“Every patient you see is a lesson in much more than the malady from which he suffers.”

Sir William Osler

Canadian physician known as the father of modern medicine, 1849-1919.

With Reggie’s unrivaled power of intimidation working, I was able to continue my exam on this very uncooperative ER patient.

“Mr. Donovan, I am going to do a rectal exam on you now.”

“Oh, fuck that, bitch.  No one is sticking nothing up there.  Fuck you.”

Reggie stuck his big thick index finger up to the patient’s eyes.

“Well, I can do it if you’d rather, or you can shut up and let the Doc do her work.  Which finger do you want?”

I held up my long thin index finger next to Reggie’s.

Without really waiting for an answer, I proceeded.

Good tone, no sign of blood on the hemoccult test.  I thanked Reggie, and we left the room.  I could hear the patient yelling something at the nurse, which included the words “fuck” and “bitch” many times. 

     He needed a full cervical-spine series, left arm films, chest x-ray, pelvic x-ray and head and abdomen CT’s.  Because he was obviously intoxicated, we couldn’t trust the fact that he felt no pain in his abdomen to mean that he had no significant injuries in his abdomen.  We would have to scan him to be sure.  Falling four floors could certainly cause serious injuries. Unfortunately, it wasn’t good practice to just sedate these idiots to make our job easier, because that carried all kinds of risks to the patient.  If a patient was truly in danger of seriously injuring himself, sometimes we did sedate them and intubate them, but we generally try to avoid that situation.

     His x-rays showed a left radius and ulnar fracture, some fractured ribs, a moderate-sized pneumothorax, or lung collapse, and a non-displaced pelvic fracture.   We were waiting for CT scan to be open so we could get him in for those scans.  If a lung is injured, it will leak air out into the cavity around it, causing compression of the lung.  Every breath in allows more air to pass through the injured lung tissue, getting stuck in the space around the lung.  This will continue to put pressure on the lung and cause it to collapse.  A chest tube is placed through the chest wall into that space and put on suction.  This pulls all the air out and allows the lung to expand and the patient to breathe.  Great, this asshole needs a chest tube. I’ll bet that goes well.

     I called Zayed, who was scrubbed in a case and couldn’t talk, then ran into Marcos, my chief resident, in the hallway, who was coming down to check on things.  I told him the patient’s story.

“So he needs a chest tube.  We should put it in before he goes to CT, I don’t want him getting a tension pneumothorax and coding in CT.  His belly’s alright?” he asked.

“I think so.  This guy is an asshole, a complete asshole.  He won’t answer questions, he spits on everyone, every other word out of his mouth is ‘fuck’.  I had to get Reggie in there holding him down so I could examine him.  He is drunk and stoned.  His tox screen is positive for opioids and cocaine.  He is a complete loser who should just be euthanized right now, for the good of society.”

“Oh, don’t be so hard on the guy.  Maybe he’s just having a bad day,” he replied.

“Or a bad decade, maybe,” I quipped.

     I had put in a few chest tubes on trauma patients, but they were usually unconscious.  I had not done one by myself on an awake patient.  Usually the seniors did chest tubes on the floor.  We went back down to the ER, and Marcos went in and introduced himself.

“I’m Dr. Smith, from surgery.  Dr. Sawmiller’s told me about you – it looks like you fell out a window, huh?”

“Fuck you, man!” the patient answered, and attempted to propel one of his infamous mucous balls across the room.  Fortunately, he was unable to move his head because we had him secured, so his aim was off.  The glob went straight up and landed right back on his own cheek.

     Marcos chuckled and wiped the glob off the guy’s cheek with a gauze, much like you would wipe the face of a four-year old after he’s made a mess eating some ice cream.  No disgust or loathing, as if this was normal behavior.

“Well, it’s best if you help us figure out what kind of injuries you have, but we can do it just as well without your help,” Marcos cheerfully informed the patient.

“I don’t want your goddamn help,” he said, struggling to get loose from the restraints.

“You have a collapsed lung, and we are going to put a tube through your chest wall to fix it.  Otherwise you just might die, and we surely can’t let that happen,” Marcos told him.

     He responded with the expected litany of cursing and threatening.  He must have been aware enough to understand Marcos had an accent, and he made some racial slur about Hispanics.  Marcos again chuckled heartily.  He was from South Africa.

“That was a good one, sir, but I’m afraid you’re directing your insults to the wrong continent.  The wrong hemisphere, actually.”

     We set everything up, and Marcos gave the patient a nice dose of Versed, which is what we had all been waiting for.  The patient’s eyes glazed over a bit.  He started to really slur his speech, and his oxygen saturation dropped to eighty percent.

“What if he stops breathing?” I inquired.

“So what,” said Marcos.  “You know how to intubate a patient, don’t you?”

“Yes.”

“Then what are you worried about?  If you’re going to stop breathing, there’s no better place to do it than in the emergency room with two doctors standing beside you.” 

     We positioned him and prepped his chest.  I injected some anesthetic and made my incision with minimal response from the patient.   The worst part of having a chest tube put in was when we actually popped through the pleura, the membrane lining the chest cavity.  It was nearly impossible to get this adequately numb and was usually the most uncomfortable part for the patient.

     Marcos stuck his finger into the incision to check things and instructed me to push a large clamp through, into the pleural space, and spread it enough to make a hole for the tube.

     I pushed the clamp into position between the ribs and popped it through. A little rush of air burst out, and the patient yelped out in pain.

“Mother fuck!!!  Mother fuck!!! “he yelled, as Reggie helped hold him still. 

“Hold still, we’re just about finished, sir,” Marcos said.

