Any Way That The Damage Doesn’t Show

Tonight is one of those shifts where it’s difficult to really care about the patients. Earlier in the evening, a guy who’d been stabbed in the brain with a hunting knife comes into the ER on a stretcher. I don’t have much direct involvement in his care; I intubate him and place a nasogastric tube and then neurosurgery takes over from there. He is sent off to the CT scanner with the knife still sticking out of his head like a birthday candle.

Then I get the guy who stabbed him as my next patient. He’s in police custody. Although he certainly hit his mark, the man is no professional killer; his hand slipped, and the blade sliced into his palm. I order an x-ray and tell him I’ll be back to stitch up his hand as the police officer stands silently in the corner of the room. I talk to the patient as though he didn’t just stab someone in the brain, as though he’s someone standing in front of me in line for coffee. He is polite and seems to exist in some invisible space of cathartic bliss—the stabbing must have been worth the trouble.

The next patient I see is a young man complaining of testicular pain, as indicated by the triage nurse’s note in the chart. My mind is already running through a differential diagnosis: epididymo-orchitis versus testicular torsion, to start. When I pull back the curtain, I see the guy with his girlfriend. They’re both smiling at me all coy like. I think it’s probably not torsion then.

I begin taking the patient’s history. Like most doctors, I use a mnemonic referred to as OLDCARTS: onset of symptoms, location, duration, character, aggravating/relieving factors, radiation, timing, and severity.

Onset was two hours ago, he tells me. He nods at his girlfriend and says, “We were having sex… she was sucking really hard on my nuts, and they started to hurt. That’s why I came in.”

“Understandable,” I reply as I glance at his girlfriend, who looks back at me.

Now that the cat’s out of the bag, she’s not looking so coy anymore—in fact, she looks almost proud. Hearing this story, I get the gnawing feeling that I’ve been sorely missing out on what the world has to offer, as though I’m the guy getting cuckolded in a porn scenario. I order a scrotal ultrasound (there is such a thing as testicular fracture, though I have low suspicion in this case) and a urinalysis to cover my bases (i.e., protect myself from any future litigation, a thing that is as American as starting wars and supporting genocidal regimes abroad), but I suspect the rest of his night will be more fun than mine anyhow.

After preemptively starting Ball-Suck Boy’s discharge paperwork, I grab another chart that’s been placed in the rack. G-tube problem, it says. I walk into the patient’s room and see a man who looks like he climbed out of a trash can. I immediately recognize him. He’s one of those bald guys for whom whatever hair remains is long and wildly unkempt. He comes into the ED almost weekly for abdominal pain from his metastatic esophageal cancer, and there’s never much we can do for it except get a CT scan for peace of mind and send him on his way to suffer at home. Today, however, he’s here for leakage from his gastrostomy tube site along his abdominal wall. He’s been through this before, too. The tube needs to be upsized. He’s pissed off about it, and not happy to be in the ER and I don’t blame him. No one is happy to be here. Not even me.

There was a time when everything in medicine was new and exciting for me. When I jumped into patient encounters with a fresh enthusiasm, like that of a space explorer. But when you do the same thing over and over, it gets boring. That’s a basic fact of life. Novelty is exciting. Yet it’s sad to think that often what excites doctors is the kind of cases that spell doom for a patient:  a rare disease manifestation or a particularly extreme or, say, creative trauma. I’m talking about more than just a brain stabbing; if you work in a Level 1 Trauma Center, even that sort of thing becomes garden-variety after a while. The work itself—a white collar assembly line—is all very physically, mentally, and emotionally draining. But the tedium is the insidious killer, the kind of thing that leads down the primrose path toward extramarital affairs, drug addiction, suicide. Or just some off-the-wall obsessive side-hobby that we mistake for our true calling in life (like, maybe I should be a writer!).

Angry G-tube Guy is already beginning to foam at the mouth while my mind wanders; there’s a thin line of saliva splitting his lower lip as he barks at me. He tells me if he wasn’t sick, he’d open up a can on me. That’s a rather quaint expression by today’s standards. It reminds me of watching WWF matches at my pals’ sleepover parties in middle school, the way we all used to bring our crossed forearms down over our scrawny pelvises and shout, “Suck it!”

