A nice fat stone, wedged in the left ureter. When I saw the X-ray, I did a little cabbage patch dance. "I got a di-agnosis, I got a di-agnosis." The seated radiologist looked up at me without smiling, then stepped on the foot pedal to fast forward the X-ray screen. Didn't matter. I was happy.
In the E.R., definitive diagnoses are much rarer than one might imagine. I wish more people understood that. Doctors are much better at telling people what they don't have than determining for certain what they do. This guy had come in writhing, his face pale and sweaty, and for the life of him, he could not hold still on his stretcher. He gripped his left flank and wiggled as though he was trying to get away from it. Absolutely classic renal colic. Kidney pain. Then he peed into the urinal, and without even using the dipstick test, I could see that there was blood there.
By the time he got the X-ray, he was gorked from the morphine and an IV was running saline into him "wide open," meaning as fast as gravity and the bore of the catheter would allow. Hopefully the stone that showed up clearly on the X-ray was riding Grade 6 rapids on its way out.
(As I'm writing this, a patient in a stretcher right next to me just started whistling "Jingle Bells." Considering she came in for an asthma attack, I'm taking this as a good sign. Even though it's June.)
I walked to the patient's bedside to tell him the news. On the way, a woman from another booth called out to me. "Nurse, could you lower my stretcher?" I sighed. In a typical 12-hour shift, I get thousands of these requests. "Lowermystretcher ... Raisemystretcher ... Glassofwater ... Anotherblanket ... Callmybrother ... Findmyshoes ... Bringmethephone ... Getmeabedpan ... MyIV'sfinished ... Takeawaythisbedpan. … This woman was looking right at me so I couldn't very well walk by. I reached around the back of her stretcher and fumbled for the head-lowering mechanism. Perhaps deservingly, I had just squashed my finger between the squeeze-bar and the bed frame when I heard the red phone ring.
"SURGICAL NOTIFICATION, TRAUMA TEAM TO TRAUMA," Dionne yelled on the PA system, then handed me a piece of paper: 53 bm sev. head tr. 160/80 60 4 min. Meaning that a 53-year-old black male sustained severe head trauma, had a blood pressure of 160/80, a pulse of 60, and the ambulance would be here in four minutes.
Four minutes later, as we were moving the patient to the stretcher, the paramedics told the story: 53-year-old guy assaulted with a baseball bat, not responsive to pain, normal vital signs. As the others cut off his clothes, started IVs, and readied to intubate him, I looked him over. He was a big man. His body was injury-free. His almost-bald head, however, was lumpy in an ominous way. It looked like a cauliflower. There were no open lacerations, just irregular discolored lumps on the sides, on the back, and above one eye. He didn't withdraw his arms or legs to pain. I grabbed the phone on the wall and sent out a "Trauma Level One," a call to the stat operator that gets neurosurgery and anesthesia down to the E.R. in addition to the trauma surgery team.
In my experience, the victims of such brutal attacks are much younger than this man. They usually aren't dressed in collared shirts, nor are they typically wearing wedding rings, as he was.
"What exactly happened to this guy, do you know?" I asked the paramedics.
They looked at each other, almost as if they were playing a silent rock-paper-scissors game to see who had to answer. Finally one of them spoke up.
"The guy who called us said that this guy bought some milk from a deli and took it home for dinner with his family. But he brought the milk back to the store because it was sour." Here, he drew a deep breath. "And someone there did this to him."
Everyone looked up from what they were doing. "What the fuck?" said one of the surgical residents, speaking for all of us. The paramedic shrugged and said, "That's what they told us." Then he added, "Oh, yeah, and the cops were there. They told his family; they're on their way in."
I shook my head to drive the absurdity of the situation out of my mind, and kept working. The man was intubated and given some medicines, but not a lot of IV fluid for fear it would exacerbate the internal injuries in his head.
The CT scan confirmed what we had feared—he had major hemorrhages filling up the space around his brain, compressing it dangerously. As the CT images appeared on the screen, I looked at the neurosurgeon and raised my eyebrows. His face was tense, and he shook his head slowly in response. "What do you mean?" I blurted. "Is he definitely going to die?" The neurosurgeon explained that with increased intracranial pressure like this, even with surgery, the chances of this man's survival were almost nonexistent.
When we returned to the trauma bay with the patient, there was a woman who didn't look familiar standing there in a white coat holding a clipboard. She read the name on my coat and introduced herself.
"Hi, Doctor, my name's Lisa Linehan, I'm from the transplant team."
She let it sink in. Of course, with patients sustaining major head injuries, it is part of the protocol to notify the transplant team, in cases where the patient is a potential organ donor. With the extreme degree of head injury and his virtually untouched body, this man was an obvious candidate. Lisa wanted to know if anyone had spoken to the family yet, because at some point she felt she would need to make contact with them as well.
Oh, God, I thought. His wife. I dreaded this task more than any other. If the story the paramedic told was accurate, this woman had watched her husband get up from the dinner table to run down the block for fresh milk. Then she had gotten a call that he was in the emergency room. If the cops hadn't said anything—and they aren't supposed to—then she didn't know any details. Given the benign nature of his errand, and the fact that it was a Tuesday night, she was most likely expecting that her husband had twisted his ankle.
And I had to tell her. What I had to explain was even worse than telling her he was dead. As awful as that would have been, at least I could say it outright and get it over with. Instead, I had to tell her he was dying. Oh, and here's a woman to talk about organ donation.
A pretty middle-aged woman, Mrs. Sands sat patiently in a chair, hands folded in her lap, reading the public health posters and nodding polite hellos to people who walked by. I could tell by her demeanor that the cops had told her nothing.
I started to approach her but then remembered something. "Hey Dionne, what's the man's name?" I asked the clerk. He had been listed as Unknown Black Male.
"Sands. John Sands."
I introduced myself to his wife and with a weak smile guided her into the "family room," which may as well have a skull and crossbones on the door for all that goes on in there. She asked if I wanted to talk to her three children as well, but I said no as the lump in my throat grew bigger.
No question, this is absolutely the worst part of my job. Deep breath. Ready, go. "Mrs. Sands, your husband was assaulted tonight, and he has a very severe head injury. He is unconscious … and there is a strong chance that he may die." I clenched my jaw tight shut and swallowed hard, then added, "I am so sorry."
She looked at me for a moment blankly. "Is … Did … Who … He might die?" I nodded. Mrs. Sands brought her hands to her mouth and started to cry, but it wasn't the crying of true understanding. It never is, early on. I got up to sit next to her and put my hand on her quaking back. "I am so so sorry," I repeated, as the tears began streaming down my face.