Respiratory Therapy 101: Just Keep Breathing

The ER physicians at my hospital are addicted to ABG’s. Our blood gas reports seem to have a crack-like effect on them; they take on hit of the ABG report and suddenly they can’t stop ordering them. It’s not just ABGs, it’s everything: CAT scans, lab tests, and more.

Not all of the ER physicians are like this. A large number of the ER staff only order ABGs if they’re indicated. But we have a large group of serial offenders who will order ABGs on every single patient that comes in: patients with hangovers, patients with GYN complaints, patients with orthopaedic malfunctions and the like.

Most recently one of our serial offenders has begun ordering ABGs on psyche patients. Recently I was asked to stick a needle into the artery of a paranoid schizophrenic who was having some sort of psychotic delusional episode; the patient had been brought in by police after acting in threatening and bizarre ways. Since the patient has a known psyche disorder and their chief complaint is purely psychiatric, why would the doc order an ABG? This doctor has also asked me to get gases on patients who were having homicidal ideation, nervous breakdowns, and a patient who was hallucinating that the Beatles were trying to kill her.

My question is, why? On a patient with abdominal pain or chest discomfort you can sort of justify asking for a blood gas; but on a patient whose only complaint is psychiatric, why would he ask me to stick a big giant needle into their arteries? Why, when a patient is already feeling threatened, would you ask me to go perform painful tests on them? What exactly is he hoping to achieve here?

This same group of serial offenders has developed a habit of ordering full-body CAT scans on everybody. While a CAT scan is very useful, it is not automatically indicated for everybody. Just because somebody says their head or their gut hurts doesn’t automatically mean we should make them ride the donut. The serial offenders will also check off every lab box on the standard order sheet, all the way from the BUN and BNP to the Urine and Stool specimens. Shit, for all the actual “thinking” they do, I could do their job: they walk into the room, interrogate the patient for all of five seconds, and then check every single box on the order sheet.

At that point, the question in my mind is: why even have an ER doctor? Any monkey can check off all the boxes, wait for the results, and then call the hospitalist to admit. The serial offenders don’t even do procedures most of the time; they’ll simply make the paramedics or the intensivists do the procedures for them. I often ask myself why we’re paying them to check boxes and delegate; I could do that just as effectively for a fifth of their salary. And I’d probably have a lot less of an ego about it too.

I should add that not all of our ER doctors are like that. Probably 60 or 70 percent of them are really quite good. The good ones that we have triage and sort their patients, order only what’s indicated, try to expedite the emergency medicine process. They don’t order tests that aren’t indicated, they don’t admit every single patient just because they can, and they do make an effort to perform high-quality medicine. But that bad 30-40% really make the ER a frustrating place to work.

In summary, the few physicians we have who are using inappropriate diagnostics way too much are driving costs and wait times up for the rest of us. They are increasing workloads on their staff, increasing expenses for the hospital, and decreasing efficiency and safety out of the force of their habit and quite possibly out of pure laziness. The few bad apples who inappropriately apply diagnostics are ruining it for the rest of us. How very frustrating.

Recently I was accused by a Californian of not being compassionate enough for my ER patients.  This individual points out that she, a chronically ill person on social security disability and medicare, has apparently used the ER twice in the last five years for asthma attacks.

To that I say, good for you! You’ve learned to use the ER only for emergencies. But you are one of the few who has figured out that the “E” in “ER” stands for “Emergency.” But judging by our patient population, I would say that the vast majority of people have yet to discover that.

The Californian accuses me of not having enough compassion towards my patients. This is probably true: a vast majority of my ER patients I have very little sympathy for. When somebody reeking of cigarettes comes in complaining of difficulty breathing, and then they whip out a 200 dollar cell phone to call somebody on while they’re presenting their medicare card to the registration person, it kind of pisses me off. If you can afford a 200 dollar cell phone and two packs a day of cigarettes, you’ve got too much money to deserve government aid. Why should I feel sorry for this person? Their problems are clearly their own fault and I don’t really see why we should waste our time treating people who clearly don’t want to participate in their own care beyond bitching at their caretakers.

Or how about your “chronic pain” patients? Before somebody else sends me a pissed-off email, let me state that I’ve seen some people with bona fide chronic pain, people who can’t even move or get up because of nerve damage or pinched discs. My mother herself had a herniated disc one time and I truly hope to avoid the pain of an experience like that.  But more than I see people with actual pain, I see people who are chatting happily away on their cell phone and laughing with their buddies until a doctor (or someone who looks like one) arrives, at which point they suddenly writhe about in agony and claim to be allergic to everything but morphine. They’re not sick, they just want to get high, and I’d rather that they generated a real medical emergency by playing in traffic. Then they could have something to complain about. They too need a reminder that the ER is a place for emergencies, not a substitute for your dealer.