 I must not be good at hiding my amusement because the man then snaps, “What the fuck are you smiling at, you little twerp?” I’ve got to hand it to him, “twerp” is the perfect word to describe me.

“I’m not smiling, sir,” I lie. “I’m sorry, I just have a thing… a tic.”

“A tic? Did you say a tic? You millennials and your ‘silent diseases,’” he says. I don’t know how to respond to that, so I pull myself together by thinking of the vast well of emptiness that exists inside me, and likewise outside of me. It’s a good way of centering oneself during moments like these. Kind of Zen, I might venture to say, although I’m too exhausted much of the time to really do a deep dive into any of that.

I tell him I’m going to reach out to interventional radiology to sort out his G-tube complaint and I’ll be back soon.

“I’m not complaining,” he growls.

“Wrong word,” I say, “I mean G-tube concern.”

“I’m not concerned either,” he says, “it’s just a royal fucking pain in my fucking ass!”

“Of course, sir,” I say as I rush to leave the room.

My first inclination every time I step into an exam room is to gauge how neurotic the patient is going to be. In short, I make a two-second judgment call. I think after all the years I’ve been doing this, my sense for people is rather honed. But I’ve been surprised a time or two. This next guy I’m seeing is complaining of burning pain along the back of his shoulder. He and his wife say they recently moved here from Texas. He tells me he’s in 24/7 agony. I perform a physical exam and find what looks like an inflamed epidermal inclusion cyst. I tell him that with this sort of thing, if I were to do an incision and drainage here in the ER, it would likely recur, so I’ll set up a referral to general surgery clinic for further management. For now, the thing to address is the pain. The couple seems nice enough, although they are from Texas, and as everyone knows, Texans are awful. Somehow every one of them seems to adopt the idea that being from Texas equates to a personality trait. What’s honestly tempering my expectation though is that he’s an older white guy, probably conservative, which can go either way.

Ironically, the type of patient demographic I’ve often found most challenging is the white liberals. The white liberals who, for all their carefully choreographed displays of virtue, are really the ones Martin Luther King, Jr warned us about in his Letter from Birmingham Jail. The type with yard signs that loudly begin “IN THIS HOUSE…” Sure, they’ll accept you as a part of their world… insofar as you debase yourself to accommodate a specific vision of who you’re supposed to be: a decorative ornament to their white-centric order of things, which invariably places them at the center of the universe. You make sure to pat them on the back for being so accepting and do not dare ask for more. In the way no one really knows what the back of their head looks like, the white liberals will never fully grasp the degree to which they have been born into and raised by a system that props them up to the highest echelon on the socioeconomic food chain in America. It is this confident sense of superiority that is fundamentally shaken to its core when suddenly they become sick or injured, and the white liberal must swallow their pride and come to the hospital to be treated by a doctor with a foreign-sounding last name like mine, when the realization sinks in that physiologically they are no different, no more special than anyone else and they must give up the reins of power and authority to which they are so deeply accustomed to someone they have always quietly perceived as lesser.

The white liberal’s more openly bigoted counterpart, on the other hand, lend themselves to a smoother doctor-patient relationship—it’s easy to shoot the shit with a redneck about jousting on ATVs or building an AR-15 from common household items without once letting on to how frighteningly left my political views actually veer.

Epidermal Inclusion Cyst Man meanwhile says he is dying from the pain, which I kind of doubt. Like most Americans, regardless of political leaning, he’s rather soft-shelled when it comes down to it. I tell him I’ll get him started with 800mg of ibuprofen and circle back to reassess things. Husband and wife are perfectly agreeable to this plan. This seems to be the first normal interaction I’ve had with a patient so far tonight.

Next on my to-do list is a drunk schizophrenic patient who’s inevitably going to the psych service, but I must lay eyes on him anyway as part of the protocol. More boxes to check, more billing codes, more money for the hospital, and so on. He’s lying on the bed and his face is all bloated like that of a corpse that washes up on the shore after months at sea.

