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EIGHTEEN
MONTHS LATER
2
Dr. Andy Carlson applied a dressing of four
by four gauze and wrapped the stab
wound to the left hand of a twenty-three year old intoxicated woman. She had been trying to separate frozen
hamburger patties with a butcher knife and had managed to shove the knife up to
the hilt into the palm of her left hand.
Carlson had
no emotional response to the girl. She
was a bread-and-butter night shift patient.
His mind was on other things.
“In this
case, we shouldn’t sew up the holes on either side of your hand,” Andy said. “When
the knife went in, it brought germs and hamburger. When I pulled the knife out, some germs and hamburger were
probably wiped off inside your hand.”
“What’s
going to happen?” she slurred.
“You didn’t
damage any tendons or nerves,” he said.
“The latex drain that I left in the wound tract will allow the infection
to come out of each side while you take oral antibiotics and keep your hand in
a splint and an arm sling.”
“How long
does that drain stay in?”
“When you
come back to the wound clinic in two days, we’ll take the drain out. Hopefully you won’t have any infection. The worst
thing that could happen is that your hand would need to be opened up in the
operating room to drain a pocket of pus, an abscess. I’m optimistic that this
won’t be necessary. Penny is going to
give you written instructions and prescriptions.”
“Thanks, Doc.”
“One more
thing,” he said. “If you will put those
frozen patties in the microwave for about forty-five seconds you won’t need a
knife.”
Upon entering the exam room, Andy had
detected alcohol, marijuana, raw hamburger, spearmint gum, and too much
perfume.
While un-wrapping the bloody towel from her
left hand, he had noted the pattern of blood spattering on the patient’s upper chest
and left arm as well as the lack of blood on the bathrobe she currently had
on. She had not been wearing clothes at
the time of this accident, and did not put on the bathrobe until after wrapping
her left hand and the knife with the towel.
The lipstick
underneath her left ear and the frantic girl who accompanied her to the ED
suggested that the patient was gay. The angle of the knife confirmed that this
was indeed an accidental stabbing, not an injury sustained in self-defense. There would be no need to notify the
police. Certain antibiotics could
safely be used with little risk that the patient could be pregnant without
knowing it.
“Dr. Carlson?” The triage nurse
approached him.
“Penny,”
Andy said, “How’s your leg?”
“Getting
better.”
Penny was a
petite equestrian with short brown hair.
She loved her horse so much that she didn’t seem to tire of the
continuous stream of injuries the animal inflicted upon her. Her latest trauma was a kick to her right
thigh, from which she was still limping ten days later. It was never the horse’s fault. Andy thought
that if her husband had caused the same injuries, he would have been locked up by
now.
“These two
guys the paramedics brought in are interesting,” Penny said. “They’re brothers, medical students at
Eastern Virginia Medical School. They’re
real Saudi princes, members of the Saudi Arabian royal family. Their demographic page says to send the bill
to the Saudi Arabian embassy in Washington.
Apparently they were walking outside their home in Ghent, where they
live together, and two men assaulted them with baseball bats.”
Andy looked
toward exam rooms four and five.
“One has a
nasty forehead laceration over his right eye with a big hematoma, but it’s no
longer bleeding,” Penny said. “He had no loss of consciousness. The other got
hit across his left knee and can’t walk.
Other than that, it looks like minor bruises. Neither patient had been drinking. The prince with the head injury has a sore neck. Neither has back
pain. Both have stable vital signs and are alert.”
“Send the
guy with the head injury over to CT to get a head and neck study,” Andy said. “When
he gets back, do a visual acuity. Send
the other prince for a left knee film.
Check on their tetanus status and I’ll get to them as soon as I can. Do
they speak good English?”
“Better than
that Southern twang of yours,” Lindsey Baker, the night shift charge nurse, said
from behind him.
Andy Carlson
was now a thirty-four year old bachelor. His thick brown hair was bleached from
outdoor work on his farm. It flopped across his forehead when he lowered his
head. All Carlson men had prominent
cheekbones and noses, with midline dimples in their chins.
