Here's a story:

Patient is brought in by the cops, barely able to stand up by himself, completely drunk. Blood alcohol level is almost 300. [80 is legal limit for drunk driving in most states.] Why we have to babysit drunks who don't actually have a medical problem we can treat is the larger question, but anyway...

We keep him overnight, next morning he's belligerent but doesn't seem drunk anymore. We're trying to discharge him. He doesn't want to be here anymore. We don't want him here. We're getting the papers together. We tell him it'll be an hour. He calms down.

An hour later, my intern goes to deal with the discharge. Comes back and tells me he doesn't seem right. Slurring his speech, can't sit up straight, etc.

I go and check on him. Yeah, he seems drunk again. We run his blood alcohol level again, and it's actually higher than when he came in, pushing 350.

We call hospital police to search his room. What did he sneak in here, and how?

They find nothing.

So we're baffled. My intern asks if something else might be going on, and I don't really have an answer. I don't know.

By habit, I squirt some sanitizing foam on my hands as I leave his room...

There's no foam in the dispenser.

It takes me a second.

No, can't be.

We look, shoved behind the door, the squeezed-dry, empty bag of hand sanitizer.

Alcohol-based hand sanitizer.

He drank a bag of hand sanitizer.

Awesome.

Happy Thanksgiving.

I was working, of course.

I thought the ER would be empty on Thanksgiving. Or if not, that I would at least get some funny stories out of it. But no such luck. Just the normal assortment of alcoholics and the uninsured.

My ER rotation ended yesterday; today I started back on the hospital floors. I've got two interns and a med student under me... and no one between me and the attending. So I may actually be able to accidentally kill someone this month. You'll have to stay tuned.

Another resident and I are going out for a belated Thanksgiving dinner tonight, since we were both working last night. I think he's even more jaded about this place than I am, so conversation should be spirited.

"What's that smell?" asked the nurse.

"I don't know."

And we scanned our wing of the ER for a few minutes before determining that, yes, our drunk 21-year-old had gone to the bathroom in his pants.

Again.

We gave him three new pairs of scrub pants, over the course of four hours.

He kept soiling himself.

He kept apologizing for it.

And then he kept doing it again.

How much did he drink? We don't know.

Is this the first time he was drunk? Maybe.

It was the first time he'd been to our ER.

***

"I need you to remove my hemorrhoid," said the 50-year-old postal worker.

"Sir, we don't do that in the ER. You need to make an appointment with the clinic, or with an outpatient specialist. It's not an emergency, and it's not something we can spend the time doing here."

"Doctor, I've been to three different ERs this past week trying to get someone to take care of this, and every time I've been turned away."

"Yes, exactly. That's not something anyone's going to do for you in the ER. You're wasting your time. You need to make a clinic appointment."

"I'm not coming back again. I've already wasted three days on this--"

"Yes, you're wasting your own time. You will have to come back again, but not to the ER. You need to go to the clinic."

"But I'm here now."

"And I can't help you now."

"Then I'll wait."

"Sir, this isn't a problem we are going to take care of in the emergency room. You should leave, call the clinic tomorrow, make an appointment, and then come in when they tell you to come in."

"No. You're going to do this now."

"Sir, I'm not."

"Then I'll wait."

"I don't want to have to call security."

"Does security know how to remove my hemorrhoid?"

"I can certainly ask them to try."

"While I'm here in the ER anyway, will you..."

No. No, I won't. I won't check your cholesterol. I won't give you a colonoscopy. I won't renew your birth control pills. I won't give your husband a drug test. I won't fill out your son's school physical form. I won't call your boss and tell him we need to keep you overnight (even though we don't). I won't give you a box of band-aids. I won't check your vision. I won't tell them to go ahead and put breast implants in your wife while they have her chest open anyway...

The emergency room is not your one-stop medical clinic, to deal with all of your problems at once. You're here for a reason. Hopefully. We're going to deal with the reason and then you're going to leave so someone else can take your place. We're not going to go through your file and do all of your outpatient checkups, renew your medications, and look at the bruise on your leg. Go to a doctor. Go to a clinic. If it's not an emergency, do not ask me about it. This is the emergency room. For emergencies. Not for elective medical care, maintenance, follow-up checks, or workplace physicals. This is for when you've been shot or you're having a heart attack.

Or you've tried to kill yourself and failed.

And maybe this is a controversial point of view, but I don't really understand why we're making people who actually want to live wait around bleeding to death while we spend our energy trying to save people who want to kill themselves.

We're saving them so they can try again. Or we're saving them but now instead of just being depressed, they're going to be depressed and in a nursing home, painfully recovering-- or not recovering much, and having minimal brain function for the rest of their lives.

