Tales from the ER #8

In med school I did a one-month rotation at the local Veterans Affairs (VA) hospital. From a medical perspective, it was a wild month. From a social perspective, it was utterly depressing. Everything you’ve read about the abysmal state of the VA’s facilities and its byzantine system is true. There are real good people who work at the VA, but even the good people devoted to caring for our soldiers are fighting a losing battle.

In hindsight, the civilian healthcare system should’ve paid more attention to the VA as it was a looking glass into our future. The plight of our armed forces trying to seek care for problems the government inflicted upon them (e.g., Agent Orange, Gulf War Syndrome, burn pits, etc.) should also serve as a warning to the civilians who our society now views as threats. Once your utility is gone (e.g., the factory worker who used to be a Blue Dog Democrat but then voted for Trump), your physical and mental ailments will not be solved by the healthcare system, but rather, amplified by it. This is how ultrapotent and addictive opioids are given government approval - the bureaucrats’ thinking is that those pills will be prescribed to people whose lives don’t matter.

Despite being mistreated, people manage to survive and some even thrive. The first VA story I share shows how far a man call fall and still somehow stay alive. The second VA story exemplifies the ridiculous situations that arise as society falls apart, and that we should embrace those moments because they are are a source of humor and even happiness.

“We’ve got a new admission down in the ER, I know you’re supposed to be signing out, but do you want to come see him with me?”

I was assigned to a nice intern, for once. He taught me real medicine instead of scutting me out to write notes and run blood samples to the lab. Even though it was 5:30 pm and I had been at the hospital since 5 am, I couldn’t say no.

The patient was an African American Gulf War vet, although he looked much older than his age of 48 years. He had come to the ER complaining of chest pain, openly admitting the pain started after smoking a bunch of crack. “Crack is whack” as Whitney Houston said, and smoking crack can cause a heart attack. However, this patient wasn’t being admitted for a heart attack. He was being admitted for pericarditis, which is inflammation of the tissue that lines the heart.

Pericarditis gets a lot of attention now because of COVID-19 vaccines, but pre-COVID-19 it was relatively rare, except in certain conditions. Since the patient used drugs, his pericarditis was most likely due to undiagnosed HIV. However, the patient swore up and down that he didn’t have HIV. Regardless, we assumed that’s what it was, sent off a blood test for HIV, and got him started on treatment with indomethacin.

I learned all about pericarditis from the intern – including how it can kill people. Inflammation attracts fluid, and so in pericarditis fluid can build up in between the tissue surrounding the heart and the heart muscle itself. If enough fluid builds up in that space, it can compress the heart and make it harder for the heart to effectively pump blood. That condition is called cardiac tamponade and can be fatal.

Around 7 pm we wrapped up writing the patient’s admission orders and the admission note. I would present the patient on rounds tomorrow morning to the attending and the rest of the team.

I arrived at 5 am to “pre-round” and see what had happened with the patient overnight. To my surprise, his room was empty. I asked one of the nurses if he had switched rooms.

“That crazy crackhead left. He was scratching himself, itching for drugs, tore out his IV. The overnight resident barely got him to scribble his signature on the AMA form before he ran out of here to get high.”

Well, that was disappointing. I looked up his lab results anyway just to see what had come back overnight. Turns out the patient wasn’t lying – he was HIV negative. But he was positive for antibodies against his own DNA, which is a hallmark of lupus. Lupus is a nasty autoimmune disease that typically affects women, but regardless of who has it, lupus can cause pericarditis and a whole host of other issues.

I relayed that info to the intern, who remarked:

“Well, his pericarditis might get better on its own, but his lupus won’t.”

Two days later we got a call from the ER to admit another pericarditis patient. The intern and I both felt déjà vu walking down to the ER. Either the sensation of déjà vu is real, or it was a full moon, because the patient to be admitted was the exact same crack-smoking patient with lupus. The patient hadn’t made it far after he left AMA – he had spent those days and nights in the VA parking lot smoking crack. I was shocked. My intern smiled.

“You didn’t know? You can get any kind of drug in that parking lot. Crack, ketamine, PCP, LSD…”

It was funny until we realized that the patient was in much worse shape than before. He was unable to lay back without getting very short of breath. He insisted on sitting forward, which helped relieve pressure from the fluid building up against his straining heart muscles. The intern grabbed a portable ultrasound machine and placed the probe on the patient’s chest. Clear in the ultrasound screen’s black and white image was a very bad case of cardiac tamponade.