Physically, the most impressive thing about
Andy was his upper body. His neck, shoulders,
chest, and forearms were massive. Perhaps
the size of his upper body was more noticeable because he spent most of each shift
in the ED leaning over stretchers, his neck flexed and forearms extended. Chronic
neck pain is an occupational hazard for emergency physicians, especially tall
ones.
“Dr. Carlson,” Lindsey said, “the chronic
lunger in room twelve has had three nebulizer treatments and oral steroids. He feels better and wants to go home.”
The typical
chronic lunger is a middle-aged to elderly patient who has destroyed his lungs
by smoking, yet continues to smoke, even after requiring oxygen at home, or
having a hole cut in his neck to breathe through, or having been placed on a
mechanical ventilator in the past. Any respiratory infection is life-threatening
to these patients.
“Get a
room-air oxygen saturation and bring me his vital signs,” Andy said. “What
about his chest X-ray?”
“It was read
negative by the radiology resident,” Lindsey said. “The guy with the kidney stone in room six says his pain is coming
back.”
Andy
reviewed his evaluation and treatment of the kidney stone so far. “He has a three
millimeter stone in the middle of his left ureter on CT. He’s had thirty milligrams of Toradol , four
milligrams of Zofran, and two milligrams of Dilaudid IV about two hours ago.”
“Correct,” Lindsey
said.
“Give him
another milligram of Dilaudid IV,” Andy said.
“He should be able to go home soon with a prescription for Percocet and
a referral to urology. A stone that
size will pass on its own. I’ll go in
and explain it to him. Make sure he has
somebody to drive him home.”
Lindsey
stepped closer and whispered, “You’re not going to cancel out on me this
weekend, are you?”
“Not on your
life. I’m having trouble thinking of anything else.”
Lindsey
Baker had only worked at DePaul for three months. She had a lot of ED experience and had applied for the job of
night charge nurse. She said that she
was twenty-eight. Her
nose was subtly turned up. She wore her thick auburn hair short and, so far as
Andy could tell, never wore the same ear rings twice. She was five foot three inches tall and weighed less than 110
pounds. Her eyes sparkled when she laughed. Andy felt overwhelmed when she was
close to him.
Andy worked all night shifts, partly
because he had no family to go home to and partly because they paid him ten
dollars per hour more for a night shift.
He noted that the male interns and residents often hung around when
Lindsey worked nights with him. She
appeared to enjoy ignoring them.
“Dr. Carlson,” Lindsey called. “The
heroin overdose left A.M.A. He ripped out his IV and ran out the
ambulance entrance shortly after we gave him Narcan.”
Andy nodded.
“Too bad we never had a chance to tell
him he almost killed himself. Leave the
chart on the counter and I’ll sign it.”
“I’ll check
for him outside,” Lindsey said.
She placed
the patient’s chart on the doctor’s side of the long desk at the nurse’s
station and walked out of the ambulance entrance into the parking lot.
Once
outside, she looked around and took a cell phone out of her pocket. “Harrison,
it’s me. The Saudi princes are
here. I was worried that the EMS crew
would take them to Sentara.…They’ll survive…We
leave in the morning. Make sure everybody
is in the right place…Dr. Carlson is thinking about getting lucky… See you tomorrow afternoon.”
She closed
the phone, walked back into the emergency department, and said to Andy, “The
eloper isn’t in the parking lot.”
Andy’s thoughts shifted to his family
farm as he completed his chart work. The
Carlson farm in Farmville, Virginia had been purchased from King George II in
1743 and the 3400 acres had never passed out of the family. Ten generations of Carlsons were buried
there. Most of the property was
encircled by the Appomattox River, resulting in unusual privacy. Since his
father had been killed in a light plane crash a year ago and his brothers were still
doing mission work in Uganda, Andy owned and operated “The Farm.”
