Friday, December 11, 2009

Shared Interests

While it’s probably true that opposites attract (see “first marriage”), it’s also important that people in relationships share some basic interests, views, and values. That’s why I’m pleased to tell you the following story of two people who are truly meant for each other. Let the chant of the cherubs begin:

Dennis Krimmons arrived in the ED on a Pleasant Valley Sunday, girlfriend in tow, complaining of swelling in his left leg. This was especially important as it was his only leg, having lost the lower half of the right one as a result of complications from a motor vehicle accident (MVA). He said the swelling had started four days ago after he was helping out in the yard and got scratched on his leg by some branches from a rose bush. Shortly afterwards, a friend had managed to run a chair over his foot, and later that day, in a trifecta of minor trauma, he managed to tip over a curb and hurt his foot yet a third time. On exam, he had some small scratches over the inside of his ankle, and lots of swelling in the foot and ankle as well. He complained bitterly of pain when I ran my hands over his foot. The foot, while swollen, was not red or hot like there was an infection; it did not go along with any calf pain or swelling like you might find with a blood clot; and there was no specific site of bruising or bony pain as is typical of a fracture. In addition, Dennis had a hard time staying awake while I was talking to him. He was noted to be taking multiple pain medications, including Oxycontin and Valium, for neck and back problems, and had the kind of thick, slurred speech that goes along with enjoying your prescription medications to excess, thank you very much. Fortunately, he assured me that he was just really very tired, having not been able to sleep the night before due to his intense leg pain.

(Incidentally, in another bow to political correctness and legal avarice, the MVA is now more properly called the MVC, or motor vehicle crash. This is because there are no such things as accidents, as every event has both a cause and a fault.)

I suggested to him that the plan of action would include an x-ray of the left foot and ankle to make sure that nothing was broken and causing the swelling, and if that looked good we would get an ultrasound study of the leg to make sure there was no blood clot causing a problem. I explained to him that his findings were pretty non-specific, but since he was having intense pain and it was the only leg he had left it made sense to spread the net widely. Unfortunately, Dennis thought that was a bad idea. He was pretty sure it wasn’t broken, and was worried about the cost of the x-ray. (For the record, his payer status was “Charity Care,” meaning that he wasn’t going to pay for the radiograph, but that I and other residents of our hospital taxing district would.) He then proceeded to demonstrate to me that his foot and ankle wasn’t broken by removing his prosthesis on the right and hopping about the room on his one remaining foot, calling out, “If it was broken, I couldn’t do this now, right?”

He did agree to the ultrasound (a more costly test, which should have raised a red flag but didn’t). This was negative, and I reassured him that nothing serious seemed to be going on, and since he was already on good pain medications at home and there was no sign of infection I couldn’t tell him exactly what was going on, but it didn’t seem to be an emergency and he could follow-up with his own physician.

I was preparing his discharge paperwork when the nurse told me that his girlfriend had disclosed to her that the real reason Dennis had lost his leg was because he was crushing tablets of Oxycontin (a narcotic pain reliever) and injecting himself under his skin. She also suspected he was going to inject himself here in the ED since we gave him no additional pain medication. She also told us that if he knew she had told us, he was likely to beat her when they got home.

The nurses did the absolute right thing. One nurse got her away from him and into a separate room in the ED so they could talk to her about domestic violence services and the need to stay somewhere safe. Meanwhile, another nurse tracked down the patient to find he had locked himself in the bathroom for twenty minutes and would not answer the door. Security got the door open, to find the patient standing at the washbasin. I peered in.

“You doin’ okay?”

“Man, I’m taking a (euphemism for movement). What’s your problem?”

“When someone spends that much time in the bathroom, we worry that they might of fallen or something. It happens, you know.”

“I’m fine. I need a laxative.” (This is probably true, as constipation is a common side effect of narcotic use.)

It was then that I noticed two small drops of fresh, wet blood staining the outside of his jeans over his thigh. I pointed them out to Dennis.

“What’s going on there?”


“The spots of blood on your pants.”

He looked down. “They’ve been there.”

“Tell you what. Appease me. Let’s check it out and make sure you’re okay.”

He drew himself up. “I refuse your care, (euphemism for an Oedipal event),” he proclaimed. He strapped on his other leg and clip-clopped rapidly from the ED.

Meanwhile, the Charge Nurse was taking special pains with the girlfriend to try to arrange a safe environment for her. But when she learned that Dennis had flown the coop, she couldn’t leave fast enough to be with her man.


This is how the story stood for the next hour and a half. We finished our paperwork (one of the paradoxes of modern medicine is that it takes longer to do the paperwork on a patient who is unpleasant, unruly, threatening, or drug-seeking than it does on someone with a cardiac arrest…one is more likely to complain to administration.) Life in the ED moved on…a kid with strep throat here, an older person with VD (“Veak and Dizzy”) there. The radio sputtered to life with reports of an overdose patient being brought in. She had been found asleep in a taxicab near the beach just south of the hospital.

The patient looked familiar when she was brought in…more disheveled, speech slurred, makeup smudged. No obvious signs of trauma. But it was undeniably Dennis’ girlfriend, and she brightened up when she saw us. (Nothing like being among friends.) The reunion lasted but a few moments before she went back to sleep, which is how she stayed while we drew blood, passed a catheter into her bladder, and put a tube down her nose into her stomach so we could give her a whopping dose of charcoal…crushed up Kingsford briquettes, albeit without the impregnated lighter fluid…to try to absorb whatever was in her system.

And what was in there? Yep, you’re way ahead of me. Oxycontin and Valium.

Ain’t love grand?

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