Welcome to The John

My stomach burned. I was too nervous to eat breakfast. I gulped a cup of instant coffee brewed in a dirty mug on an illegal hot plate. My coat pockets bulged with notes written on index cards. I hoisted the most recent edition of Cecil and Loeb’s Textbook of Medicine under my arm for ready reference. 

The John Gaston Hospital was a three-dimensional, Technicolored collage blending tragedy and absurdity. A yellow sign with black block letters in the clinical area of the emergency room warned there was to be, among other things, “No Musical Instruments.” The hallways smelled of body odor, cigarettes, antiseptic, and alcohol breath. Arrested  men and women were handcuffed to gurneys lining the hallways. The hospital was a relic of President Roosevelt’s New Deal, named after a wealthy Memphis businessman from France. The wide halls echoed with the footsteps of medical dinosaurs from when medicine was practiced by touch, taste, and smell. Watson and Crick had unwound the mysteries of the double helix, but that hadn’t changed the practice of medicine yet.

A hierarchy for the doctors-to-be and the doctors-in-training reigned supreme. Medical students like me occupied the lowest tier. Interns were a notch above the students. Second year residents had made it through the internship. Third year residents were eligible to sit for the Internal Medicine Boards upon completion of that final year. One or two exemplary third-year residents were invited to stay a fourth year as Chief Residents. These were aspiring academicians who invested an extra year of scholarly activity while learning administrative and leadership skills they practiced on their fellow residents.

This blend of naïve learners and the incrementally more experienced clinicians met daily at Morning Report. The lowest-ranking member of the on-call team gave a summary of every patient they had admitted overnight. Sometimes there’d be a dozen patients, and a dozen repetitions of pertinent positives, those historical or physical examination findings that by their presence supported a working diagnosis. The pedants often recited pertinent negatives, those signs and symptoms that in their absence ruled out other diseases.

The hub of activity for the on-call team was the emergency room. There were no elective admissions. Many of those who came to the check-in window seeking help found there were no words to describe how bad they felt. The clerk filled in the column used to document the reason for being seen as “just sick.” Those cries for help outnumbered the more specific complaints, like headache, diarrhea, or some other attempt at self-diagnosis.

A few people sat in plastic chairs provided in the waiting area. The others overflowed out the door into the long, wide hallway that was neither heated in the winter nor cooled in the summer. It was poorly ventilated year-round. They sat on the floor, their backs against the wall, where some of them waited for hours.

Other patients were delivered to the John Gaston in ambulances, taxis, and police cars. They often had no medical history other than the name of the street corner or the abandoned building where they were found. Many were unable to talk, and most weren’t accompanied by family or friends. These wounded souls of humanity, with no known address, no next of kin, and no emergency contact with the outside world were then given to a terrified neophyte like me, charged with sifting through the ashes in search of a diagnosis.

My first patient was a tiny, cadaverous-looking Black woman, lying motionless on a gurney with her eyes closed. After ensuring she had measurable vital signs, I spoke to her. She didn’t answer. I leaned, touched her arm, and yelled into her ear. No answer. As the textbook had taught me, I rubbed her sternum, the flat bone in the middle of her chest, with my knuckles. She still didn’t respond. I moved on to the rest of her exam. I pinched a small ridge of skin on her forearm. If she was well hydrated, it would revert to normal immediately. It took several seconds for hers to resolve.

I traced the bones of her skull with my finger. She had lost a lot of weight. Something was consuming her, something internal, like cancer, or something external, like the lifelong deprivations of a long list of social maladies that result in starvation of the body and the soul. More often it was a combination of both.

Her lips were cracked and bleeding. I used my gloved finger to find she was toothless, and her airway was clear. Her tongue was hard and dry. It reminded me of a charcoal briquet. I used my brand-new stethoscope to find that her heart sounds were faint and rapid, and her breathing shallow, but not labored. I pressed on her stomach, systematically, dividing it into four quadrants, examining each in a clockwise manner. I found no masses or enlarged organs.  Again, she showed no evidence that my touch caused her any pain. My touch resulted in no response at all. 

I tied a tourniquet on her arm above the elbow to look for a vein big enough to place an intravenous catheter so we could give her fluids. I looked where I’d hoped to see a vein appear, knowing that my experience with IV placement was limited to one unsuccessful attempt on a classmate, who, in what I still consider an act of retaliation, had also failed to start one on me. While I was considering my lack of qualifications and wondering whether it was humane for me to even try on this, my first patient, an intern appeared behind me.

“She’ll need a central line,” he said without introducing himself. I assumed by his air of authority that he was from the admitting team, and therefore, in charge of me. “Have you ever done one?”

“Never,” I said. “This is my first day.”

“Get us a tray,” he said.

I didn’t know what I was looking for or where to look for it. When the intern realized I was helpless, he sighed, stalked down the hall, and returned with a package in a light blue sterile wrap. He pulled an over-the-bed stainless steel instrument table to the bedside and opened the package. While keeping sterile technique, he examined the syringes, needles, and catheters. He freed up a stack of four-by-four gauze pads. “Go get some betadine,” he said, but having already decided I was worthless, he moved off to get it himself. He returned and poured the betadine into a metal bowl, pinched up some gauze with a forceps, then left it there to soak.  “The rule is to see one, do one, teach one,” he said. I realized this might only be his third, if he had only seen and done the requisite cases that qualified him to teach one.

He took off his gloves and threw them into a bucket under the gurney. “Help me get her positioned,” he said. “This ain’t gonna be easy.” We lined the patient up straight on the stretcher and adjusted her arms and legs like she was a toy doll. She was five feet tall at the most if she was standing. “She looks like an old person in a little kid’s body,” the intern said. He prodded at her neck, clavicle, and the top of her sternum, finding the anatomic landmarks by which he’d guide the needle into her jugular vein.

