To someone who has never experienced it before, the degree of dysfunction that occurs in a small community hospital can be astonishing. And I don't mean small things, like labs being misplaced or orders for physical therapy being ignored, I mean big things like losing power to the entire OB wing of the hospital and finding that someone has died in the waiting room while waiting to be seen.
Thankfully, I was getting close to when I wouldn't have to work any more shifts in this God-forsaken place, but I still had to get through this week of nights, another week in March, and then a few more scattered weekends over the next eight months. Our night shifts started at 7 pm with what was called "sign out," which is where the interns would take turns running through "the list" of patients that they were managing, and the shift ended the next morning at 7am.
During sign out, the day team would give you a brief synopsis about what the patient had been admitted for, what had been accomplished during the day, and what labs or tests still needed to be followed up on. Sometimes there would be a lot to do in terms of monitoring them, but sometimes the patients would just slumber peacefully through the night without needing much intervention on behalf of the mole (the position that I currently occupied). I should rephrase that; no one who has ever had to sleep in a hospital would call it peaceful. Patients were subjected to constant interruptions from doctors, nurses, aides, phlebotomists, therapists, chaplains, cleaners, family and friends. You could tell sometimes when a patient was reaching the end of their rope at the hospital and I would always say to them, "the hospital is where we keep sick people, so if you want to go home to get a good night's sleep, you're going to need to get better!"
Recently, our residency had changed how we organized the night shift so that there was both an intern - who was a first year physician, fresh out of medical school - and a third year resident on duty every weekday night, and then only a third year (but a different one) on "weekend mole."
From the standpoint of the third year, this was a pretty sweet deal because it meant that there were two people who could do all of the things that needed to be done during the night, but it also meant that there was a responsibility on behalf of the third year to make sure that the intern was learning the ropes of the hospital but also thriving and not being terrified to the point of quitting residency. It may sound silly, but this was actually pretty tough: like threading a needle while on the back of a moving motorcycle.
I hadn't worked with many interns in the new first year class, so I didn't know much about the person I would be working with this week other than that his name was Clayton Howard, and that he was from Kentucky. When I arrived at the resident room in time for sign out at 6:50, Clayton was already there, dressed in a pair of light blue scrubs (one of the perks of the mole shift is that scrubs were allowed, whereas those residents working days had to wear "work clothes.")
The day team wasn't quite ready to begin because they had had a late admission at around 5:30, and apparently there were two more people in the ER who were also likely going to need to be admitted, so I was anxious to get sign out underway. At 7:05, the day interns still hadn't even finished updating the list and were nowhere near ready to begin sign out, and we got a page from the ER (yes, actual pagers were still used in the hospital, an anachronism so dated that it was almost cute). I asked the intern who had been carrying the pager to toss it to me so that I could call them back.
"Hey, this is Jen, the night mole, what's up, I was paged?"
"Hey Jen, this is Abby down in the ER, let me grab Dr. Crane, I think he's got two for you."
I waited patiently as she went to go get Dr. Crane, and pulled out an empty piece of paper so that I could take notes. When Dr. Crane got on the phone he greeted me warmly. "Hey Jen, long time no see. You're doing well, I hope?"
"Hey Dr. Crane, I'm here, so how well can I be, right?" I joked, knowing that he would not be put off by my morose sense of humor.
"Well, I've got two nice and easy ones for you to start the night off right. Just kidding, one is nice and easy and one is a complete train wreck. Should be fun."
"Hit me," I said, with my pen poised above the paper.
"The first is a 76 year old female, sweet lady, she's got diabetes, hypertension, depression, anxiety and osteoporosis. She fell and broke her hip; ortho has already seen her, and they're hoping to go to the OR tomorrow morning, but they want the medicine team to manage her diabetes. Biggest problem for her is going to be her A1c, which was 11.7, and pain control, which she has been struggling with here in the ER.
The second one is a little bit more complicated, but basically he's a 35 year old male who was found down at his apartment by a sheriff's deputy who was serving him an eviction notice. He's got a multitude of problems, which will become evident when you see him, but I would say that his biggest issue is acute renal failure and, uh, let's just call it 'failure to thrive,' you'll understand what I mean when you see him. He's going to the ICU, and we've already touched base with Dr. Leung who is ready for you guys to come down and take a look at him. Oh, and Jen, make sure you're wearing scrubs," he said, barely able to conceal the glee in his voice.