At this point one of the ER attending physicians got involved because the fluid pressing on the heart needed to be drained:

“Sir, we’re going to have to drain this fluid. I’m going to stick a needle in your chest.”

“NO NEEDLES!!!”

The patient went crazy and started thrashing around. At this point I realized he must only smoke crack, because he seemed very averse to needles. The intern, with his high emotional intelligence and already cynical to people’s true motivations, intervened:

“Hey sir, you want to make it back to that parking lot, right? If you don’t let us stick this needle in your chest, you are never, ever, going to smoke crack again.”

And with that the patient stopped screaming, laid still, and said:

“Well then go on right ahead.”

“We’ve got a consult from urology. They’ve got a guy who wants a Viagra script but he has hypertension, hyperlipidemia, Type II diabetes, COPD on baseline oxygen but he refuses to use it, and obesity, so they want us to decide whether or not it’s safe for him to take Viagra. He’s on simvastatin, metoprolol, metformin, hydrochlorothiazide, Advair, albuterol as needed…”

“No need to give me the full list, I’ll look it up and go see him for you.”

The nice intern was sending me on a mission over to the surgical wards. I felt like a student trying to please a favorite teacher, hoping to make him proud since he was giving me the freedom to go see the patient on my own.

It took no less than 30 minutes to get to the surgical ward. The VA’s buildings were added over time, and so you could get from one building to the next by taking the elevator up to the fourth floor, walk down the hall, take another elevator down to the second floor, walk down another hall, etc. Finally, I got to the patient’s room. The door was slightly ajar, but given my previous experience on my pediatrics rotation, I still knocked loudly.

“Come on in!” an enthusiastic voice bellowed.

I walked in and the first thing I saw was a hairy ass crack. The patient was an older man sitting up in the hospital bed facing the window with his hospital gown completely open in the back.

“Hi Mr. Johnston, I’m one of the medical students and…”

I was quickly interrupted.

“You want to see my new dick?”

“What?”

I should’ve looked up what procedure the patient had undergone. Rookie medical student mistake.

“I got a brand new dick. Here, let me show you.”

And with that the man flung his hospital gown off his legs to reveal a small, flaccid penis.

“This thing’s amazing I tell you. What a great surgeon.”

I didn’t want to dampen the patient’s enthusiasm by misspeaking, but he was so friendly I felt comfortable asking him a question.

“What exactly did you have done?”

“It’s the latest in dick implant technology. I can’t believe they even offer it here at the VA, though I did have to wait six months for the surgery. I thought they were going to stick some steel rod in there and I’d be hard all day long. It turns out it’s more like those old sneakers that you pump up!”

And with that he reached down, grabbed his scrotum, and started pumping with his fist. Sure enough, his penis got erect and much, much bigger.

“Wow, I bet your wife is gonna love this.”

His smile faded for a split second.

“No ball and chain for me! The second they discharge me I’m off to the Philippines. I spent time there when I was in the service and those ladies are the best. After a few trips there though I felt like I had to give back, and I’m not blind, I knew I didn’t have the greatest dick. But boy has that changed!”

“So why the request for Viagra?”

Again his smile faded, but only for a split second.

“Well first, one lady’s never been enough for me. And two, I’m not getting any younger. I got a new pipe down there but the surgeon says the blood vessels upstream aren’t so good for sex anymore.”

“I’ll be honest sir, and I have to check with my supervising doctor, but I don’t know with all your conditions and other medications that you should really be taking Viagra.”

“Let me tell you something I know you can’t understand right now because you’re young and by virtue of that you can’t imagine what it’s like to be old. I still got Agent Orange bullshit in my body and I wake up in the middle of every night screaming for my buddy who stepped on a land mine in front of me. I know I might sound and look ridiculous to you but this is how I want to enjoy the rest of my life. I’ll also have you know I’m one of the few patients in this whole VA who’s not on anti-depressants. And damnit if you don’t prescribe me some Viagra I’m just going to go buy the shady blue pills they sell in the parking lot.”

Enough said. I went back to the intern and told him the story. He smiled and wrote the script.