C). For those of you wondering, this is borderline "incompatible with life." The nurse wasn't even sure if the thermometer would be able to read that high. I'm fairly certain he was septic, although I think he ended up surviving. The ED really alternates between the mundane and the unbelievable.
The Bad
I'll end on good so as not to leave you feeling (too) depressed. Unfortunately, the ED is not generally a happy place. It is visited out of necessity rather than desire, which makes it ripe for unpleasantness. When you add pain/nausea/malaise/uncertainty with long, seemingly arbitrary waiting times, things can get really, really unpleasant. The worst cases occur when someone gets to "cut in line." Triage works like this: the nurse takes your vital signs and a brief history. He/She makes any quick assessments necessary, like a vision test or brief neuro exam, along with a self-reported level of pain. This is all summed up by a triage score 1-5, 1 indicating immediate life-threatening condition (like cardiac arrest) and 5 indicating minor condition with no necessary procedures (like a cold). The severity of the condition dictates who sees the doctor first. Things possibly affecting the heart (chest pain) or lungs (dyspnea) are the more common sources of line-cutting. On certain occasions, it's very obvious someone needs to go back right away (serious laceration, head trauma, altered mental status, etc) for instance, like the man who seized while being triaged. These types of problems draw few objections from the waiting room. Most times it is less obvious why someone goes back first though. One day in particular, I had a women who was fairly sick, with nausea and vomiting (n/v). However, her vitals were essentially normal, with perhaps a mild fever and and tachycardia due to the nausea. Unfortunately for her, several ambulances showed up, and we were already full. Additionally, a few other walk-ins had deviations in vital signs like hypotension, which needed to be worked up. She waited for at least three hours before she had enough. I tried to explain to her why other people went back first, but I wasn't getting through. I think she ended up leaving to go to another hospital (where she will probably wait just as long again).
On my final day, a woman showed up, depressed and on the verge of tears. She was looking for her son, who had gone missing the night before. His car was deserted, and his wallet was left behind, suspicious for foul play. But he wasn't at our hospital, and there was nothing I could do. I told the woman he wasn't at our hospital, but I would look out for the name. She then asked me what she should do. I told her to contact the police (which was her best option). She said okay, and thanked me sadly before leaving. It is a difficult thing in medicine, to want to help others but accept that sometimes, there just isn't anything you can do.
Another part of the ED is that bad news often arrives unexpectedly. People go from alive to dead without any warning or preparation. I've seen a few people coded, and not one of them survived. Listening as the doctors break the bad news is not something you easily forget. I arrived a couple times to deceased children, which is about the worst. I've seen several repeat patients, one of whom always arrives by ambulance, always complains of dyspnea, and then immediately proceeds to go outside and smoke a cigarette. Patients are often obese, some are drug seekers, some malingering for disability or other reasons. And many lack the capacity to understand how medicine and the ED works. They struggle with their own problems, and fail to appreciate the perspectives of the people trying to help them. I've seen people arrive intoxicated or high on drugs, sometimes dangerously so. Patients are combative or abusive to the staff, especially the behavioral or law enforcement ones. And the worst part of all is that so many of these people will return with the same problems, lacking the money or reinforcement they need to change. To see the human condition so exposed, so gritty, it can turn even the most optimistic people cynical.
The Good
Like most jobs that deal with the seedy side of life, you survive for the few good things. Occasionally, you will get a patient who is helpful and courteous, and it makes all the difference. Elderly people tend to be better mannered and more likely to wait patiently, but that's not always the case. The clinical and support staff can also make a big difference. Some people are naturally easy going and funny while others crumple under stress. There was one nurse in particular that I remember, because initially I think she didn't like me. When you start volunteering, you're basically a massive tool because you don't know anyone, you don't know where anything is, and you don't know how things run. As Samuel Shem puts it in the House of God, "Show me a [medical student] that only triples my work and I will kiss his feet." Such was the case with this nurse. But after spending time in triage with her, she eventually considered me a colleague/friend. If you establish yourself as a competent, trustworthy person, you'll make friends easily.
Getting to know the patients also helps. Towards the end of my volunteering career, I started spending more time talking to people. I wish I had done this sooner, because it gives you new perspectives. One man I talked to lived in NYC with his girlfriend until they broke up. He moved to a small town in Arizona, but left because of a drug problem (in the town, not necessarily himself). Another man I talked to was younger than me and had just been released from jail just a few days ago. He suffered from substance abuse and was probably in withdrawal. I chatted with him in the waiting room, and then I checked up on him once he was in a room. He was very grateful that I had spoke with him. The epitome of grateful patients occurred when a woman walked in with questions about medications for a surgery she had a few days ago (yes, she showed me the scar). I didn't want to make her wait in the ED, so I talked to the unit clerk, who managed to contact the surgeon. He said she didn't need any prescriptions for antibiotics or pain pills. I walked back out to the waiting room, expecting to hear objections raised. When I relayed the message however, she smiled and thanked me. She didn't want to take anything in the first place!
Most of my memories from the hospital are snapshots, brief clips that struck me as poignant or odd. Most are relatively neutral, but several fall under the Bad category and even fewer into Good. I learned a lot from my two and a half years at the hospital. Most importantly, I learned that communication is everything. It can mean the difference between making friends or creating enemies; the difference between gaining patient's trust or losing all credibility. What you say can make just as big an impact as what you do, medical or otherwise. When you understand a patient's perspective, it allows you to better help him or her. Medicine is all about the good, the bad, and the ugly. You just never know what your next patient is going to show you.
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