Angels in the ER (23 page)

Having solved this dilemma, I relaxed just as our minister was getting to his feet and approaching the pulpit. I no longer noticed the continual shaking of the head in front of me.

We were a few minutes into the sermon when it happened.

There was a rustle of movement behind me. Not a lot, but just enough to distract my attention. And then there was a tap on my shoulder.

Turning to my left, I saw one of the young men of the congregation leaning into the pew behind me. He whispered, “Robert, we need you in the back. Something has happened to John Stanford.”

I immediately stood up, and I looked beyond him to the back of the sanctuary. A few rows from the back wall, several people were huddled around the slumped-over body of John Stanford. A murmur of hushed voices began to sweep through the sanctuary, and somewhere in my subconsciousness I realized the minister had ceased speaking.

Making my way across the pew, I turned to Francis and said, “Come on, I’ll need some help.” John Stanford was in his mid-seventies and, like Willis Stephens, he must have weighed in excess of two hundred pounds.

My mind was racing as we hurried down the aisle. What had happened to him? Was he breathing? Had someone called 9-1-1? As we neared the back of the sanctuary, I watched as three or four men fumbled trying to get him out of the pew. This was not going to be easy, and I wondered how we were going to get him to the back of the church. We needed some space, and first we would have to get him out of the narrow confines of the pew. Then it struck me again: the “fireman’s carry.”

We reached his pew and I pointed to Francis and said, “Here, go in this row and get beside him.” I made my way down the row behind John, stepping on a few toes as I negotiated my way.

Though John seemed completely unconscious, I quickly determined he had a pulse and was breathing. I said to the men standing around him, “Give us just a little bit of room.” I then proceeded to instruct Francis in the carry. We fumbled with each others’ elbows for a moment and then it all came together. It wasn’t easy, but we were able to lift John and make our way down the pew and out the back to the foyer.

Gently, we laid him on the carpet and I again checked his pulse. It was there, but weak. He was pale, and his skin was clammy. Undoing his tie and unbuttoning his shirt, I asked Francis to raise John’s legs to get more blood to his central circulation.

“Has someone called 9-1-1?” I asked the group in the foyer.

“They’re on the way,” came the response. “Should be here in about five minutes.”

John was beginning to stir. His eyes opened, and he looked around him and then up at me. He was confused and afraid.

“John, everything’s going to be okay,” I told him. “Just relax and take some slow, deep breaths.”

His color improved, and his pulse was stronger now. By the time the paramedics came through the foyer doors, John was talking and asking, “What happened?”

The EMS team had him on a cardiac monitor, an IV started in his right arm, and oxygen prongs in his nose within minutes. He was
stable and was soon on his way to the hospital. He later told me that when visitors came to his hospital room, he would tell them, “The worst part of the whole thing was waking up on the floor and finding Robert Lesslie taking my clothes off.”

As the ambulance siren faded in the distance, I turned to Francis and put my hand on his shoulder. “Thanks for your help. That was something, wasn’t it?”

He was sweating, and I noticed that my shirt was soaked.

“Man, Robert, I didn’t know how we were going to get him out of that pew. I’m glad you thought of…whatever it was we just did.”

I knew then that, while those thoughts about Willis had been mine, they had come from some other place. I had never done the fireman’s carry. I had never needed to—and to this day, I have never again performed it. On this particular day, however, John Stanford had needed some help, and I had been made an instrument. That was a humbling thought.

2:30 p.m.
Wednesday.

The chart of my next patient read,

Brad Jenkins

42 year-old-male

sore throat, cough, and congestion

The triage nurse had placed him in our ENT (ear, nose, and throat) room.

This should be straightforward enough,
I thought. No fever. Blood pressure was fine.

With the chart in hand, I turned to walk down the hallway.

“You might want these,” Amy Conners suggested to me. She was shuffling and straightening some medical documents. They were recent ER records, copies of visits, which we kept in the department. The file drawer they were kept in had a folder for each of the previous
31 days, allowing us to quickly retrieve the records of each patient visit for the prior month. We had a few “frequent flyers,” and this system allowed us to better track these patients and their multiple visits.

“Looks like he’s been here a half-dozen times in the past two weeks,” she added, sliding the stack of records across the counter.

That was a little unusual, and before I went to the ENT room I needed to take a look at these.

Multiple visits represented a potential red flag. One of the cardinal rules in the ER had to do with return visits. It also had a lot to do with attitudes and assumptions. A dangerous tendency among inexperienced ER staff members was to assume that an unscheduled return visit was a nuisance and probably bogus. This tendency would lead to a superficial examination and evaluation on the return visit, which in turn would sometimes result in disaster. The returning patient might in fact have something serious going on that had been missed on the first visit. It sometimes required discipline to remain objective and dispassionate, but these patients needed to be approached with a finer tuning of one’s clinical radar.

Amy was right. Including today’s, I counted six visits for Mr. Jenkins during the past two weeks.

Hmm. On the first visit, I had been the examining physician. He had complained of head congestion, drainage, and a mild cough. My diagnosis had been an “upper respiratory infection,” and he had been treated with a decongestant and cough medicine. I looked carefully at this note, making sure his vital signs had been normal, and that I had not missed any subtle bit of information. Everything seemed routine.