"Wear scrubs? What, is he, like, covered in shit or something?" I asked, wondering what could possibly be so bad to warrant that bit of advice.
"Oh, definitely 'or something'" he said, chuckling to himself.
"The day team hasn't even started signout, so I might send the night intern over to get the lay of the land, and then I'll be down in a minute."
"Sounds good," he said casually, "we'll be here." I hung up the phone and surveyed the progress that the day team had made on updating the list, which seemed minimal.
"So we've got two people waiting in the ER, can one of you guys start signing out to us so that we can get a move on with those admissions?"
The second year resident who was in charge of the day team was looking over the shoulder of one of the interns who was updating the sign out sheet. "Yes, Leslie's almost done, and then we can print another copy of the list when Steven has finished updating. Here Leslie, why don't you start presenting and I'll update those last few things on the list."
Leslie printed two documents, one for me and one for Clemson to take some notes on, and then she settled down around the table to start presenting. Interns were at the stage of their medical career where their presentations were overly long and sometimes still omitted key details that were useful for the covering night team, but on the whole Leslie did well, even if it did take her sometime to get through it.
Once Clayton had heard about her first 5 patients, I sent him to the ER to start getting the history from the two that we had waiting.
Leslie then finished with her last two and Steven started with his seven. I had taken a few notes on the temporary piece of paper Leslie had given me at the start because I didn't want to have to transfer too much to the updated list. However, when the list had been completely updated and reprinted, I did transfer my brief notes onto the final document. By the time we finished it was 7:47 and I needed to head down to the ER.
"Ok, good job you guys, let's just try to be a little bit more prepared tomorrow so that you guys aren't here so late doing sign out, ok?"
Both Leslie and Steven and Kyle, the second year, looked like they had been rolled over by a bus, but they nodded. I had them print one more copy of the updated sign out that I could give to Clayton, then I left the resident room and made it down to the ER.
When I arrived, Dr. Crane was sitting in his little cubby, looking at an X-ray. I ran in to my friend Ashley who was a fellow third year and currently on her ER rotation.
"OMG," she said, "have you been in to see the guy who was found by the sheriff yet?" She could hardly contain her excitement.
"Not yet, why? Is it that bad?" I asked, suddenly feeling a great sense of foreboding.
"Oh, it's probably the worse I've seen pretty much ever. Even Dr. Crane was a little bit shocked, and you know him, he's seen it all, nothing surprises him. There are gowns and other personal protective equipment outside his room, which you'll definitely want to use."
"Has Clayton seen him yet?" I asked, looking around at the busy ER to see if he was around.
"It didn't seem fair to throw him into the deep end just yet, so we had him start with the pelvic fracture."
"In other words you saved the train wreck for me?" I asked, smiling at Ashley.
"Exactly," she said, and moved back over to her computer in the cubby across from Dr. Crane. I could see on the shelf above her desk she had a big pile of knitting, that looked like it was probably the Outlander scarf she was making me for my Halloween costume. I smiled again, grabbed a pen from the counter just above her head, and went to the nurse's station to find the physical chart for my mystery patient.
From what I could tell, they hadn't done much yet, as there was nothing in the history section, and no information about past medical, surgical, family or social history. I looked at his labs in the computer; his serum creatinine, which was a marker of kidney function, had been sky high when he arrived at 6.34. His electrolytes had also been way off with low sodium, high potassium, and his other salted that were variably high or low. His sugar was also very high in the 300s, which suggested that he had diabetes, and his blood pressure had been really low, 80s/50s when he was brought in, suggesting either that he was in shock or had sepsis or both.
Since I couldn't really glean much more from his chart, I moved over to his room, which was one of the negative pressure isolation rooms. There was a sign on the door that he was under contact precautions, over which someone had penciled in "wear EVERYTHING," so I dutifully donned booties on my clogs, a yellow contact gown over my scrubs, a hair net, a face mask and gloves. I also grabbed the "contact precautions" stethoscope that was about as effective as just putting my ear to someone's chest, and walked into the room.
Holy fucking shit, I was not prepared for what I saw.
First of all, the odor inside the room was unconscionable - it was a fetid combination of leakage from every orifice: diarrhea, vomit and urine, to name but the most obvious and most pungent. No wonder they had put him in the isolation room. If it had been the smell alone that would be bad enough, but it was his appearance that was most shocking. Even though his chart said he was 35, he looked much older, and probably white, but here's the thing, it was impossible to tell, because I kid you not, he was covered from head to toe in shit. Scratch that, not shit, but rather a liquid solution comprised of fecal matter, bilious vomit and urine that had been combined in a blender and then his whole body had been repeatedly dipped in, like a fucking candle.
If that had been all, though, one could maybe begin to understand the series of events that had lead up until now: he had had some kind of viral gastroenteritis, had not been maintaining adequate hydration, and this worsened into kidney failure, which further weakened him, making him even less able to get up and out of bed... if that had been all, then his present condition could be explained. But here is the crucial point, the salient point: he was also covered from the nape of his neck to the bottom of his legs in twenty dollar bills that were attached to his body, almost papermaché style, with the shit-vomit-urine mixture acting as a mordant-like glue. This poor man had been tarred and feathered with shit and money.
On the bright side (???) he was breathing on his own, and they had thoroughly cleaned off one arm, which was separated from the rest of his body by several blankets, and he had an IV. He did not appear to be conscious-though, which honestly, was probably for the best. Who would want to be awake for this kind of misery? I walked up to the (sort of) clean side of his body and said his name, which was John Anderson. At first he made no sound, so I said it again, and touched his clean hand gently. With this he did move a little and moan. I asked him if he could squeeze my hand, which he did, and to open his eyes, which he did not. Obviously I wasn't going to get much story from him.
I decided that the thing to do was to get him out of the ER and into the ICU where we could begin the slow process of reviving him; given his current state, he would likely need hemodialysis, tons of fluids, insulin, and most definitely a bath. In fact, of all the things that he needed most, the bath might be the most important. He was about to have about a dozen needles jammed into him from every which way from Sunday, and if he wasn't septic already, he would be, from injection site contamination alone.
I leaned over him and squeezed his hand and said rather loudly, "John, you are not alone, ok? I'm here to help, I'm going to help you get better." He mumbled something and then squeezed my hand again, then his grip slackened, and I left the room, removing my contaminated gown as I left.
I walked over to the sink and scrubbed my hands three times with a surgical scrub brush, then walked over to where Dr. Crane and Ashley we're sitting.
"What the ever loving fuck is going on with him?" I asked, completely dumbfounded at the series of events that could have possibly led to the situation in the containment room I had just exited.
Dr. Crane chuckled, then looked at Ashley, then at me and said, "what's your best guess?"
"Honestly, I don't think I am equipped with enough creative depravity to even imagine a scenario that would result in what I just saw in that room."
"Come on," he said, "take a stab at it."
"Well, he's in renal failure, that's obvious - which reminds me, we should probably call nephrology, he's likely going to need hemodialysis."
"Already done; we paged them before we even called you."
"His sugars are high too - so I guess diabetic ketoacidosis is a possibility - but his electrolytes looked really fucked up. I haven't calculated an anion gap, but I suspect that this guy is a poster child for a mixed acid-base disorder."
"He was hypotensive when he got here, so obviously shock and sepsis are a concern, but he's protecting his airway, and he's not on pressers, which means that his blood pressure normalized with fluids. Obviously this doesn't exclude infection, but it's reassuring. I'm assuming you guys got a tox screen, but I didn't see the results, did anything come back?"
"Still pending," he said, "but this is all the medical stuff, which is boring, and for the most part stable. Jen, why is the poor man covered from head to toe in shit and twenties???"
"I'm getting to that, don't rush me," I said, smiling. "The application of the shit is too evenly distributed to be from incontinence, I mean, it looks like he was dipped in a vat of it, so I have to think that this was applied intentionally. It also smelled of vomit and urine, and that may actually be from his own secretions, because it really does stretch the limits of imagination to think that he would intentionally combine all three of those together. But fuck if I know how and why that poor soul is covered in $20 bills." I exhaled deeply, shook my head and leaned against the wall. "Ok, my best guess is that this was done to him, some sort of cruel torture or pay back or sick sex thing. Honestly, only bad things come to mind. So, what is it, what's this dude's story?"
