The Catharsis

I was just 29. Twelve more hours in the Emergency Department and then I would pack my car and drive across the country to start a new life in San Francisco. I had a long list of stories about the Hopkins ED. My Dad would tell his tales about life there back in the ‘70’s when they still called it “the Axe”, which was a not so friendly reference to it being the accident ward. I had been a patient there several times as a kid with an assortment of broken bones and other injuries and maladies, imagined and real. I had more than a few stories from my days as a medical student and then of course as an intern and resident where the numbers 2280 would forever trigger the panic center in my brain. It was a remarkable place. And I mean remarkable in the not always the best way. I could probably write an entire book just about the Hopkins ED. I might be able to write a few chapters just on the smells. It was a fitting place for it all to end, and this would be a fitting end to the end.

My shift was 7AM-7PM. I was at the end of my second year of residency, and this was my last day of my last rotation. In two weeks, I would begin my fellowship. I was tired but confident. I was starting to understand how much I had learned over the past 7 years, and I had not yet completely figured out how little I actually knew.

When you were assigned a patient in the ED, you could tell a lot about what kind of patient they would be by how they arrived. Back then, they announced the arrival of the sickest patients on the overhead PA system. Others, the nurse would just hand you a clipboard. And for the rest, they would just add the clipboard to the growing pile in a box. This particular patient was not announced overhead, but he arrived with some excitement because he was accompanied by two Baltimore City Police Officers, he was in shackles, and he was screaming. He was a small, skinny guy with a pencil thin mustache and greasy hair. He was screaming obscenities at anyone and everyone he saw and probably many he never saw. The charge nurse assigned him to me. I won’t say it was because it was my last day or because I was one of the Internal Medicine residents, but it did not matter anymore. This was my last day.

He was taken to a room that was really just a concrete cell. It was at the back of the department and it was bare except for a metal table and concrete floors. It made clean up easier for the staff as they could effectively just hose everything down without touching it. It’s where they put the drunks, the homeless people, those covered in lice, scabies, or maggots or those that just smelled the worst.

The cops brought him back and chained him to the metal table. I walked in holding his chart and asked what was going on. One of the cops told me they had pulled him over for a busted brake light, and as they approached the car, they saw him swallow a small plastic baggie containing what they assumed to be drugs. We all assumed the bag contained cocaine which could be very dangerous if and when the bag came open. This might dump a large quantity of cocaine into his inners and could result in cocaine toxicity. That could be fatal. There was a protocol for this in our ED. It was not that uncommon.

After hearing the story from the cops, I approached my man and asked him if he wanted to add anything. He spat at me. He didn’t know it was my last day as a resident. He did not know what the previous 2 years had been like.

I managed to dodge the spittle and said, “Would you like to try that again?”

This time, he got me square on the blue scrub pants emblazoned with “MHL” for Maryland Hospital Laundry. I was getting mad. I put the clipboard down and came at him again, this time from the side.

I said, “Look, this is serious. If you swallowed cocaine, you could likely die if the bag opens up. We have to do some tests on you and then we need to have you swallow charcoal and then drink a gallon of GoLYTELY® to help move things along.”

He did not respond. I said, “we can do this the easy way or the hard way.”

He cocked his head and went to spit again and I moved to the side and nodded to the nurse while mouthing, “Security.”

The Hopkins ED was staffed with a dozen or so security guards at any one time.  These guys were there in addition to the many police officers who were there all the time. They were all big. I would guess they were also from the surrounding neighborhood which meant they were also tough. When things got interesting, they would put on oversized yellow gowns, masks, and gloves. It was oddly comforting, and it seemed that they enjoyed it too.

Four of the biggest ones around walked slowly into the chamber where I was standing with the patient, a few nurses and the two cops. They made a point of putting on their gowns and gloves and masks in front of the patient. It was intimidating. The four of them surrounded him and I approached again, and again I said, “We can do this the easy way or the hard way.”

And again, he spat. So, without saying anything, I nodded and the 4 guards each grabbed a limb while the nurse lowered the table. They held him still while he screamed like a dying cat and the nurses performed an electrocardiogram and drew some blood. It was important to get a baseline so we could compare to what things looked like after the cocaine bag ruptured and his heart rate and blood pressure exploded. We then wheeled in the portable x-ray which revealed a small metal twist tie somewhere in his small intestine.

This was all we needed. I reminded him of what we had to do and again asked him if he would cooperate all while the 4 guards stood around him. He did not respond. The nurse handed me one of those 32 ounce Styrofoam cups full of activated charcoal, with a straw. I think she left the little white wrapper on the tip like they did at the diner.

After she handed it to me, I moved cautiously toward our patient and reached out to hand it to him. He took it, and then immediately threw it right back at me spilling the charcoal all over my scrubs, shoes and white coat. The guards reflexively each grabbed a limb and held him down while he screamed. They pulled harder than they needed to. I wiped as much of the charcoal off my scrubs as I could while the nurse made a new batch. I did not bother putting on a yellow gown at this point. I was done.

I came back at him and said one last time, “Look, there is an easy way and a hard way. This is your last chance.”

This time, his spit hit me in the forehead, and again the guards pulled on his skinny limbs. Before I could wipe the spit from my face, the nurse had handed me a large nasogastric tube. We called them NG tubes. The naso part referred to the nose which was where the tube entered. The gastric part referred to the stomach which was where the other end would find a home.