I try asking him questions but he’s mostly muttering nonsense until a single moment of clarity—if that’s what you’d call it—where he lurches forward, stops short, and says to me, “A storm is coming, a great flood… you’d better know how to swim.”

“Yeah, I think I’m ready for all of this to end,” I sigh and pass him off to psych.

I come back around to Epidermal Inclusion Cyst Man’s room a half hour later and he’s walking in circles, steaming like an angry cartoon animal. His wife looks annoyed too.

“How’s it going?” I ask. “Did the nurse come by with the ibuprofen?”

“Ibuprofen? Are you kidding me?”

I pause. “We discussed—”

“I am having the worst pain of my life. I can’t even sit still. I can’t sleep. And you’re offering me fucking ibuprofen?”

I start to say that ibuprofen is actually very effective, but his wife cuts me off and says in her stupid Texan accent, “Well, now we have a problem, see.”

What the fuck? I think. Did we not agree to start with ibuprofen?

I hate confrontations—in hindsight, this was probably the wrong field of medicine for me—and my head is swimming as the man and his wife berate me about pain meds. It pops into my mind that maybe this guy is a malingerer. Maybe he’s not even from Texas. I need to check his chart a little more deeply to see if he’s been frequenting other EDs and urgent care centers around town recently. That’s often the dead giveaway. Americans and our drugs: we love drugs almost as much as we love suing people; almost as much as we love our tax dollars being spent on bombing children overseas. I offer him something else, a step up, but still a far cry from “Vitamin D”— Dilaudid, that is. He gapes at me in disbelief, as though I just whipped my dick out in front of him. He’s getting hysterical following my newest suggestion.

“I can’t exactly hook you up to IV morphine for shoulder pain,” I accidentally think out loud.

My act is slipping. My “professionalism,” as they call it. Honestly, that’s just it: an act. Medical schools work hard to prepare you for the great art of customer service that medicine really is. And I suppose that is good because many of us are driven by ego and/or childhood pathology rather than real empathy. Of course, there are also those of us (and I fall into this category—I think) who bought into the marketing of becoming a doctor, a healer, as some ultimate calling in life only to discover that it’s really just another boondoggle of late-stage capitalism—the healthcare system is broken, intentionally, so that a few ultrarich assholes at the very top continuously get a fuck-ton richer. 

In medical school they had us practice fake clinical scenarios with patient actors ad nauseum, people who were struggling to be “real” actors but for some reason lived in the suburbs of Cleveland. Sometimes we’d see them on television commercials for tortilla chips ingeniously shaped like bowls for optimal salsa-scooping and shout, “Hey! I fingered that guy’s prostate gland last week!”

 We learned to act out the role of a concerned doctor again and again with these fake patients until it was hardwired into us, until we could no longer tell the difference between our real and feigned empathy.

But my last remark about the IV morphine has elicited a flurry of anger from these two Texans. I need to grab on to the reins of this situation before things devolve further. And I need to investigate this patient’s chart to see if he’s a potential malingerer. I stall him. I tell him I will be sure to get him some pain relief before sending him home, to just give me a few moments.

In the meanwhile, I try reaching out to the on-call interventional radiologist regarding Angry G-tube Guy. After two pages I’m wondering why he’s not calling me back. It’s only 8pm. He’s probably jerking off in the same abscess-stained scrubs he wore to work today. Finally, he calls me back while I’m in the middle of sewing up Mr. Amateur Neurosurgeon’s hand before he gets sent to jail. I order a tetanus shot for the guy and tell him to take care, which is a meaningless farewell for a guy like him.

The interventional radiologist sounds annoyed over the phone. I ask him to come see Angry G-tube Guy about upsizing his tube.

“It’s not an emergency,” he says.

“Yeah, I know.” No shit, I think. “But the guy is here, and he’s upset. It would go a long way if someone from your service [the service that placed the g-tube in the first place] would come pay him a visit and get him scheduled to upsize it as soon as reasonably possible.”

“Place an ad hoc consult and our schedulers can take care of it in the morning,” he says. I hear him filling a glass from an ice machine in the background.