He stopped. “Prop her feet and legs up on some pillows, really high.” He didn’t explain, but I deduced that gravity would drain what little blood she had out of her legs, into her chest, then fill and dilate the vein in her neck he hoped to cannulate. He draped her chest with a sterile towel, took another, and draped it over her face. She didn’t react. He placed towels around a square area on her neck where he planned to insert the catheter and splashed betadine over the area of exposed skin.

He turned back to the instrument tray, picked up a small syringe with a smaller needle, waved it at me, and said, “We forgot the lidocaine.” I pondered the implications of the word “we” and whether that was a statement of shared liability or another teaching moment to show the importance of teamwork. A nurse who had been watching us handed me a vial.

“Give it back when you’re done,” she said.

I held the vial toward the intern, who said, “Swab the top of it with alcohol, then hold it upside down where I can aspirate it.”

I did so.

“And don’t hold it over the sterile field, and don’t touch my gloves.” He filled the syringe and squirted a small stream on the bedsheet like it was part of the ritual. I handed the vial back to the nurse while the intern positioned himself at the head of the bed. He leaned over the patient again, and yelled the time-honored warning, “This will sting for a second.” No response.

He found his landmarks, pinched the skin over her neck, and prepared to numb the area where he would puncture her with the larger needle. He pricked the skin, injected a little, then continued to inject as he moved the needle deeper.

The little woman shrieked a high-pitched other-worldly scream. She thrashed her arms and legs, tore the sterile towels off her face, and nearly dumped the tray and the instruments onto the floor.

The intern remained calm as he replaced a new set of towels and re-prepped the area with a second helping of betadine. The nurse reappeared with a disposable sterile syringe and more lidocaine, opened the packet without touching the syringe, handed it off, and positioned the vial where the intern could aspirate it.

“Hold her this time,” he said as if her outburst on the first attempt was my fault.

“Hold her wrists,” the nurse said. “Then lean over her chest. She’s too weak to fight. Touch her just enough that she can feel you’re there.”

Her wrists were so small I held both of them in one hand. I leaned over with my chest barely touching her. The nurse stood at the foot of the bed, her hands gently holding the woman’s ankles.  “These feet have walked some hard miles,” she said touching the thick callouses, the hard, curved nails. I hadn’t noticed them during my examination. Her knuckles, fingers twisted in different directions, also showed evidence of a hard life.

Without warning this time, the intern pricked the skin and injected the lidocaine.  She moaned softly, but this time she didn’t move.

“They’s gonna cut my throat,” the patient said, her first sentence said in my presence, said to no one in particular and as if she was resigned to it. The intern went ahead with the numbing, then picked up the syringe, found his landmarks with his left hand, and plunged the large bore needle through the betadine patch in search of her jugular vein.

She screamed, “Save me, Jesus!” But she didn’t move.

Blood flashed back into the syringe. The intern found the guidewire with his free hand, threaded it through the large needle, withdrew the needle, advanced a large catheter over the guide, withdrew the guide, and sutured the catheter in position. The nurse hung a bag of saline and turned the stopcock wide open while the intern applied a bandage and taped it in place. The entire process took less than a minute.

“You own this catheter,” the intern said without looking at me. “Don’t let her pull it out.”

His pager beeped, and he walked away to find a phone. My heart was pounding. I was drenched with sweat. The tiny patient now seemed unaware of anything that had happened.

“Help me put these on her,” the nurse said. “We don’t want to put her through this again.”

We buckled soft, wool, restraints to her ankles and wrists. The nurse left and returned with a tray full of glass tubes. “You’ll want to get some lab work,” she said. “Write your orders and I’ll get the blood.”

I sat with the chart opened to a blank order sheet. I couldn’t think of anything to write. The nurse rescued me again. “Get a full chemistry panel, complete blood count, and two sets of blood cultures,” she said. “Almost everybody who comes through here gets those.”

“What about a urine sample to culture,” I said.

“Good idea,” she said. “She won’t be making any urine until she has some more fluids. If you order it now, it’ll be missed. Make yourself a note to order it when she pees.”

We labeled the tubes, and I ran them down the hall to the laboratory. When I returned, the nurse was tucking blankets tight around the patient.

“Good,” she said, smiling. “You came back. She has a bed. We need to take her upstairs.”

I pushed the gurney, and she guided it onto an antique elevator that creaked and groaned up two floors then opened onto a long hallway in front of a busy workstation full of nurses, students, and doctors. There were stacks of charts on the desk, some with pages folded indicating there were new orders to be checked. Everyone was talking. Everyone looked exhausted. The charge nurse, who looked like a recent nursing school graduate, was on the verge of tears. 

She directed us into a large room with hospital beds lined with the head toward the wall, the foot extending outward forming an aisle between the two rows of twelve beds on each side. Each bed had a small table beside it, some cluttered with an assortment of empty water pitchers and bedpans, others with clean sheets and towels. The odor of urine, feces, and vomit mixed with the wintergreen smell of soapy water thickened the air. Most of the patients were like mine, barely alive. I paused by the door and imagined them reaching for me as I passed, pulling at my coat sleeve, their mattery eyes pleading, their mouths with rotten teeth and parched tongues, begging for one drop of water like the biblical rich farmer in hell, their helpless, hopeless bodies falling back on the bed in our wake. 

The nurse and I lifted our patient onto the last empty bed, replaced the restraints, covered her with a blanket, and then pushed the gurney back to the hallway. She punched the button to bring the elevator back. When it arrived, she stepped into the elevator. I looked at her, waiting for instructions.

“Welcome to the John,” she said.  The doors closed between us.