Thursday, August 23, 2012

Read Another Exciting Chapter From The Farm!

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 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?”
“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.


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