Emergency medicine

Thirty Hours in a South Africa Emergency Department

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Taken from an anonymous subreddit post. One often wonders whether such things are fictional. Yet the details of this anonymous post are such that I am very sure it is genuine. Simply by chance those several specific details confirm that I was in South Africa when this student was there. The original is more than 3500 words, so I tried to edit it some. Yet I could not bear to cut more than about 5%. It was too close to the bone. The last 20 years of my own life were spent in a very busy Emergency Department, and I started there as a ‘moonlighter’ in medical school; these scenes, though more intense than those I lived, are familiar. It may be that part of the author’s name appeared once in the post; first or last is unclear. I expect to read more, somewhere, some time. S-He is a writer.</em

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"Having been originally sucker-punched into medicine during high school by reading the romantic and adrenaline-laced tales of war doctors, I wanted to get my own taste of trauma during my elective. I chose to go to [a very large hospital in a developing country].
It was mental. As an overseas student, you essentially function as a doctor because of the huge patient load. During one of my 30 hour shifts, I tried to chronicle events, the patients I saw and helped resuscitate, as best I could.
07:00 – I walk through the front doors. The scent of the Pit hits me – old foot sweat, fetid pus and a special ingredient I still haven’t been able to identify. I walk through the resuscitation bay… past a young child half inside a morgue bag, still warm from dying of burn injuries. The relatives are grieving around him, while arguing with hospital staff about … harvesting the organs.
07:01 – “There you are, get some gloves on and get this guy stitched up.” He has been stabbed in the face with a broken bottle, big deep cuts across his forehead and face. “You sure?” I ask – pretty sure this guy would be sent straight to Plastic Surgery at home. “Yeah it’s fine, just make sure to stay away from his eye when you do the eyelid, and line up his ear and eyebrow properly.” I grab the suture pack and get to it. The scissors don’t cut, the forceps don’t grab. It’s like knitting with a knife and fork.
07:45 – 6 year old boy has been hit by a car on his way to school. His left thigh is swollen to the size of a party balloon – he has broken his thigh bone. He comes in gritting his teeth, not a sound. “What a brave little kid” I think as I help cut off his school uniform, to reveal a worn-out Batman costume he was wearing underneath. It’s only when we have to cut that off too that he starts to cry. Comment: Many details make it certain I was in S A when this student was there. Because uniforms were required to attend ‘free’ schools, and a uniform cost more than many people lived on during half a year, to lose a uniform was tragic.
08:20 – A taxi has gone through the wall of a house, killing the girl sleeping inside. The front passenger died on the scene. The driver is comatose. We rush him to the resuscitation room, put a tube down his throat to let him breath. We put a catheter in – he is urinating blood. The FAST scan of his chest and abdomen shows large amounts of free fluid inside. We take him to theatre, but it’s too much, his liver, spleen and kidneys are in pieces. He dies on the table.
10:00 – I come back to the Pit, and there is a bit of calm….I start to see some non-urgent patients.
10:05 – a chap with headaches after being beaten in the head with an iron pole 3 days before. I ask the important questions, examine him to rule out the serious things, then tell him that a few headaches probably are to be expected, and send him home with pain relief.
10:30 – A man with a wedding ring trapped on his sausage size swollen digit after being cut on the finger 5 days before. I anaesthetize his finger and slice off the ring with the nifty tool.
11:00 – A guy with a swollen left eye and a bleeding eyebrow. I ask what happened. “My girlfriend tried to bite off my eyebrow.”… the same girlfriend bit off his ear in 2009… I tell him that the relationship might not be too healthy.
11:30 – A lady has spilled acid all over her lap, with deep dry burns across her thighs and buttock, maybe 15-20% total body surface area. Nasty, but not life-threatening. Not much we can do for her until the chemicals wear themselves out – they don’t have any neutralizing stuff here. I send her to the ward.
12:15 – A middle aged man who has sliced his palm and fingers with a circular saw. I test all his nerves and tendons – his hand is still working fine, it’s just bleeding and a little mangled. I stitch him up carefully, and it looks nice afterwards. He is happy. “I’m glad I got white doctor” he grins. I tell him for the umpteenth time that no, I’m still a student. He is still glowing.
13:15 – Lunch. A treasured 15 minutes.
13:30 – A man comes in after being dragged behind a car by an angry horde after being caught in the act of a crime – #mobjustice. He has degloving injuries to his thighs & buttocks, and his scrotum has been torn away, leaving his testicles completely exposed.
14:15 – Walking to the radiology room I am stopped by a man. “Hey doctor” he calls. Look friend, I’m busy. And I’m not a doctor, sorry. “Quick boss, quick.” Ok fine, what is it? “I’ll trade you gun for your stethoscope.” [Gestures towards butt of gun sticking from his belt.] I hurry away.