On the next visit, two days later at midnight, he had been seen by one of my partners. His complaint then had been of persistent cough and difficulty sleeping. His vital signs again were completely normal, and nothing suspicious showed up in his health history. On this visit, he had received an extensive workup, including a chest X-ray and blood studies. Everything was normal. My partner had made a diagnosis of bronchitis and had given him an antibiotic, covering any
potential underlying bacterial infection. Again, everything seemed appropriate. And he had again been instructed to follow up with his family doctor should he not improve.

Mr. Jenkins had come back to the ER three days after that visit, stating that he was no better. His complaint was “cough, congestion, fatigue.” The next visit was for “nausea,” and the ER sheet from yesterday simply read, “no better.” Each time, his exam had been normal and he was told to follow up with his doctor.

Maybe he didn’t have a doctor. Maybe he didn’t have any insurance or the financial ability to afford follow-up elsewhere. I glanced at the demographic portion of today’s record and noted that he was employed by one of the large companies in town. He had listed his job title as “regional manager.”

This was unusual. “Thanks, Amy,” I told her, attaching these records to his clipboard under today’s encounter sheet.

I closed the door of the ENT room behind me and stood at the foot of the exam table. Brad Jenkins was sitting on the bed, leaning forward with his arms outstretched and his hands grasping the edge of the thin mattress that provided only a modicum of comfort. His legs swung in tandem beneath him and he looked up at me as I entered.

He seemed comfortable enough, and in no obvious distress. He wore khaki pants, a light-blue button-down collared shirt, and a red tie. Nothing struck me as being out of the ordinary.

“Mr. Jenkins, I’m Dr. Lesslie,” I perfunctorily introduced myself. “What can we do for you today?”

He stopped swinging his legs but maintained his posture, leaning over and holding onto the bed.

“I’m sure you’re aware I’ve been here a few times recently,” he began, nodding at the clipboard in my hands. “I’m just not getting any better. Still feel lousy, with some congestion and occasionally a little cough.” He cleared his throat after this last statement. “And I understand you’re the medical director here, so I just want to say that each time I’ve been treated, the doctors and nurses have been very
professional. I have nothing to complain about regarding my treatment, except that I’m just not getting better.”

Six visits in two weeks—and he sat here in front of me completely calm, and actually complimenting us. I looked down at his chart again, making sure he didn’t have a low-grade fever, or a slightly elevated heart rate—something, anything, that might tip me off to a significant underlying problem we were missing.

“Well, thanks,” I responded. “But our goal here is to make sure you’re okay, and to try to figure out what’s causing your symptoms. Have you had any weight loss, or night sweats? Any unusual changes in your appetite or daily routine? Any bleeding?”

The answers to these questions were all in the negative. I continued to probe for any possible clue to his problem, any bit of information that would lead me to a correct diagnosis. I would be happy for something that just pointed me in
some
direction.

Nothing. Everything seemed completely normal, except for this slight cough and sore throat. And even these symptoms, when pursued, were vague and nonspecific.

His exam was completely normal as well. Ears, nose, throat, heart, chest—all normal. His muscle tone and neurological exam were also normal.

I rubbed my chin and looked at the previous visit’s notation. He had had a CBC (complete blood count) done then and it was completely normal. No evidence of infection or anemia, or any problems with his platelets.

“Well, Mr. Jenkins,” I began, having exhausted any thoughts and ideas, “I don’t see anything bad going on today. And I’m sorry I can’t give you a specific diagnosis as to what’s causing your problems. Sometimes it just takes a little while to sort these things out. I think the most appropriate thing for us to do is have you seen by one of the ENT docs here in town. Maybe in the next week or two. We can help you set that up.”

I paused, waiting for a response. He said nothing, just looked at me.

“Does that sound alright?” I asked him.

He lowered his head and stared at the floor, nodding.

“Hmm. I suppose,” he said. There was resignation in his voice, but no frustration, and certainly no anger.

“Okay then,” I responded. “Let me get some paperwork together and we’ll be right back. We’ll help you get lined up with one of our specialists.”

There was no response, and I stepped out of the room.

As I walked up the hallway, I realized I had no sense of closure with Brad Jenkins. There was a small measure of release. I had taken a complete history and performed a thorough physical exam. I had done my job. Yet there was no closure. Sometimes that just doesn’t happen in the ER and you have to move on to the next patient. But this was somehow different. There was something else going on here and I couldn’t quite name it.

At the nurses’ station, I stood at the counter writing on Brad Jenkins’s record. Amy was reaching into the referral file to retrieve the slip of paper with the names, addresses, and phone numbers of our ENT doctors.

“What’s going on with him?” she asked. “Seems like a straight-up guy, don’t you think? But with all these visits…”

“Yeah, he seems straight-up,” I agreed. “But I don’t know exactly why he keeps coming back. Everything seems okay.”

I put my pen down, struggling with what to write in the box entitled “Diagnosis.” What
was
my diagnosis?

Something was bothering me, and I didn’t like the feeling. Trying to shake off this unwanted emotion, I picked up the pen again. Its point hovered above Mr. Jenkins’s chart, momentarily suspended while a thought formed in my mind. I don’t know where it came from, but as it crystallized I knew what I needed to do.