Suffering in the World

We’re called for chest pain at the court house. We question whether it is a case of "Jailitis." We find the patient sitting in the lobby on a bench surrounded by marshals and firefighters. It is a young man – twenty-five. My first reaction is he is a prisoner, but then I realize he is wearing street clothes. We hear the story. He was walking down the street when suddenly he felt an intense tearing sensation in his chest going into his back. He is a heart transplant patient. A firefighter hands me a paper with medical history on it. It is a typed report from a hospital saying the patient has a diagnosed Aortic dissection.

"Aortic dissection is a condition in which there is bleeding into and along the wall of the aorta (the major artery from the heart). This condition may also involve abnormal widening or ballooning of the aorta (aneurysm)."

While the man looks okay, he also seems extremely tense. I would be too with that history. An aortic dissection rips open and the person bleeds out in a minute. One moment awake, the next dead.

I nod to my preceptor as I lower the stretcher. Let’s just get him on the stretcher and on the way to the hospital. His pressure is okay. When my preceptee says he is going to start a line, the man says he has no veins, the hospital has to use central lines so we shouldn't bother. We are already enroute to the hospital. I hand the CMED radio to my preceptee. He stutters some with the patch. The patient snaps at him when he says stomach pain. “It’s not stomach pain, it's chest pain, pain into my back.”

When I ask for the meds he’s on, he starts rattling off a list. I ask him to repeat one; he says the name again, but with thick frustration. He glances back to try to look ahead. “Are we at the hospital yet? How far is it?”

“Just up the road.”

When we finally approach the hospital, the man, seeing the ambulances out the side window, says urgently, “You just went past the ER!”

“No, listen, I know you are concerned, but we know where we’re going. It’s a one way drive.”

He apologizes.

“We’ll get you good care.”

In the ER, I tell the triage nurse the man has a possible AAA. "No! It's not possible, it’s been diagnosed,” he snaps. “I have it.”

“Okay,” I say. “We’re getting you a room now.”

He looks like he is about to snap as we wait for the triage nurse to give us a room assignment. His hand keeps tapping his leg. “Man, I can feel it pulsing!” he shouts.

**

My preceptee is discouraged that he gave a bad patch. He apologizes for doing poorly.

Doing poorly I say, you haven’t done poorly yet. And you will. Just wait, you’ll have a call from hell where everything will go wrong. You haven’t seen anything yet. Just be prepared.

While we are talking another medic tells us about the call she just had – a code. They couldn’t get the tube, they had to keep suctioning. Blood was billowing out of the man's mouth. The messiest call she had ever had she said. She even considered doing a crick -- cutting the man's throat to get an airway in. In the end, she was able to get a combi-tube in. Not a good call for a medic, much less a call a new preceptee would want.

**

Our calls are all routine. "Severe pain" is a man with knee pain and a month old rash on his legs. "Irregular ECG" at a health center is a woman with abdominal pain and cirrhosis of the liver. "Violent psych" is a seven year old is acting up at school.

**

We do a woman in a nursing home with abnormal lab values. She has an ETOH history with liver disease. She looks like a matron in her late fifties, maybe sixty who’s had too many martinis. I look at her age. She was born in 1963 -- four years later than me.

I’m proud of my preceptee when he realizes the woman has badly soiled herself he gets an aide to get her cleaned up before we take her out. He talks with the woman in calm, compassionate tone.

**

Later we do two heroin abusers -- a sixty year old Puerto Rican man who last used in the morning, then went to a detox center, but when they checked him in they found his sugar was over 600, so they called us to take him to the ER and a thirty year old man involved in a car accident in a bad neighborhood, who seemed a little odd to the cop. He was also an insulin dependent diabetic, although his blood sugar was low in the 40's. We ended up giving him one and a half amps of Dextrose. The younger man did not want to admit his heroin use. When we tried to roll up his sleeves to look for a vein, he resisted and said he had issues. We told him we didn't care, we just wanted to make him better. He had track marks, but not hard core ones like the older man. The older man talked freely about his addiction about how he fell in and out of it and back in again. He's spent 18 years in jail. Hald his family had been killed by drugs. He said when he got out of jail, he saw there was so much suffering in the world. Other people couldn't see it, he said, maybe because living on the outside they had gotten used to it, but it affected him. When it became too great, he was susceptible to the needle. But he wanted to get clean again. He wanted to live at least until he was seventy, he said. His father had lived into his nineties.

***

We never get back to the first hospital to find out about the young man with the dissection.