15:30 – The pit is busy. I’m trying to help out seeing the non-urgent cases, and notice the homeless man I noticed a little earlier is still here. He has wet gangrene of both his legs, he stinks, and he is drunk. No-one in general surgery wants anything to do with him. The waiting line is long, there are other patients to see. He eventually gets bored, drops his pants, and starts playing with himself vigorously. STILL no-one bats an eyelid, and he is left there vigorously jacking.
16:30 – A young man with the first gunshots of the night. The first grazed his arm, the second went through his thigh. He is stable and not bleeding much, so we x-ray him. The bullet has smashed his thigh bone apart, he will need surgery. We put him into traction.
17:15 – A 16 year old kid trapped in a house fire. Many people living here have rudimentary shacks for homes, and rely on open fires for warmth. This lad had 60% partial-full thickness burns. As we do the immediate resuscitation, I can hear the senior doctor talking angrily with the Burns Unit over the phone. They won’t take him – 60% is their cut-off. She slams the phone down. “Cover up the burns, keep him warm, and then move on” she sighs. He died later in the evening.
18:00 – Old guy with a massive inguinal hernia comes in with burns all over his football-sized scrotum. Another open fire. This time the Burns Unit take him.
18:50 – A man stabbed in the temple region a few hours before. He has a sore neck, severe headaches and has lost consciousness a couple of times…I can’t feel a fracture in the skull… Neck collar him, and order the brain scan.
19:40 – A middle aged guy who got kicked in the nuts a couple of weeks ago now comes in with pain and swelling in his scrotum. I can get above it, it’s not a hernia. He gets an ultrasound scan, which shows the testicle has died and is now festering. I call the surgeons.
20:40 – I’m eating dinner, and watching the news with some other docs. Nelson Mandela is still sick in hospital, and the whole nation waits – everyone is hoping he hangs in there until his 95th birthday.
21:15 – A guy who got knocked over by a car, twisted his ankle and hit his head. Remembers waking up to his concerned mates standing over him. Scan the brain.
22:00 – A car hijacking. The three assailants chucked a rock through his window, and then forced opened the door. Guy comes in with stab wounds to his palms from where he tried to defend himself from their knife. He gets yanked out of the car… manages to start sprinting away, but they catch him. He has his front teeth kicked in, a sore neck, painful ribs and spine. His ankle is badly swollen. His head is fine and pupils are reactive. I just order him xrays wherever he is hurting.
22:40 – A guy comes in who has taken an axe to the face. His parotid gland is hanging out, and is squirting arterial blood. “Put some stitches in there quickly to stop the bleeding, I’ll be there soon.” I put one in. That bleeder stops, but it starts up two more; it’s like a Hydra. I eventually give up and get the registrar, he gives it a shot, but no luck. By now he has lost about a litre of blood, and his whole face has swollen up to the size of a grapefruit. “Ok let’s get him to theatre.” We go quickly to write the forms, and come back. He has gone, just up and left to no-one knows where.
23:30: “STAB CHEST, LETS GO”. A man has been stabbed just above his heart, and he is deteriorating fast. Everyone runs in. Get the airway, intravenous access, ABGs, put in a catheter. He’s still crashing, his oxygen saturation is going down. His neck veins are distended, his heart sounds are distant, and his blood pressure is in his boots. Unwavering, the consultant steps up, grabs the scalpel and slices open the chest; with what looks to be a hammer and chisel he cracks open the ribs. Blood splashes out all over the doctor’s scrubs as the pressure is released, and there it is; the man’s beating heart is laid open to the air. I’m dumbstruck. Purple lung pumping up and down on the other side. They start giving him blood but it’s all leaking out. …I hold the heart between my hands as it beats slower and weaker until he dies.
00:05: “GUNSHOT CHEST”. It’s a young guy covered in blood, brought in by the paramedics. Looks like it has gone straight through front to back and out through his shoulder blade. The bullet has torn through his right lung, deflating it, but aside from that he is ok. He is struggling to breath so they give him morphine to calm him down, and pump him full of oxygen. “Your first chest drain for the night.”
00:30: “GUNSHOT CHEST”. Almost a carbon copy of the previous guy, shot front to back through the right lung. …He does well, too. There is a row of stationary bikes on the ward where the guys with chest drains do their workouts the next few days; they usually go home in a day or two.
01:20 – The drunk people start rolling in. Young lady was in the back seat during a car accident, and is in serious pain. She is making a big fuss as the paramedics pull her from the stretcher to the bed; obviously stressed out and frustrated at the endless stream of intoxicated people they have seen tonight, they are shouting at her to keep calm and cooperate. …I look at her legs – one of them is shorter than the other and rotated inwards. “Stop pulling her hip, I think it’s dislocated!” I urge. They back off, and wait for the xrays. I mentally high-five myself.
01:45 – A guy in his mid teens has been clocked in the face with a brick. His whole side of the face is mashed, and he is struggling to breathe. They are struggling to intubate because there is something in the guy’s mouth. The brick broke the eye socket and the orbit has fallen … into his oropharynx, blocking the doctor’s view of the throat.