Andy had
completed a one year fellowship in trauma at Sentara Norfolk General following
his retirement from the Navy. He scheduled
himself for four twelve-hour ED shifts in four days, twelve-on, twelve-off.
That left him four consecutive days off, time that he used to do those things
that were in his blood—farming, building, and hunting with primitive weapons.
Such a routine
also allowed him to schedule his binge drinking. He didn’t drink in Norfolk.
He looked forward to getting drunk during his first two days at the Farm,
using the next two days to sober up.
This had been his habit since his dad’s death.
Up until a
month ago the only woman in his life had been Sahar, whom he had enrolled in
Old Dominion University in Norfolk. She
was majoring in computer science, but her primary interest was Andy. The fact that he was twice her age did not deter
her. Despite his reassurances that she
would soon find the right man, Sahar stalked him like a panther. They met
regularly for dinner, but Sahar refused to accept him as a father figure.
Sahar had
abandoned her abaya. She was a lovely
eighteen year old woman now, integrating rapidly into America. Andy felt guilty whenever he thought about
her. To give in to his physical
attraction for her would be dishonorable.
He didn’t save her life to take advantage of her.
Andy
classified himself as an amorous drunk, as opposed to a mean drunk, a fightin’
drunk, a sleepy drunk, a crying drunk, or a giggling drunk. As a teenager, alcohol had helped him dull
the pain of losing his mother. He hadn’t
grown up with a sister. Approaching any
woman who wasn’t a patient without the help of alcohol was a steep mountain to
climb.
On the other
hand, once he had a few drinks Andy tended to be amorous with whatever was
available, especially during his Navy career.
On more than one occasion he had left a bar with a sure number ten, only
to wake up with a number two. He could
attest that such things happened in the real world outside of country music. The
experience had scared him sober for more than a month on two occasions, during
which time he treated himself for imaginary STDs that might have gotten through
imaginary holes in his condom. In the
Navy, he had solved the problem by taking Josiah with him to serve as an
advisor in bars. Joe had a steady girl
back in Virginia Beach and seemed content in this role.
Since his
retirement from the Navy, Andy had come to worry that he could not have sex
without alcohol. Sahar aroused feelings in him, but she was out-of-bounds. He vowed to abstain from drinking around
her. Without alcohol, no other woman evoked
sexual desire in him. Until Lindsey had
appeared in his life. While they had
never actually had sex, there was clearly no lack of motivation on his
part. Curiously, since Lindsey took
over his thoughts, he had lost his desire to drink. He had never even discussed his drinking problem with her.
The abrupt
end of his need to binge had set off a round of introspection over the
preceding weeks. What had he been seeking in his binges, in exchange for the
hangovers and self-loathing the following days? How had booze and loss and sex become so entangled? The answers were coming into focus. He had been seeking love. The love he had lost from his parents and
from Joe.
For him, even those mindless one night stands
were about love, the only cure for loneliness and emotional pain. Alcohol had
become his only access to love. For this love he had been willing to crawl on
the floor to empty his stomach in the toilet, over and over. Lindsey was going to change all this.
Lindsey had
all of the physical attributes that Andy admired in a woman. As a lad he had an aunt who tried to
suffocate him with her gigantic breasts every Sunday after church, using the
guise of a hug. He tried to hide from
her, but she would not be denied. He
traced his love for small breasts back to this frightful period in his
life. Drunk or sober, petite women were
his first choice.
“Excuse me,
Dr. Carlson.”
Lindsey had
silently walked up behind him while he was suturing a wound. She leaned forward
with her mouth next to his left ear. He
could feel her breath. Her perfume locked-on. Her right hand lingered on his shoulder. She spoke softly, updating him on the status
of several patients. When she finished,
he wished he had paid more attention.
Andy knew
that other people who worked in the ED had picked up on the sparks between him
and Lindsey. It was impossible to keep any secret for long in the ED.
They planned
to have three days and three nights together on the Farm. He had invited Lindsey once before, but she
had a schedule conflict. Things had fallen into place. They were planning to leave at the end of their
shift at seven in the morning for Farmville, Virginia, a two and a half hour
drive.