     I couldn’t get the tube to go in between the ribs, and Marcos told me to get the clamp back in there and spread.  I did, and the patient proceeded to simultaneously urinate, curse, and bite the respiratory tech that had come in to help.  Luckily, the patient only got a mouthful of lab jacket, which the tech was able to pull free when the patient opened his mouth to tell us he wanted a lawyer to sue our fucking asses.

     Marcos laughed, seemingly genuinely amused by the whole situation.  I was ready to inflict the maximum amount of pain and suffering possible on this guy.  I shoved the tube in and got it sutured in place and hooked up to suction.

     Marcos patted the guy on his head and said “Well, good luck with your lawyer.  We’re going to do a few more tests on you, and you’ll be staying with us for a while, I suspect.”

He turned to me, instructing “Get the CT’s, admit him, give him a PCA (patient controlled analgesia pump) for pain, he’ll probably need it, he’s not going to have much pain tolerance.”

“I’m not giving him a PCA.  He doesn’t deserve it.  He is a completely worthless human being, he will never pay a dime for any of this care he is getting and he won’t even be slightly grateful.  We saved his life, for free, and he’s an ungrateful jackass,” I responded bitterly.

“Oh, so cynical for such a young doctor.  What happened to wanting to help people, isn’t that why you became a doctor?” Marcos remarked somewhat surprised.

“Why don’t you ever get mad at these idiots?  I never see you actually get pissed off when these imbeciles act like complete morons, spitting at people, screaming at us, threatening us, biting us.  How can that possibly not bother you at some point?  Do you ever get mad at these worthless losers?” I asked incredulously.

He paused for a moment and thought.

“They’re not worthless losers at all.  You think they contribute nothing to society, but they make a great contribution.  In fact, they answer a very noble, honorable calling.  They are essential for the rest of us to be able to do what we do.”

     I gave him a what-the-hell-are-you-talking-about look.

“You think I would have let you put that chest tube in if that was some CEO, or some board member, or my wife?  No way.  No one gets to do their first procedure on someone like that.  Without the Donovan’s of the world, nobody gets any experience actually doing the things we need to do in order to save someone’s life.  Mr. Donovan just taught you how to put in an urgent chest tube.  Now, when my wife comes in with a spontaneous pneumo, you will be capable of saving her life.  Because of Mr. Donovan.”

     I just stared at him.

“Remember the grocery store owner who came in after he was stabbed in the chest during a robbery?  I did a thoracotomy in the ER and we got him to the OR and saved him.  He walked out of here a week later.   A nice guy with a nice family, he ran his own business, a perfectly upstanding member of society.  The only reason that guy is alive is because I already did ten thoracotomies on drug addicts and gang members right here in this ER, so I knew how to do it.  They teach us how to save lives.  The only way you’re going to learn how to crack a chest, how to fix a hole in someone’s heart, how to stop someone from bleeding to death is if these guys keep shooting and stabbing each other or getting stoned and falling out of windows.  They may be too stupid to be grateful for what we do for them, but you should be smart enough to be grateful for what they give us.  Experience.  Skill.  Knowledge.  So what if they aren’t all as charming as they could be, we cannot learn to be adequate surgeons without them.”

“So they’re our experimental animals?” I retorted.

“I like to think of it more like that is their divine purpose, their unique calling in life.  That guy may never contribute one single positive thing to society.  There is no other reason you may ever find to justify his existence, other than what he did today.  Some people are put on this earth just to teach residents to operate and do procedures and become better surgeons.  They’re not really the dregs of society at all.  They keep us all safer, because we’ll always have doctors who know how to do stuff.  I love these guys.”

     I could tell he genuinely believed all that, and it was a good point.  I thought back to all the unappreciative, unpleasant drug addicts and gang members I had taken care of, and how I resented them for taking my time.  I saw them as just another obstacle to endure and forget.  It took Marcos’ explanation of their profound value to my education to make me see that they were a vital part of my journey to reach my goal.  While submerged in residency, I was overwhelmed with learning all the technical skills and trying to gather in and retain the vast amount of knowledge that I would need to succeed.  I was so focused on getting by on a day-to-day basis so I could finish my internship that I was overlooking the value in these daily interactions with people.  It would be foolish and even self-destructive to ignore what they offered me, and to underestimate the importance of their role in my career.  I started to figure out that becoming a surgeon was not just about getting through residency, tolerating the misery until I could get out and start in a private practice and put it all behind me.  If I had seen that six-year residency as simply an obstacle I had to get past to reach my goal, could I have endured it?  Six years of working hundred-plus hour weeks can be a very, very long time if all one can focus on is getting it over with.  But when I was able to look at that time as an opportunity, to see the lessons in the day-to-day activities, those difficult times became valuable to me.  I focused on the long-term goal but recognized that one needs to absorb everything possible along the way to the goal, seeing the value of all the experiences that come along, both good and bad.  I managed to learn some of the most lasting, useful things during the roughest times of my residency.  Had it all been easy, I would have been very ill-prepared to practice medicine out in the real world.  I learned not to lose sight of the goal while moving towards it, but also to treasure the experience of the journey itself, to recognize all the opportunities along the way to learn and improve. 

     Over the years, as I was trying to suppress my anger and loathing towards some uncooperative, drunk, belligerent patient, I would recall Marcos’s words.  He was right.  I learned to do most of the procedures that need to be done to save a life on these patients.  They provided a wealth of experience that I never would have gotten otherwise, and I have used that to help many other people.  I decided to cut good old Mr. Donovan some slack, be grateful, and give him his morphine PCA after all.