“Tomorrow is Saturday,” I say.

“Monday, then,” he says.

“Ok, fine.”

I tap the red end call symbol on my cellphone. I acutely miss having phones we can slam against a receiver.

I go back to Angry G-tube Guy’s room and take a deep breath before knocking and entering. He’s not going to be happy with what I’m about to tell him, that he’s going to be leaking daffodil-colored fluids from his stomach and staining all his shirts through the weekend. Then I remember Monday is Memorial Day. Fuck. But at least he’s too sick to open up a can on me.

A middling slew of patients comes through in the interim.

A woman who spontaneously aborted a 20-week-old fetus, which she brings in in a plastic Walmart bag and places on the table next to the computer in the exam room. I peak inside and confirm that, yes, there’s the Martian appearance of a 20-week-old fetus incubating in its juices in the bag, which I also notice is starting to leak all over the table—seeping under the keyboard and saturating the mousepad, making it boggy—so I place the bag in the sink. While I elicit a complete history from the patient, her eyes are half-closed, gazing languidly past me, and she rambles on endlessly, as if to herself, about a bunch of topics unrelated to why she’s here, totally impassive to the fetus in the bag that she passed earlier like a bowel movement.

I order a pelvic ultrasound to rule out any retained products of conception. Then I leave to use the restroom (I haven’t peed in 8 hours and what comes out is concentrated to the color of rotten pineapple) and when I return, the woman has vanished. I inquire with the nurse who explains to me that the patient left AMA (against medical advice) because she suspected her boyfriend who dropped her off was bogarting her heroin instead of finding parking and coming inside as he’d promised. The bagged fetus remains left behind in the sink. I send it down to pathology, this little being perhaps mercifully spared of the world.

There’s a guy in his late 40s who comes in with a severely broken ankle after jumping off a highway overpass while trying to film an Instagram reel that went awry. I’m not exactly sure what sort of outcome he was expecting. These days the midlife crisis manifests itself in increasingly fascinating ways. Because he captured the whole thing on video, he says, he’ll probably still go viral.

“People love seeing other people get fucked up,” he says, showing me the video on his phone. I suspect he’s right about that and then think to myself he’ll probably be a multi-millionaire overnight like that Hawk Tuah girl while I’m still paying off my medical school loans that have amounted to a sizeable mortgage.

I call up orthopedic surgery for recommendations. He needs to be admitted for surgery but “per hospital policy,” the surgeon tells me, because the man has controlled hypertension and diabetes (also well-controlled), he has one too many medical comorbidities (i.e., two) than the orthopedic service can manage, and the patient therefore needs to be admitted to internal medicine as the primary service during his hospital stay for surgery.

I ask him if he’s serious and he responds, “Very.”

Very well. I call up the hospitalist who then acts like it’s my fault that orthopedics won’t take the patient. She shits all over me like every other consulting service classically does and then begrudgingly accepts the patient to her service. I know she’s overworked; we all are—you’d think we’d all get along better for it.

I pick up the last patient chart that I’ll realistically be able to get through by the end of my shift. A pediatric patient with a headache. This should be easy. Most pediatric patients are cut and dry: viral bronchiolitis, swallowed a penny, and so on. And most headaches are benign. I knock on the door and enter the exam room and introduce myself. There’s a five-year old girl and her two doting parents. The girl is surprisingly brave in the clinical environment for her age. She clearly has loving parents, which goes a long way toward developing a sense of security in the world. With the help of her parents the girl describes for me a bad headache that started a few days ago. The girl takes a break from drawing a picture of a ghost of a snail and asks me in a tiny voice if I’m going to give her a shot today. I kneel down to her level and smile, “No, not today. But I’ll try to find a lollipop for you anyway for being brave enough to come to the emergency room this evening.” Her face lights up. There’s got to be a lollipop around here somewhere, I think. Someone’s got to have one—medical staff are too worn down to practice healthy lifestyles themselves.