Dr. Crane swiveled in his chair, laughing to himself and said nothing, so Ashley spoke up.
"The truth is, we don't really know. He obviously hasn't said much to the sheriffs or to the EMTs who picked him up, or while here. The crew that got him said that the place he was staying was pretty run down, lots of detritus and waste all around - but none of it was human or animal waste - just, like, empty food wrappers and dirty clothes. The bathroom was grimy, but not disgusting, and only the bedroom was truly foul. They also found a bag of cash next to the bed, also $20 bills, and his cell phone and keys. But other than that, we don't know much. We cleaned off his arm by using some surgical scrub brushes, hibiclens, alcohol and betadine. As you can imagine, he was a hard stick, but our ER nurse Julie was able to place an 18G. I assume you're gonna want to get him to the ICU soon, so let's have Julie call over there to give report."
I nodded in agreement, and then my pager went off. It was Dr. Leung in the ICU. I called him back and let him know what a shit storm (literally!) I was bringing with me and that we'd be heading over as soon as report had been given and the room was ready. I then wandered around the ER, looking for Clayton, so that we could discuss our little old lady who had the fall, and also so that I could induct him properly into the shitshow that was our dear, poor Mr John Anderson.
***
My adventure in the ER admitting the two patients was only the beginning of a very long night. Once we got Mr. Anderson to the ICU, things started to get really interesting. And by 'interesting' I mean horrible, things started to get horrible. The first problem occurred when we attempted to give him a bath. It wasn't clear immediately why he was obtunded, at least not until his tox screen came pack for a veritable potpourri of illicit substances including marijuana, methamphetamines, narcotics, benzos and alcohol. But something about the idea of getting clean really seemed to sober him up, and he did not want to get clean - I suspect literally and figuratively. Rather than sedate him with drugs, which we did not want to do given his kidney failure, we had to resort to using restraints. Eventually though, he was just getting too agitated, and after discussion with the ICU attending Dr. Leung, we instituted a CIWA protocol, which meant that we could use some benzos for agitation, assuming (I suspect quite likely) that some of his agitation may have, in fact, been due to alcohol withdrawal.
Once calmer, it still wasn't easy to clean him up. The twenty dollar bills were particularly adherent to his skin, and even when soaked in water to loosen the "shit mortar" were still very likely to remove the underlying hair, since the shit-vomit-urine mixture had dried into a sort of crust that adhered to his body hair like a clay face mask. Attempts at removing it with surgical scrub brushes created a sort of "shit slurry" that positively reeked of foulness. Some parts just would not come off and had to be removed with a picking motion, almost like a scab, which ended up removing some of his hair as well. In the end, he looked sort of like a plucked chicken who had recently gone swimming in a sewer treatment center.
When he was as clean as we could get him with him lying in bed, we transferred him to a special chair and moved him into the shower, where we hosed him off, head to toe, lathering him up with a potent antibacterial cleaner called hibiclens. His level of alertness had waxed and waned and he only intermittently became agitated, requiring only that you say his name a few times and tell him that we were giving him a bath. As we finished, the head nurse in the ICU came over to help us get him into bed. By the end of the bath he was able to bear weight with considerable assistance, and we transferred him carefully to the waiting hospital bed outside of the shower.
Finally, the nephrology attending arrived and ordered a new set of labs: his kidney function had improved with fluids and his electrolytes has begun to normalize, so dialysis wasn't needed, in the end. While I had been attending to him, Clayton had been answering the pages we received on our other patients and would pop his head into the ICU periodically to ask me questions and to offer assistance. The whole ordeal from moving him from the ER to having him fully cleaned and back in an ICU bed took about 2.5 hours.
By the time I left, we had quarantined the shit-soaked "paper maché" twenties into three sealed biohazard bags and placed the whole package in a locked safe in the security office.
I looked down at my scrubs which were smattered with fecal material, soap and water and wandered off in the direction of the physician's restroom in the surgical suite to get cleaned up.
It was only 10:30 pm, the night was still young.