My Crescent Moon (A Collection of Short Stories). Joseph Dylan
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had told me the GI bleeder was fairly stable when she called you,” said Jennifer. Julie Turley had been one of my interns in July. Her competence impressed me. That she was an emergency department resident, I didn’t hold against her. But I didn’t care for a lot of the interns from the program. They were too proud. Beginning my third year of internal medicine, the university medical center started an emergency medicine residency, taking in a half dozen residents each year. They were the top students in their classes from across the country. Unlike the rest of the residents at UNM Medical Center, they wore bright, blue emblems on their white lab coats, signifying that they were not only residents, but that they were residents in the Emergency Medicine Department. No, they were too proud. While we were busy managing patients in the internal medicine, general surgery and pediatric departments taking care of patients, the cloth emblem exuded an attitude that bespoke a bias saying: “We’re here saving lives.” Just what were we doing? Their interns in the emergency department residency program spent a couple of months doing their internship on the internal medicine wards. And that was how I knew Julie.
I nodded at the secretary and thanked her as I watched Ann suture the Swan-Ganz catheter to the patient’s skin with thick, black silk thread so it would not slide out, nor farther into subclavian vein. I looked up and out of the window of Mr. Gonzales’s room. The rain that began that morning, had turned to sleet and the weather was all aslant. Sleet balled up on the windowpane and dripped down in thick rivulets. The cold front coming through central New Mexico was turning into a tempest. So many of the homeless with any ailment would be presenting to the emergency room and the urgent care, searching for a warm bed, clean and dry, rather than under nature’s tempest. Though days like these seemed endless for a resident, I couldn’t help but feel sorry for the homeless. For those so down-on-their-luck, they had no roof over the heads. And God knows there were enough of them in this city slung in the swale of the Rio Grande Valley. “You’re did fine, Ann,” I said as she checked the balloon at the tip of the Swan-Ganz catheter one more time. Now once an hour, the nurse attending Mr. Gonzales would inflate the balloon long enough to record the wedge pressure while taking the rest of his vital signs.
Feeling someone at my shoulder, I looked up from Mr. Gonzales chest to find one of my other interns. It was John Naylor. He was known to the other residents and the medicine interns as “The Terminator.” He had earned this appellation from so many of his patients succumbing from their medical problems under his care. But the nickname was unfair, for John was a good intern. Live had just dealt him the sickest patients. In the internal medicine rotation, each intern gets their patients in the order they present to the resident from the emergency room or the urgent care. John couldn’t help the fact that the deck seemed loaded to him. “John,” I said. “I have another admission for you. A GI bleeder. I have to go down to see him when Ann and I are finished here. Then you can see him when we move him up to the intensive care unit. I looked back down at Mr. Gonzales. As Ann finished attending to Gonzales, I took the back stairway that led down to the emergency room, the emergency department in the medical center being directly below the intensive care unit.
But if my nerves were set on edge by all the beeping telemetry units, the groan of the ventilators, the constant ringing of the telephone, I was even more dismayed when I entered the emergency department from the staircase from the ICU. It looked like a Fellini film, each gurney holding someone deep in misery, from the elements, and from some medical or surgical emergency.
Now that Turley was no longer on, I sought out Paul Perkins, the intern who took her place in the emergency department. Turley had gone off shift not more than an hour ago, not long after she had beeped me. Unfortunately, so too had the nurses who had taken care of Jose Garcia, my GI bleeder. That was all too typical for an emergency room in a busy medical center like UNM. But she had signed out Paul Perkins, and I sought him out. When I found Paul Perkins, he was wearing that white lab coat with the emblem that I detested. “Paul, tell me about this guy?”
“I only know what Julie told me about him. She said the nurses put an Ewald tube down him and it was positive for blood. Apparently, Albuquerque’s finest brought him in after he complained of abdominal pain. That caught him driving drunk. He’s on a police hold.” He handed me his ER chart. On it were his complaints, his exam and his labs. On the emergency room record, Julie wrote he had been brought in by two police officers complaining he had abdominal pain and then thrown up blood. The nurses put an Ewald tube down his throat and into his stomach, the return looking pink, which they believed consistent with a bleeding ulcer. I perused his notes quickly. His hematocrit, the percentage of blood in the blood after one lets them settle out in a tube, was 39%. Yet his last pressure recorded on the notes was 99/60 mm Hg, and his pulse was one hundred and twenty. I looked for a nurse who had taken care of him, hopefully the one who had put the Ewald tube into his stomach. None was to be had. He had been in the emergency room for almost three hours according to the log sheet.
As the saying goes: When in doubt, ask the patient.
I strode over to Jose’s gurney. His eyes were shut and he was moaning. “Mr. Garcia,” I asked. “I was told you were throwing up blood and that’s why we’re admitting you to the hospital.”
“I never threw up any blood.” Pain sparkled in misery in his eyes. He looked startled. It appeared as though he was not trying to move; as if it hurt too much to move, as if death would bring welcome relief. The nurses had prudently hooked him up to a cardiac monitor and place two intravenous lines. Though it was clear that he was inebriated when he was brought to the emergency room, he seemed quite sober now.
“Here it says you were throwing up blood.” I held the ER record upside down so he could see it.
“No man, that’s not it at all. I was drinking. I was drinking more than I should have been. I admit that. I was pulled over in the south valley for driving erratically. The cops who pulled me over beat me up back at the police station. I’ve had belly pain ever since they hit and kicked me.”
“That’s a different matter,” I said puzzled. “Show me where you’re having the pain.” He lightly stroked his whole belly. “I’m going to push down on your belly. I pressed lightly on every piece of real estate of his abdomen. He winced each time. It was rare to see a GI bleeder in as much pain as Garcia was. In fact, I had never seen one in that much pain. “Pay attention to me, Jose. Does it hurt more when I push down or let up? It’s important to determine where the pain is coming from.” He winced as I slowly pushed against the center of his belly. But what caused Jose to nearly scream, was when I suddenly let up. He had what is called rebound tenderness. In this he demonstrated there was peritoneal irritation of some sort in the abdominal cavity. Bleeding, if he had it, was pouring into his abdomen. Unless he had an ulcer that penetrated the abdominal cavity, the exam confirmed what he had told me. He had been beaten so badly that his assailants had perforated a blood vessel or two. None of seemed to make sense. On the IV pole that recorded his blood pressure, and it was slowly sinking, like a receding tidal bore.
I asked the ER nurse to get another CBC on him and finished evaluating him, trying to my full extent to determine something else was going on. When the nurse left with his blood sample, I asked her to have them run it stat.
“I went over to Garcia’s bedside. You’re swearing that the two police officers beat you up?”
“Yeah, I do. Now can you just get me something for pain.”
“Can you give him fifty milligrams of Demerol and twenty-five milligrams of phenergan?” I asked his nurse.
Apologizing to Garcia, I had the nurses put another Ewald tube into his stomach. The returning secretions were clear – there was no blood.
I walked over to the doctors’s partition. I took the one unused phone and asked the hospital operator to get the surgeon on call for me. If I had had a hard day so far, I was certain his was just as trying. In a few moments, he rang me back. I started to tell him about Garcia, but he said. “Hold that thought for a minute, Bill. I will be down in a few minutes.” And so I waited.
No more than fifteen minutes later,