If you're a 92-year-old with terminal cancer who swallowed a bottle of Tylenol PM hoping to end it, why are we fighting to bring you back, to a vegetative state, so you can linger for a few more months?

While we leave the guy in the car accident on a stretcher, waiting for a doctor to be free to deal with him.

And, no, I won't clip your toenails while you're here anyway. Go away. The ER is terrible.

"Mr. Walker said he thinks I'm an incredible doctor."

"You realize Mr. Walker also called the meat loaf incredible, right?"

***

Oh, come on.

Give me one moment to believe I can do this.

Give me one moment to forget about the sixteen times I stuck someone with a needle looking for a vein, lying to him through the whole process, telling him this was normal, telling him it takes every doctor this many jabs to get blood.

Yeah, every doctor who doesn’t know what he’s doing.

"This makes your veins healthier."

"I’m just trying to air out your skin."

"These holes will make it easier for you to breathe."

Believe me, it’s hard to keep a straight face. But this is the job. Stabbing sick people, fruitlessly, over and over again, without laughing.

And then the attending has to go and ruin what I'm pretty sure is the only compliment I’ve been given by a patient the entire month I've been in the ER.

Argh.

"I am right," said the attending, to a room full of residents at the annual lecture on professionalism and effective patient care.

"See, before you’ve even asked me a question, I’m already telling you I know the answer. Say it with me. I am right. Make it your mantra. You can’t be afraid. All we have is our authority, and as soon as we start letting any doubt creep into our patients’ minds, we’ve lost our power completely. This is what separates us from WebMD. This is what keeps us in business. This is what their insurance companies are paying for. Confidence. Decisiveness. Answers. I am right. I am always right. I am right, I am busy, and I don’t have time for you.

"That last bit is especially important. Patients are expecting more and more from us. 24-hour access. Calls back when they leave a message. An answering service that actually answers. E-mails. Web chats. Doctors on demand. They’re starting to forget how the system has always worked, and who holds all the cards in the doctor-patient relationship.

"Be upfront. 'I don’t have time to hold your hand and walk you through it.' Leave them wanting more. Whether they’re asking about their prognosis, or they’re asking where the bathroom is. You are the one with the information. You are the one with the power. Yield it only when you have to, and tell them only enough to get them to the door. You tell them too much, and they get greedy and want more. And pretty soon you’re spending your whole day explaining the pros and cons of eight different kinds of birth control when really you should just be sterilizing any patient who dares even ask you a question.

"They want second opinions, let them try. But don’t make it easy. 'You can look for other answers, but you’ll only be wasting your time. There are people out there who will tell you anything. There are always going to be people who will prey on your vulnerability and give you the answer you want to hear. They’ll drag you down a path of false hope and wishful thinking, dead ends in the maze of life, until you finally get back to the very same place you’re sitting right now. And we’re just talking about directions to the bathroom, which, as I’ve already said three times, is only for doctors and hospital staff, and we really can’t have you using it.'

"People have forgotten that we’re the ones who went to medical school. Ten years ago, would anyone even think of bringing in a printout of a medical study and asking us to look at it? Not a chance. They would accept whatever disease we’ve told them they have, and learned to deal with the consequences. If your doctor didn’t know something, that piece of information simply didn’t exist for you. We can’t know about every new protocol, every new treatment, every new cure. But the way to learn is not from people handing us pieces of the Internet. It’s from drug reps or the natural course of information-sharing. They can’t expect to have every chance to survive. They’re lucky we give them a fraction of the medicine that’s out there. And we can’t let them forget that.

"Don’t admit mistakes. Blame the patient. Pretend you have to leave. Create a distraction. Hide the ball. Instead of dwelling on the cancer, and how you should have seen it on the previous scan except you never even looked at it before it went into the file, berate the patient for having the nerve to keep you waiting. 'Why people like you don’t go to the bathroom before you come see me will never make any sense. I kept you in the waiting room for an hour and a half. Surely at some point, it could have crossed your mind that you’d be better off going to the bathroom now than waiting until I’m ready to see you. But, no, let’s waste my valuable time—and the less valuable time of everyone else still sitting in the waiting room. I know, it’s too late for this visit, but maybe you’ll remember next time. If there is a next time. The cancer’s inoperable, and I don’t know how much longer you’ll live. So this may be the only time I see you. Thus my last time to teach you this lesson.'

"'Although I’ll try to squeeze in another appointment, since your insurance has an unusually high reimbursement rate.'"

I think I raped a patient last night.

Okay, that's an exaggeration-- maybe-- but to the patient, who knows.