Lindsey returned
to give more follow-up information and Andy tried harder to pay attention to
what she was saying this time.
“Your head
CT on the Saudi prince is on the PAX machine.
The radiologist has already read it negative.”
“I’ll take a
peek at the CT and go see him.”
A
computerized axial tomography study, or CT scan, allows the physician to take
X-ray slices through any part of the human body, and then reassemble those
slices in any plane. It is difficult to
hide injury and disease from a CT scan.
The prince’s
CT showed only soft tissue swelling outside the skull with no intracranial
injury. The CT of the neck was normal.
Andy picked
up the prince’s chart and walked into exam room number four. “I’m Dr. Carlson.”
He shook the
patient’s hand. The prince listed his
age as twenty-three. He was dressed as
an American, with short dark hair, clean shaven, polite.
“I
understand that you’re a medical student at EVMS,” Andy said.
“I am Muhammad
Abdullah. My brother is also a student
at EVMS, only he is one year ahead of me.
This is my first year.”
“What
happened tonight?”
“We were
walking near our apartment, not far from here, when two men jumped out of a car
and beat us with baseball bats.”
“Did you
know either of these men?”
“We didn’t
know them or why they would want to beat us up.”
“Were you
robbed?”
“No.”
“And you
reported this to the police?”
“The
paramedic said that the police would come to the emergency department to
interview us. My head was bleeding.”
Andy asked,
“Have you been the target of a hate crime before?”
“We have been treated very well in the United
States,” the prince said. “We are so
busy studying and going to classes that we don’t travel much. No one has ever tried to harm us.”
“Your wound
needs to be cleaned out a bit and I need to remove some of the clotted blood
under the skin,” Andy said. “Are you
allergic to local anesthetics?”
“No, sir.”
“Have you
ever had sutures before?”
“Once, in my
foot, in Saudi Arabia, at King Faisal Hospital.”
“Then I’m
going to open up a suture tray and anesthetize your wound with a small needle
and one percent lidocaine,” Andy said.
He prepared
the tray with non-sterile gloves, anesthetized the wound, and then switched to
sterile gloves. He painted the area
around the wound with Betadine, an antiseptic. The laceration was just above
the right eyebrow, horizontal, seven centimeters long, but did not involve the
right orbit. Swelling had already
extended to the soft tissue around the right eye. Andy placed sterile drapes around the wound and began to remove the
hematoma with his index finger.
“You’ll have
a black eye from this wound,” Andy said.
“The blood gravitates to the loose skin around your eye, and it takes
about ten days for all of the breakdown products of blood to be absorbed. There’s
nothing wrong with your vision and you don’t have any broken bones in your
face.”
Andy cleaned the skin around the
wound with Shur-Clens and irrigated the wound with a syringe of saline. He repaired the wound using individual nylon
sutures and gave his standard speech about wound care.
“Lindsey, could you give this gentleman
a wrap-around pressure dressing for his forehead, with an ace bandage to top it
off?”
She
nodded. “Mr. Abdullah, I have some
written instructions for you. Your tetanus status is up to date. Your sutures will need to be removed in seven
days. We can do it here in the ED.”
“They will
have to be taken out in Saudi Arabia,” replied the prince. “Our school year has ended and my brother and
I will be traveling home on Sunday.”
Lindsey
looked up. Two Norfolk police officers were
walking toward them. “The police are
here to interview you, Mr. Abdullah.”
Andy moved
on to prince number two in the next room, Fahd Abdullah, age twenty-four. They looked like brothers.
“How is my brother
Muhammad?” asked Fahd.
“He’ll be
fine,” Andy said. “The police are
talking to him. I’m Dr. Carlson. Tell
me about your injury.”
The prince
extended his hand. Prince number two seemed as amicable as prince number one. He told essentially the same story as his
brother.