I do the whole OLDCARTS thing all over again, piecing together a rather nonspecific history, but when I perform a rudimentary neurological exam, I notice something that gives me pause: the gaze of child’s right eye is deviated slightly down and out. I ask her parents if they noticed this too and, if so, when it started. Yes, they did, it’s been a few days, they say, somewhat nervous but still smiling, nonetheless. Their daughter has otherwise been her normal self. I tell them I’m going to order a CT scan of the head just to make sure nothing major is going on and we’ll go from there. On my way out the door, the mother asks me where I’m from. I know what she’s really asking.

“Cleveland,” I say.

She glances at her husband for help as she struggles to reformulate the question, but I’m merciful and answer it for her by revealing the country from which my parents come.

“Oh, I think our vacuum cleaner was made there,” she says by earnest means of finding common ground, in response to which I cannot help but smile. I decide not to hold it against her because I can tell that she’s a good person. That’s the small power we have in this world: we can pick and choose, based on our own subjective and arbitrary criteria, who we want to vilify or give a loving pass to for any perceived ignorance.

I can’t quite explain why exactly, but this family exudes a certain warmth the likes of which I haven’t felt from anyone else tonight, and I get the sense that returning to their exam room later will feel just like coming back to a circle of friends around a campfire.

I step out of their room. In the distance, I see through the glass doors of his room Epidermal Inclusion Cyst Man walking in circles like a frenzied tiger in a cage. I quickly look in the chart to see if this guy brings up any red flags, but it seems like he truly is from out of town. Maybe he isn’t a malingerer after all. I need to find a way to both cool him down and address his pain commensurate to his wishes and within the legal bounds of my medical license. Admittedly, I may be unconsciously ignoring this guy a little bit, hoping his problem will go away, but it’s not, and I’m going to have to face up to him. I’ll get to that soon, though; his shoulder pain isn’t so urgent really—not to me, at least.

I’ve just finished with some exhausting family drama involving a patient who told me he has a bed bug infestation immediately after I performed a complete physical exam on him without a protective gown when the diagnostic radiologist calls me about results of the little girl’s head CT. I feel an increase in the gravitational pull of the earth, as the radiologist will typically only call when there’s something bad happening.

“On the CT,” she says, “it looks like there’s a mass in the pons. It’s causing some mild-to-moderate obstructive hydrocephalus.”

I’m not sure what the fuck “mild-to-moderate” means in this context.

“What kind of mass do you think it is?” I ask.

She sighs, “Well, in a kid this probably represents a brainstem glioma.”

Truthfully, I don’t know much about pediatric brain tumors; everyone in medicine gets sucked into their hyper-specialization and everything else falls by the wayside.

“I take it this is a bad prognosis?” I ask.

“Yes, it’s bad,” the radiologist confirms. She recommends getting an MRI and consulting neurology and neurosurgery. “Although,” she adds, “this type of tumor is non-operable.”

Right when I hang up the phone, Epidermal Inclusion Cyst Man has appeared in my face like an apparition, with his wife by his side, and he’s red as a dog’s dick.

“I’ve been waiting forever for you to do something about my pain. Is this what you call customer service?” (See? He gets the big picture).

His wife pipes up, “We were told that this hospital provided excellent care, but boy, were we misled.”

“Sir, Ma’am, if you’ll just be patient with me,” I begin to say.

“No,” he interrupts. “You’re the worst doctor I’ve ever had. We’re leaving. You’ll be hearing feedback from us, though, don’t you worry.”

I’m not worried. I’m actually relieved he’s leaving AMA. It’s one less pain in my ass, especially now that I have more pressing concerns at hand than his inflamed little cyst. A negative Press-Ganey patient satisfaction score sounds bad, but really what the dickheads at the top care about—the ones with business degrees who barely do any work, make obscene amounts of money, and attend masked orgy parties with their fellow elites every Christmas—is productivity and throughput. If my notes are replete with patient history and physical exam checkmarks, detailed procedure notes, and other wording that maximizes profits, and as long as I’m cattle-prodding patients through the ER to their next destination, be it home, another medical/surgical service, or the morgue, they’ll leave me alone.