03:20 – The guy with the twisted ankle comes back, 6 hours later. He has finally had his head scanned, and has been sitting there for hours waiting for someone to check the result. He’s fine. They splint the ankle and leave him for the bone doctors.
03:30 – Man comes in with scalp lacerations. He is extremely confused and abusive, but is it because of the alcohol or because of a brain injury? We aren’t sure so scan him.
03:40 – Same story. Scan him.
03:45 – Same fucking story. A woman this time.
04:20 – I walk out into the pit; “Dooooctor” a man lying in the stretcher moans. I tell him I’m not a doctor. “Man, the pain is too much”. I look to see if he has been given any pain relief. I get a tiny splinter of glass through my finger from the broken windshield he went through. My finger is bleeding. I squeeze the glass out and pour alcohol disinfectant over the wound. I ask the senior if it’s ok, is it an HIV risk, and she reassures me its not. I double check; he is HIV negative.
04:50 – The drunks have filled the pit. They all need a special mix of what they call “Rocket Fuel”, and so everyone is working together to get the drips up. My guy is shouting abuse at me as I talk to him. He pisses his pants and laughs at me. I try and get the needle in, but he thrashes around and starts hitting me. I back off, breathe, and come back in for another go. This time he to bite a chunk out of my cheek; o I explode. JUST FUCK OFF I yell, and slam him to the bed angrily. The other doctors see I’ve lost it and jump in to help. With two on the legs, two on the arms and one on the chest and head, they eventually get the line in. After it’s all over one of them comes over to me, pats me on the shoulder. “Don’t worry about it man. It happens.” I’m gutted.
05:00 – 07:00 –… I remember at one stage standing out in the freezing cold, trying to unclog the blood from my zipper so I could zip up my hoodie. I remember a guy who had been pistol whipped, and the end of his nose was hanging off. They told me to sew it back on, but I was saved by the plastic surgeon who thought it was a bit beyond me. I remember trying to sneak a nap in the bereavement room – the place where they tell bad news to the family. They have the nicest couches in there. I got interrupted by a bereaving family. “I’m sorry” I mumble as I stumble out.
07:00 – End of the night. I’m falling asleep on my feet, but I still need to go and help on the wards. In a daze, listen to chests, take blood and fill out forms, check blood results.
08:30 – One of the interns gets called away so I do my best; thank god for nurses and charts.
11:30 – A little boy of 10 is on the ward. He is deaf-mute with no family; a passerby brought him because he had seizures on the street. No one has any idea what is wrong; Trauma takes his care. He gets put through the medical wringer with every investigation they can do, many of them painful and invasive. He sits there in the corner of the ward, drooling, staring as you walk past with nothing behind his eyes. It’s heartbreaking and unsettling. Today it’s a lumbar puncture. We give him some panadol and ketamine, then one of the interns hold him while I put the needle in.
13:00 – I finally walk out the front doors, blinking in the crisp sunlight. Somehow I make it to the hospital shuttle bus, and 30 minutes later I am shaken awake by the driver. “You are home now, you sleep at home, not here” he smiles.