Elderly man who spoke a language I'd never heard of (and virtually no English). Comes in, seems to have a fever, but we can't understand what he's trying to say. Finally we figure out what language and get the right interpreter on the phone. We think. But it doesn't seem to be going well.

We're trying to see if he's oriented. We ask him what year it is. The interpreter says he didn't really answer the question. That he just said something like, "I'm an old man." We ask if he knows where he is. The interpreter again says he said, "I'm an old man." Finally we figure out he's got chills and some other vague symptoms, some bleeding, possibly some urinary symptoms, it's not entirely clear.

The attending is getting frustrated with the pace of the translation, finally gives up and disconnects-- so we're just left with this guy who's fairly confused and definitely doesn't know what we're saying.

And the attending tells me we need to do a rectal exam. Tells me I should do a rectal exam. Tries to explain to the patient what's going to happen, but the patient pretty clearly isn't following and has no idea what we're saying we need to do.

I'm trying to go slowly and explain, with reasonably-appropriate hand gestures, what we need to do. The attending is looking around at the backlog of patients, clearly wants me to hurry up. Finally just tells me to do it. He yanks the patient's pants down, and tells me to do it.

So I do it.

And the patient just stares straight ahead, this look of shock on his face. As in, "what is going on here? what is happening to me?"

And I don't even really know how to say, "I'm sorry," or "This was important," or "You can pull your pants back up."

And the attending heads back to our alcoholic homeless patient, and I hear just the tail end of their conversation-- "You really want to know in the METRIC SYSTEM how much alcohol I drink? You think I know the METRIC SYSTEM?"

"I have a neck injury from an accident I had three days ago. I need some pain medication. I've taken Vicodin in the past for similar and that seemed to work. Can I have some Vicodin?"

"Did you see a doctor after this accident?"

"No. The pain wasn't so bad right afterwards, so I didn't see a doctor. But I feel the pain now. And it's pretty bad. Can I have some Vicodin?"

"Sir, we should really do some tests to get a better sense of your injury. Can you show me where it hurts?"

"No. It hurts too much to start showing you. Can I have some Vicodin?"

"Well, we're definitely going to need to do some lab work before we give you a prescription for anything."

"No. Why would I need lab work? I'm fine except for the pain. Can I have some Vicodin?"

"No. You may not."

Which is the fake ER patient?

1. Woman comes in saying she tried to commit suicide, took 25 sleeping pills, mixed it with alcohol. She seems normal and alert. Blood alcohol comes back negative. She says she actually thinks she only took 10 pills, and no alcohol. Still no evidence she actually took anything. We tell her to rest for a bit and we'll check on her later. She screams as we walk away. "Aren't you going to give me something to help me sleep?"

2. Young guy comes in with a friend, drunk, says they're from a local college. ID badge says he's 25, so I ask if he's a grad student, says no, he's an undergrad. Looks young too. We let him sober up, seems like he's fine so we're doing the discharge paperwork, and his friend says wait, that's not his name on the paper. So I'm thinking uh oh, someone screwed up the ID badge and got him mixed up with someone else. Nope-- the same fake ID he used to get the alcohol, he used in the hospital. So he got admitted under a fake ID, is really an 18-year-old freshman. The nurse tried to get hospital police to scare him but they said that if we got them involved they would have to actually arrest him and didn't want to bother. So the nurse just pretended she was some kind of hospital administrator and gave him a stern talking-to (and took away the fake ID). I'm just glad the friend was stupid enough to screw it up for him, because otherwise we've got records under a fake name, no way to bill the patient, etc. What a mess.

3. Obese woman comes in with a varicose vein that literally burst. She is dripping blood from her leg, it's coming out in spurts. And she also has a bunch of bedsore-like ulcers all over her leg-- basically big sore holes. I nearly passed out, this was seriously disgusting. I've never seen anything like this before, but the attending said it's not that uncommon. Still disgusting.

4. Elderly woman comes in, quietly pulls me aside. "I'm itchy." I step back. "I keep seeing bugs on me." Scabies. I begged the attending to give her to the other resident. He liked me, so he did. I do not want scabies. I do not do not do not want scabies.

Give up?

So do I. They're all real, and they're all from one night. Along with a dozen of their compadres. Welcome to the emergency room.

Last night, a drunk guy comes in-- belligerent, reeking of alcohol, vomit all over his clothes. He's refusing to answer any questions, insists he isn't "some homeless bum," and finally we end up just letting him sleep it off.

I come around in the morning, wake him up, to try and figure out if we're just going to discharge him or what. And he opens his eyes, and politely inquires-- with a British accent--

"Excuse me, where might I be?"

"Wait-- what--? You have an accent?"

"Excuse me?"

"You didn't have an accent last night. Where are you from?"

"London."