Epidermal Inclusion Cyst Man and his wife are making a scene on their way out. They’re trying to embarrass me by badmouthing me to all the support staff, as well as the patients suffering on temporary placeholder beds in the hallway. No tact whatsoever. At least the liberal wouldn’t become so publicly belligerent as this guy; they’d wear their masks of decorum, smiling at me politely and then go home and absolutely annihilate me on the patient satisfaction survey sent to them after the fact, typing out 12 different one-star reviews on Google and Doximity and wherever else: “If I was allowed to give ZERO STARS on this thing, I WOULD!”—that sort of thing.

We’re told in medical school not to judge patients, but the older I get and the more lowest-common-denominators I have had to deal with—including Epidermal Inclusion Cyst Man, but of course there are much worse animals out there like the people who dip their kids in boiling water over a spilled juice box—it’s virtually impossible not to judge other people, especially when they’re this vile at the core.

I don’t give another thought to Epidermal Inclusion Cyst Man after that. How could I? The entire universe of that family with the kid with the headache is about to be torn apart. It’s often good people who are dealt the worst hand in life. This is how I know there is no god, and if there is, it’s unworthy of us. Any god that would impart this kind of suffering is no god of mine.

I think about how I would easily trade my life for the little girl’s. A single guy over 35 without kids like me: what’s even the point? To feed off the joyless table scraps of humanity on various hook-up apps, unidirectionally swiping a screen to order people up like a fuckable pizza delivery? To work and save money, for what? So that I can buy nice things for myself, travel to fancy destinations and take and post pictures of the food and the scenery on social media to attest to others that my life means anything at all anymore? I’ve seen the end of the story: it’s all loneliness and incontinence and bedsores, the kind of relentless pain which renders everything that came before it moot—and that’s if I’m “lucky” enough to make it that far.

After all my talk of medicine being an amateur acting gig, I must impress that this type of moment stands alone. Something else inherently rises to the surface. Yes, as a professional in this field, generally you do get used to breaking bad news, especially with adults. It’s always sad, but for the most part, adults have had their moment in the sun, they’re mostly spent, going through the motions of life on autopilot by this point. But with a kid, it’s different. You never get used to that pain.

I will not see this girl or her family again. My only role this evening is to be the bearer of the most horrific news imaginable, and I know that I must do it with grace. For me, it’s the most important part of my job. The productivity measures, the patient throughput, the Press-Ganey patient satisfaction scores all wilt in comparison to the person that I need to be for this family right now. They need every ounce of compassion that I have, which means that for a rare and fleeting moment, I too must make myself vulnerable again. I must remember how to be a human being, something that was mercilessly squeezed out of me during years of medical training in favor of becoming the perfectly efficient, revenue-generating machine.

It’s just a side of me that I have to deconstruct. A person I created to shield myself from the endless pain and horror of which this job has required me to bear witness. It’s alienated me, but I had to find any way to keep my mind from falling apart. Any way that the damage doesn’t show.

I knock on the door softly. As I enter the room, I remember the lollipop I had promised, and I pause to suppress a sudden urge to cry. The parents are reading Cloudy with a Chance of Meatballs with their daughter. It’s a beautiful sight to behold below the otherwise drab overhead fluorescent lighting in the sterile exam room. It’s like a sole flower growing in a war-razed landscape. The family doesn’t appear as nervous as before; in fact, they seem relaxed and happy that they’ll likely be discharged soon so they can return to their home, and this Friday evening will dissolve into the countless other unremarkable but safe and contented evenings of their lives.

“Hi, folks,” I say. “I’m sorry to interrupt. I’d like to discuss the CT scan results with you.”

The parents quickly put the book away. Their body language is almost apologetic as they turn to look at me intently. I’ve been racing around all evening, bouncing from one patient encounter to the next, a sort of ADHD forced upon me by the system. But I will give this family as much of my time and attention as they need.

I pull up a chair and sit down beside them. I look into the mother’s eyes, the last moment of the innocence of her unknowing forever breaking my heart. Although I am a stranger to her, and despite everything I’ve written here, she will almost certainly recognize within my weary eyes an even deeper well of love than I knew I had left.