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Castration Dreaming

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The charge nurse asked me to respond to a code yellow: an extremely urgent, situation saying only that it was a man in hemorrhagic shock, with almost no blood pressure, who had arrived by car, pale, confused, sweating profusely, and mumbling about castration. Addressing the critical problem first, we immediately began  pumping saline through three large bore IVs, sent blood for lab work,  hooked up oxygen and the usual monitoring equipment. His blood pressure and pulse began began to move in the right direction, and he became more alert. Nurses don’t usually make stuff up about castration, so without comment I exposed his genitalia.

The entire perineum was grotesquely engorged with purple subcutaneous blood despite four soft drains of the sort usually placed surgically to allow escape of serum or blood. A purplish black hugely blood swollen penis was all that was left of the genitals.  A ragged row of poorly placed stitches ran from its base to the anus, along an irregular midline incision that slowly oozed dark blood.  By providing IV fluids and perhaps blood, the emergency was essentially over;  next, call  a surgeon to repair the damage;  even that would be simple. But where the history and its legal consequences would lead was more complex; and to my mind, far more interesting. Despite being around emergency rooms all my professional life, beginning in 1954 as an $8 per night  moonlighting medical student, I had never seen,  heard of, or even imagined, this case. After so many days and nights in ERs I innocently, and wrongly,  believed myself aware of the entire sexual range of behavior in our society.

A brief health history was not particularly revealing. My patient was a computer programmer, lived with his male partner, was in good health, took no medicines, and even had  a current tetanus shot. His moderate obesity was of no medical concern  at the moment.

“ You live in New York? But of course this isSacramento”

“Yes.”

“Well,” I said, “You have definitely been castrated. Was it an assault?”

“No. I paid for it.”

“Couldn’t you have had  that done professionally?”

“Too expensive. Too many hassles. My partner told me not to do this, but it’s always been a fantasy of mine.”

He explained that several years ago he became internet connected with some people who  shared fantasies of castration. That led to sharing erotic castration phone  sex.

“Three years ago I purchased an actual fantasy experience in Chicago. Expensive, but I work hard and make good money. It was splendid, incomparable to anything else I’ve ever done.  This year the same people offered it in San Francisco.”

“But” I ventured, “this seems to be the real thing. Did you plan on that?

“Not really.”

“Do you want to press charges?”

“You know? I think I’ll be very happy with the result. I couldn’t get this done anywhere for $5000 and it would take years to convince people.”

“Do you mind telling me how it went?”

“It was in San Francisco. They said fly to Sacramento for security.”

He was blindfolded during a long ride; he remembers a toll bridge. When the blindfold was removed he found himself in a room with lots of light, a gurney with and IV hanging on the side pole, and people in surgical gowns.

“It was absolutely  overwhelming, unforgettable; but over too soon, right  after  an IV was started I don’t remember anything; the very next thing is my Sacramento contact waking me in my motel room. The sheets were soaked with blood.  I was terribly weak and had vomited. He  drove me here.”

After my patient’s admission to the surgery service, my duties were complete, right? Wrong.  Years ago a physician’s only obligation was to a patient. If a  person with a knife wound in the back said he fell on his knife, that was it.  The State ended that primitive contract, claiming a right to try to protect everyone from everyone and everything, through legislation and regulation. So, dutifully (and to avoid fine, imprisonment, loss of license, litigation, and who knows what else; no one car read all the fine print!) I called the police both locally and in San Francisco. But since my patient said he didn’t want to press charges or even provide significant details, they didn’t want to hear more or even to interview him. The San Francisco cop  I spoke with found the episode neither alarming nor particularly rare. “It’s freedom, like Joplin said. He ain’t got nothin’ left to lose. Down there anyways. Like, no more worries.” I recorded the badge numbers in the record, looked ruefully at the wall clock, and picked up the next patient’s chart.