"You came in here last night, drunk, and you did not have an accent."

"How odd."

"Yes, it is. Are you sure you have an accent?"

"Yes."

"Hmmm. Haven't seen that before. Do you remember what happened last night?"

"I gather I had a little too much to drink."

"Look at your shirt."

He sees the vomit. "Oh, dear. I'm terribly sorry for any inconvenience I may have caused you."

"Do you have a job? Where do you live?"

"Of course I have a job. In fact, that's how I got here."

"What?"

"We had a work party. I guess I should have been more careful."

"You had an absurd amount to drink at your party."

"I guess it seems I did."

"What kind of work do you do?"

"I'm an accountant."

"Oh. Wild party for accountants."

"You have no idea."

I am getting used to crazy people.

Patient comes in last night after falling and hitting his head. Seems a little altered although his girlfriend says this is his baseline. Standard next step is CT scan. Patient starts freaking out. "No, I won't let you put me inside a machine, no, no, no, no," he starts screaming. We explain that we're just trying to rule out a brain bleed and the test will be quick, won't hurt, finally he agrees. The attending has me go with the patient. We get there and he starts freaking out again. Gets off the stretcher and pulls off his gown and starts running through the halls of the hospital, naked, screaming. I call the attending, who is now even more insistent we do the scan because the guy really does seem altered. The attending chases him down the hall and corners him. The patient eludes him and ends up inside a supply closet, locks it from the inside, refusing to come out. We get hospital police, who aren't real police but just basically thugs with a uniform, who get a key, unlock the closet, and carry the patient out, force him onto a bed, and my attending injects a sedative into the patient and puts him to sleep. This morning, he is calm and has no memory of what happened.

Two gunshot victims.

And, no, they didn't shoot each other.

The homeless lawyer I'd seen a few weeks ago returned, with no real medical problem but he'd figured out the system. If you get arrested, and you tell the police you have some sort of medical issue, they take you to the hospital instead of jail. Buys you a little time. Gives them a chance to decide to forget about it. He was caught shoplifting over-the-counter medicine to sell to other homeless people. He told the police he was having a seizure and needed medical attention. He wasn't having a seizure. But they didn't know, so they brought him into the emergency room just in case. He didn't remember meeting me.

I feel like the whole night was a bit of a dream. As a person, I feel so removed from this world I see as a doctor. I don't know criminals and gunshot victims. I don't travel in these kinds of circles. I went to a good college, a good medical school, I know lawyers and marketing directors and account executives. I know people who aim to one day live in the suburbs and be active members of the PTA. I don't know drug dealers. I don't want to know drug dealers. I don't want to know police officers. I don't want to know that the world is pretty messed up.

But at night I see people who don't know doctors. Who don't know lawyers and marketing directors and account executives. I'm as foreign to them as they are to me.

One of the gunshot victims died. I didn't even get to know his name. Shift was over before they looked for any ID.

Well, that settles it.

I have no desire to work in the emergency room.

I knew it, but now I really know it.

I've also forgotten how to put in an IV, can't draw blood, and don't know the first thing about giving someone stitches. It's amazing how two weeks of vacation can wipe the slate clean.

We had a homeless guy brought in, "passed out on the street" with a bottle of rubbing alcohol. Everyone's so judgmental. "What a pathetic guy, drinking a bottle of rubbing alcohol until he passed out."

Well, it turns out he was sleeping on the street, and he used the rubbing alcohol to clean himself. And there was no reason for him to be in the emergency room.

Except that they cut his sweatshirt off of him when he got here -- more clothes are cut off people in the emergency room than I'd ever realized, and in most cases it makes no sense. You can pull someone's boxer shorts off. There is no reason to destroy them just because there's a pair of scissors you're allowed to use. I don't know why, with all of the fancy machines and tools we have access to, everyone's running for the scissors and can't wait to cut people's clothes off them.

Anyway, now he has no sweatshirt, and that sucks for him. I tried to find him a hospital sweatshirt to replace it, but I couldn't. Then I tried to get him a pair of scrubs -- just so he'd have something to go back out into the world wearing -- but the scrubs are dispensed from a machine that hates me, and I tried to trick the machine into giving me an extra pair (we're allowed two pairs -- when a pair is dirty, you put it in the machine, type in your number, and exchange it for a clean pair -- so I put the scrub top in separately from the pants, hoping the machine would think it was two different pairs -- except the machine is smarter than that, voided the whole exchange, and now they're saying I have two pairs of scrubs out when really I only have one, and I was wearing them, so I couldn't give this guy anything).

Also, don't tell a doctor someone hurt you unless someone actually hurt you. That was an hour and a half with a social worker when it turned out two kids were just pushing each other in the playground.