She was getting mad at me. She had seen this movie before, and she was tired of the leeway I was giving our little guy. I sensed it, and I was also now quite tired of the game. I took the tube and came at him pretty quickly this time, and the four guards held his limbs, and now a fifth guard showed up to hold his head still. It was quite a feat as we had to keep everything motionless enough for me not to shove the tube into his brain all while making sure he did not bite anyone.

I managed to get the tube in and down on the first shot. We had to x-ray it to make sure it wasn’t in his lungs, but I was pretty confident (and he wasn’t coughing). By this point, we had restrained him with what was basically a straight jacket and soft restraints on his 4 limbs. Once the correct tube position was confirmed, we sat up the metal table and connected the other end of the tube to a large syringe which I used to feed the activated charcoal down and into his stomach. It was quite a mess. The tube insertion had been pretty traumatic so now he was bleeding from his nose and that was mixed with the slurry of charcoal which was all smeared all over his face and the room. He yelled and yelled as we did this and the guards sat in the corner quite amused with their work. And the two cops sat there pretending not to pay attention.

After the charcoal, I started on the GoLYTELY®. This is one of the more perfect names in medicine. It was developed as a way to prepare the colon for a colonoscopy. Basically, it is a gallon of the most powerful cathartic around. So you drink the stuff, and then you poop and poop and poop till the whole gut is as clean as a kitchen. The idea here was to expedite the passage of the bag full of cocaine and neutralize it with the charcoal at the same time.

Getting a gallon of GoLYTELY® down an NG tube 50 cc’s at a time was not fun or fast. But finally it was over. And then it was time to wait. I think we got one more cardiogram, and then I left to go see what other interesting cases waited for me outside in the Department.

After about an hour, one of the nurses found me and said the patient really wanted to speak with me. I walked into his room and asked, “Yes?”

He said that he really had to “go” and that he wanted to sit on the toilet. I scanned the room first looking at the guards, then the nurses, and last the cops.

He was crying now. He begged, “Please don’t make me lie on a table in my own shit! Where’s my Mommy?”

I really thought about it. I thought about this grown man asking for his Mommy. I thought that leaving him on the table was inhumane. But then I looked down at my blood, charcoal, and snot –stained clothes, and then I thought of the spit on my face and that little fucker screaming. I looked across the room again. The non-verbal consensus was clear.

I said, “I’m sorry.” And I walked out.

He screamed and screamed and told me to fuck off and die in hell and anything and everything else you could imagine. He also begged for his Mommy again and again. He was a pathetic creature there tied to a metal bed with a large tube coming out his nose and with a mixture of blood, charcoal, snot, and GoLYTELY® smeared on his face and clothes all while crying for his Mommy. I knew what was coming next.

I came back to check on him an hour or so later. It was time for another cardiogram. He was still crying, though not as loudly as before. Here he was in the concrete room strapped to the cold metal table in what was now a river of blood, snot, charcoal, GoLYTELY® and shit. Heck, he had probably pissed himself too. I don’t think we had ever taken off his clothes. The room smelled worse than you could imagine. The nurses and guards now all had respirators on to try to blunt the stench. It was a revolting scene with this little man on the metal bed lying in this horrid mix – all while whimpering for his mother.

We did the cardiogram, and it was fine. His vitals remained stable. He just lay there attached to a metal bed and bathing in his own excrement. After about six hours, one of the nurses found me and brought me to the room. She walked toward the river of shit, piss, blood, charcoal and GoLYTELY® and pulled out a tongue depressor. I nearly vomited. It might have improved the scene. She pointed at an object that looked very much like a metal tie and maybe a plastic bag mixed in with shit.

We were getting to the end. I was also getting to the end. I started to think about leaving. I thought about leaving Hopkins – a hospital where I had quite literally grown up. I thought about leaving Baltimore and the June heat and humidity. I thought about fellowship and San Francisco.

After these few moments day-dreaming, I checked back in and found myself staring at our little man with the large tube in his nose. I looked at the mess on the floor and all the while, the two cops sat there chatting while the nurses moved about doing their work.

I approached the man and told him he was good to go. I pulled the tube out and told him the nurses would come to take out his IV and help get him cleaned up. He was still crying. I turned to the two cops and said, “he’s all yours,” and I left to go finish up work on my last few patients. It was almost 7 and it was getting close to being time to sign out – for good.

10-15 minutes later, I was standing at the counter outside the concrete room looking through a chart and my man walked out. He was in a hospital gown and pajama pants and hospital slippers and he was carrying a plastic bag labeled, “my belongings” that clearly contained his horribly soiled clothes. He was walking slowly, but he did not make eye contact with me as he turned and left the Emergency Department. A few seconds behind him, out walked the two Baltimore City Cops. They did notice me, and I noticed them.

I asked, “You’re letting him go??”

One cop approached. He looked at me calmly and quietly he said, “Doc, after what you all just did to him, there’s nothing more we could do that would come close.”

I asked, “You mean jail?”

He responded, “Look Doc, in my 23 years on the force, I’ve never seen nothing as bad as what you all just did to him. Nothing. He’s had his punishment. It’s done.”

He shook his head. I could not tell if it was a sign of respect or horror. And with that, they patted me on the back, bowed their heads and walked out.

I stood there looking at the clipboard, but not seeing it. I stared for a few seconds and then refocused on what I had left to do, trying not to think about what I had just done.