REAL MEDICINE

A Searing Emergency Department Encounter That Stayed With Me

How does this happen?

“Don’ know nuthin’ ‘bout dat” is his reply.

I introduce myself and offer my hand in greeting. Mr. Hoskins, my emergency department patient, returns a limp fish of a handshake.

“How can I help you today?” I ask.

“Don’ know” he replies.

His hand dies in mine. Either he’s unused to this standard greeting or he’s unable to maintain grip, even for a moment. His hand slides away, uncertain and furtive, weak and beaten.

Mr. Hoskins has not been acknowledged so “formally” in a long while I think.

Before going on, I try to make Mr. Hoskins comfortable. He looks 60-something but is actually 42, lying on the gurney as though he fell from 25 feet, like a nearly-paralyzed Raggedy Andy, minus the cheery face. He’s a disordered heap, seemingly unable or unwilling to arrange himself in a suitable or comfortable manner.

I attempt to help him find a semi-reclining position minus the discomfort. Propping a pillow behind him, I elevate the head of his gurney slightly, but that fails. He again slumps into an awkward position, wrecked.

Trying to obtain his basic medical information results in failure as well. His standard responses are either “don’ know nuthin’ ‘bout dat” or “if you say so, you’re the Doc.” It’s pitiful.

Mr. Hoskins’ hair is a tangled gray nest with bits of foreign material distributed throughout it. Two teeth remain standing in his slack jaw. They are black with decay. The odor of rot emanates from his mouth. That same smell, mixed with a urine and feces stench, arises from his body. His face is puffy and heavily seamed, his eyes rheumy and red, draining the crust of several days neglect. Beneath his hospital gown and bedsheets, I make out the borders of his bloated being, his chest stove-in, his belly protruding unnaturally, a mound of skin-covered disease.

After some prompting, my patient is able to tell me that he’s come in for “three days uh stomach ache.” He can’t describe it further on his own except to say “it hurts.” When presented with a list of stomach ache descriptors, burning, sharp, stabbing and the like, Mr. Hoskins goes off-topic stating, “it’s the hurting kind of pain.” With prompting he adds that the pain goes straight through to his back.

And, that’s it. Mr. Hoskins can’t or won’t recount any of his past medical history. Thankfully, I can access his electronic health record and discover a recent hospitalization for pancreatitis (an inflammation of the pancreas, an abdominal organ, often due to alcohol excess). He also has hypertension (high blood pressure) documented in his record but can’t recall if he’s ever been treated with medications for this issue.

Most of my other inquiries of the patient himself are met with “don’ know” or “if you say so” type responses, adding nothing to the discussion.

My patient is able to relate that he drinks a “12-pack uh beer ‘bout ‘vrey two days.”

He and I share a laugh when he claims “ah only smoke when ah drink.” We’re definitely chuckling for two very different reasons.

He “don’ work.”

When asked about drug use, Mr. Hoskins rears back as though I’ve touched him with a live wire. It’s the first vigorous reaction he’s had. He seems offended that I seem to pass judgment by asking about drug use. I reassure him that I’m not (just gathering relevant information) and he accepts it.

I dutifully record his social history as stated but mentally double his alcohol intake.

As our interview ends, Mr. Hoskins requests a soda and a sandwich.

Demurring, I offer instead: nil per os (medical Latin for nothing by mouth), pain medications, intravenous fluids, and a series of medical tests, suitable for someone with the presumptive diagnosis of recurrent pancreatitis. Mr. Hoskins slumps further in defeat but goes along.

Two emotions flood me as I exit Mr. Hoskins’ cubicle, sorrow, and pity, almost overwhelmingly so. I don’t dislike my latest patient or the multitude of others whose “di’in’t know” or “cou’n’t say” made me struggle in various ways to care for them. The dual burden of heartache and sympathy stays with me though.

I have wondered however how has someone like Mr. Hoskins, with just over four decades on the planet, reached this depth of decrepitude?

About the time JFK was assassinated, my patient was someone’s cute baby boy. He may have had a horrible deprived childhood and upbringing, but maybe he did not. Either way, the world seemingly was wide open to him. Even if his immediate environment was impoverished or harsh, then TV, newspapers, the voices of others should have, could have, maybe even would have, carried the news of a different world “out there,” beyond his, to him. He had only to reach for it. He could have been more. Perhaps life’s circumstances just overwhelmed him.

I can’t say for sure; and I didn’t ask.

I don’t know anything about that.

I’m just the doctor.

I’ve heard it said that “if everyone knew everything about everyone else all the time then the world would be a very different place.” I’ve searched and I have no idea who created this wisdom. But, I definitely think it’s true.

A very different version of this essay was published in 2005 in the Annals of Emergency Medicine with the title “Who Does Know?”

Encounters like this one have happened hundreds, perhaps thousands, of times during my career.

If this article resonated with you please consider reading more from Michael Burg, MD at: