The Emergency Department is garage sale of stories. Endless treasures of people and their lives that just unfold, like a dusty box sitting in the back corner of a shelf.
A 66-year-old Caucasian woman presented in the Emergency Department for increasing blood pressure.
This is how every chart begins. It is so boring. Medicine is so boring, so sterile. So much like a shiny department store. Get the new shirt, exactly the same color as you were thinking of, check out, go home. You have to dig at a garage sale. You have to get dirty and find that unknown teal sweater that you can use as a shirt. It’s that unexpected that makes it so exciting. This is why I went into medicine—those unexpected human connections.
The attending I was with went with me and interviewed the patient. He never trusted me to take the interviews by myself. Let me take that back, he was too bored to let me take the interviews by myself. He did not get the full story the first round of interviews. There is no offense to him—it’s what everyone does the ED. Nurses triage and get the patient a room. The doctor comes in and does a quick triage interview. Then they formulate a plan within about the 5 seconds of the interview. They sometimes formulate the plan before they even walk into the room—vitals check (high blood pressure), room number (22 was farther away and less emergent). Get the labs—this part would drive me crazy—the nurses would sometimes (most of the time) order labs and tests before the doctor even saw the patient. Wait for the results (EKG and all labs normal). And then re-formulate a plan. We are supposed do this. The ED is faster pace—attractive trait for some. It drives me crazy.
The first interview I noticed an elderly lady in the corner of the room sitting in a wheelchair. I waved at her. The attending did not even look in that direction. He did the “ED rounds”—which I actually liked—he would re-visit all the patients in all the rooms, makes sure he didn’t forget anything, go back and see how many he had left, how many he could kick out, how many were coming, how many were getting admitted. He was good. He did his job as a doctor.
The second interview, while we were waiting around for the labs, he asked a few more questions. “Did you have this before?” “What were you doing?” “Do you have a primary doctor…?” The lady in the corner in the wheelchair rolled herself closer to me.
“Do you know how old I am?” She said with a wink. Her blue eyes had a fiery twinkle in them. She was in the wheelchair, but she also had a cane, so I assumed the triage nurses probably made her roll around so they would not have to look after her potential fall.
She looked about in her 80’s. Osteoarthritic hands that was reminiscent of knots on tree branches. Her curly white hair loosely framing her face. Her wave-in-the-breeze whiskers that would have tickled her when she talked. She was holding her cane in one hand and the other was grasping a plastic bag full of bottles.
I engaged. The case was boring. The patient had high blood pressure, she didn’t have pheochromocytoma or anything out of the ordinary. Plus, this little old cute lady just needed my attention.
“I think you look about 85.”
“I’m a hundred years old! Well, I will be in four days.” She responded so quickly and rolled around in the wheelchair towards me; she would have rolled my toes over if I didn’t step back. She was wearing a brown plaid shirt, unbuttoned with a solid navy tee shirt inside, crumbs from a distant cracker on the lap of her black pants, white socks, and black tennis shoes.
“Oh, wow! You look great for almost being a hundred years old.”
She seemed to be really pleased with this. The face was so reminiscent of my own five-year-old when she introduces herself to people by her age rather than her name. This pride and joy. It actually is impressive. She then quickly added that she was not supposed to be in the wheelchair.
“They made me sit in this. They said I walk too slow. They probably don’t want to be sued if I was to fall. I know what they are thinking. But I know more than them!”
“Well, we just want you to be safe,” I said apologetically. By this time, the attending was giving me dirty looks. I got the impression that I was definitely not supposed to engage. We left once more to check the computer and review all the labs or reports that were pending.
“I’m not impressed. She needs to go see her primary. Her BP is 169/90. She’s fine,” my attending muttered under his breath as he squeaked his sneakers back to his chair.
The minute he sat down, the nurse poked her head at his desk.
“Your lady in 22–her BP is 198/98. You want to give her something.”
So he rolled his eyes, and gave the nurse an order for some blood pressure medication and squeaked back to the room with me tailing behind.
“So your blood pressure is higher—“ he started to say, but before he could finish the patient was already back to her story. She checked her BP pretty much all morning. Over and over and over again. On the same arm. She said she just was nervous about it because so-and-so had a heart attack once. They ended up having a conversation that I think lasted more than my attending could stomach.