Both princes
spoke the King’s English--the king of England, that is. Since Andy could not discuss his SEAL
career, he didn’t mention that he spoke Arabic or that he had been to Saudi
Arabia many times.
“They were
white males,” Fahd said, “about our age.
They didn’t say anything or ask for our wallets. One of them hit me on the left knee. Now I can’t stand up.”
“Please excuse me while I look at your X-ray,”
Andy said.
After a few
minutes, Andy returned. “There’re no broken bones in your knee.” Andy tested the ligaments of the knee and
found them intact.
“The
swelling is caused by a bruise over your kneecap, or patella. I don’t see any fluid inside your knee
joint. That means that this is not a
serious knee injury, but a bruise.”
The prince
nodded.
“The reason that you can’t bear weight is
that the kneecap is part of the system that locks your knee when you stand,”
Andy said. “Any bruise from the
quadriceps muscles in your thigh to the patellar tendon in your lower leg will
result in a feeling of giving out if you try to stand. It’s a reflex that warns you that locking
your knee will be painful.”
“What do I
need?”
“A good splint and a pair of crutches for
about a week,” Andy said. “I would
recommend an ice pack, a knee immobilizer, elevation of your knee above heart
level during the next couple of days, and some short-term pain medication. If you don’t try to bear weight, the
bleeding around your kneecap will stop.”
Lindsey moved in on cue, with a knee immobilizer
and crutches.
Andy went back to the main counter and leaned
against it as he completed the two records.
Haven’t seen any Saudis lately,
he thought. Lindsey really looked nice
with those pearl earrings.
The night wound down with coughs, sore
throats, vomiting and diarrhea, allergic reactions, and alcohol-related trauma and illness. Andy’s only real challenge was a sixty-seven year old female patient
in congestive heart failure. By 7:10 in the morning he was searching for the day
shift doctor. One of his best friends, George
“Tank” Hedley, was looking over the patient tracker on the wall.
Tank asked,
“Bad night?”
“Not
really. I have one lady, Ms. Bailey, who
was in respiratory distress from CHF, but I think she’s going to make it. The guy with the kidney stone has a
prescription on his chart, an instruction sheet, and a urology referral. He can
go. He’s been waiting on his ride. I’m
going to finish up my paperwork while I wait to see if Ms. Bailey can grab the
brass ring of life.”
“All we can
do is dangle it over the bed,” Tank said. “They got to reach up and grab it.”
“Dr. Hedley
has the con,” Andy said as he saluted him.
“Dr. Hedley has
the con. Aye, sir.” Andy loved to work
with another former Navy doctor, who understood the proper way to change
command.
Dr. George “Tank”
Hedley was a talented career emergency physician whose life-long obsession was
to stay in top physical condition. He signed his emails “Fitness is a journey,
not a destination.” He belonged to three health clubs in Hampton Roads, in case
he got the urge to pump iron at odd hours or from remote locations. Unwilling to compromise with his thinning
hair, Dr. Hedley shaved his entire head, hence the nickname.
Andy looked
up Ms. Bailey’s medical records on the hospital computer. She had a history of congestive heart
failure, which had worsened several times due to non-compliance with her
medications.
Walking back
into room two, he found Lindsey adjusting the frequency of blood pressure
measurements on the monitor over the patient’s left shoulder.
“I haven’t heard any screams from this room,
so things must be looking up,” he said.
Lindsey
whispered, “You’re good at what you do, Dr. Carlson.”
“But we
haven’t done anything yet,” he whispered back.
“I’ll meet
you at your truck.”
The patient smiled.
“You didn’t
by any chance stop taking your medication did you?” Andy asked Ms. Bailey.
“I wanted to
give it one more try,” she said. “My pastor told me that all things were
possible for those who believed. I
believe now that he doesn’t know anything about my heart.”
“That’s a
fair assumption," Andy replied. “But you should be good to go in a couple
of days.”
She said, “I
hope that you and Miss Lindsey have a nice weekend.”
Lindsey
looked at Andy and raised an eyebrow.
~~~