The little old lady rolled to me again, and tried to engage my attending this time. “You know I can out-walk her by a mile? I’m not even on any medication, except for my aspirin. I’m going to be a hundred years old in four days. Look at all the crap she takes. You need to look these over.” She handed him the plastic bag full of the now apparent pill bottles inside.
At this new engagement, he had a desperate look on his face. Now he was tasked with doing a medication review and going into a much thorough history than he had cared for and talking to another person in the room. I took my cue immediately.
“So what are you doing for your birthday?” I asked. All of a sudden, I felt transported into another place. The beeps of the BP machine, my attending, the vital checks from the nurse, the overhead operator calling for respiratory therapy in room 2 all just…poof… disappeared.
“Huh? Oh! I have to show you something.” Her knobby hands reached behind her wheelchair. She had a black clutch that looked pretty weather beaten with a long shoulder strap. It wasn’t leather so the edges were frayed and almost appeared to be moth-eaten. She slowly unzipped her purse. She dug around until she found a coin purse that was pink and dusty brown. She then unzipped that and dumped a few coins into her hand. She fiddled around with pennies, then nickels and then picked up what looked like a brass quarter. She flipped it over and over and then placed it just right in my hand and said, “Read that!”
I looked at the brass coin, which was about the size of a quarter, but wasn’t a quarter. It read “Kitty’s Cat House (heart) Jackson, Calif” and in the center “Home for Tigers”. She could tell that I had finished reading it and quickly interjected. “Now flip it over!” She had this look of glee. Flipping it over it read, “All Night (heart) Check” and a “$3” in the center.
I immediately laughed and she, without skipping a beat said, “I’m not a prostitute! You know where I got that?” She was on fire! It was the funniest thing I had heard all day!
She went on excitedly to tell me that she lived in Oregon at the time and had a project of starting a tomato garden. Her husband had died by then. She told her son to dig and get the bed ready and he ended up finding this coin buried in the ground. She had kept it ever since. Her prized possession. The garden conversation immediately engaged me further.
“So, do you still garden?” I asked.
“No…well I have tomatoes on my porch in pots. She gets mad at me if I have too many things on the porch.” She pointed all of her arthritic fingers to the patient on the bed.
“How are you two related?” I asked, knowing well enough, never to assume anything.
“Oh her…that’s my daughter. She’s too fat. I keep telling her to quit eating crap. I tell her to cook her food at home and she wouldn’t have to take so many damn pills. But she doesn’t listen. She’s too worried about her damn blood pressure. She’s making herself sick by worrying about it—you know she kept checking it all morning and getting worked up? I told her not to! ”
And there it was. The root cause. Out of the mouth of an almost hundred year old. We make things too complicated.
“…But I used to. We lived in a farm in Kansas. We grew everything. We pickled when we had too much. We had potatoes that we would keep in the cellar all winter—it was a pile taller than you! I had my tomato garden and at twelve I still remember getting mad that something was eating all of my tomatoes.”
“Oh, no…” I engaged her in conversation.
I couldn’t even imagine her at twelve; she had the energy of 6-year-old at 100! She then went in detail to tell me about her anger at her missing tomatoes. She was fed up and decided to set traps all around the garden and hide in the basement all night with her sixteen-gauge shotgun curled in her lap.
“And every time I would hear the trap close, I would run up to see what it was. It was a raccoon. I would take it out of the trap, shoot it and set it up again! You know how many raccoon I caught that night?”
“How many?” I asked.
“I shot sixteen raccoon that night! And every time, I would hide in the basement and wait for another one of those suckers.” Then she had a very sincere look on her face. “After the sixteenth raccoon… I heard another trap go off…This time it was a fox. It was so pretty. I let it go.”
Her voice trailed off, almost in remorse about killing all of those animals. Her eyes disappeared off to the distance in an apologetic reverie. She then looked at the coin in my hand and took it from me, put it back in her dusty-pink coin purse, zipped that and then zipped the main purse zipper.
The beeps of the BP machine got louder, my attending by this point had vanished, the nurse was buzzing around, the overhead operator calling for something important again… all of it came back to focus.
She sat on the wheelchair, her eyes blazing in fury and vigor again.
“Now you know how to live until you are a hundred years old!”