So who do I feel bad for in our ER? I feel bad for the homeless who come in out of desperation, for the 40-year-old with the aortic aneurysm who is going to die and leave his wife and children. I feel bad for the miscarrying 25-year-old who did everything right. I feel bad for the asthmatic who was just trying to enjoy their day when their lungs turned on them. I also sympathize with the cancer patient whose body is slowly eating her alive, for the 65-year-old stroke alert who’s never going to wake up.

So don’t tell me I’m not compassionate enough. I feel bad for the people who are having true emergencies. I really do, and I really hope I am never in their shoes. But the people who just come around to get their drugs, or to get some attention, they get no sympathy from me beyond general pity that their lives have turned out this way.

Normally I am a very quiet person. My normal persona could probably be described as mild-mannered, but sometimes…such as for example when I am working in the ER (Scumble County’s best and the State’s busiest) and under a great deal of duress…I can get a bit snappy.

Today I was working in the Pedi ER. I don’t mind the Pedi ER too much: the nurses are nice, the patients are usually less angry than in the adult ER, and the patients are less likely to be ill secondary to their own actions. Despite all of that I do get aggravated when the Pedi ER doctors get on one of their kicks and begin ordering nebulizers on everybody.

The over-zealous nebulization in the Pedi ER is compounded by the fact that our standard respiratory order sheets have the “asthma protocol” orders at the top of the page. The asthma protocol order is for three Proventil/Atrovent nebs spaced by twenty minutes. Combine that convenient placement of the neb orders with the fact that many pediatricians overuse nebulizers anyway and you have the makings of doomsday.

Anyway, this morning around 11:00 I sort of lost my cool. I had been called for three children who had been ordered on the asthma protocol, requiring me to do nine nebulizers in short order. One child was coughing too much, the other was coughing not enough, and one child had a snotty nose. I looked at the orders, looked at the assessments, and thought for a moment. I turned to the nearest nurse.

“You know, I’m perplexed by this.”

“You’re perplexed?”

“Indeed I am. You see, the doctor has ordered albuterol treatments for all three of these children. One of them is coughing too much and she thinks it will stop his cough. One of them is not coughing enough and she thinks it will loosen him up. And the third child is full of snot, which has nothing at all to do with nebulizers.” The nurse gave me a funny look and shrugged.

“What can you do?” she asked me. A little spark inside of me suddenly burst into flames.

“I suppose,” I said in a slightly louder voice than normal, “that I could go and ask the damn doctor why she orders the same treatment for contradictory reasons. Does the chemical structure of the drug change on her whim? Can she magically make the drug change effects?” I took a deep breath and crescendoed. “Or is it possible that she’s just too freaking lazy to assess her patients and order appropriate treatments?”

I turned to stalk into one of the rooms that I had been ordered to go into.

And I ran directly into the doctor. The very same one who I had just finished badmouthing.

There was a moment that could best be described as horribly awkward. She stared at me, and I stared right back. It was too late to apologize or make nice. The moment continued for an uncomfortably long time. Some primal part of our brains wouldn’t let either of us cede dominance to the other. I imagined two gorillas in a staredown. It helped me keep eye contact.

Finally the doctor broke the silence and handed me a chart that was in her hands.

“Albuterol treatment in room five,” she said. I stood there, chart clutched in my hands as she walked away. I stood for a moment and watched her as she turned and walked unconcernedly down the hallway.

Two docs, two days. Apparently I am a one-man wrecking machine. I guess the only thing I can do is to laugh about it and hope that maybe I made an impression.

It had been a long day in the ER. The clock had ticked past six just moments before, and it was with an air of relief that I sat down on the stolen doctor’s wheely stool in the office. It had been busy: running around intubating people, doing blood gases, BiPAPing little old ladies and so on. I had spent some time assisting the pedi ER therapist with his ridiculous load of asthma patients and I had been going non-stop for the better part of the eleven hours of my day.

So it was that I heaved a sigh of despair when the Spectralink phone rang.

“Respiratory.”

“I need a blood gas in hallway bed two. But don’t hurry. She just got up to pee and it’s not that urgent.” I grunted my assent and then wheeled over to the door of the office to peek at the patient in hall two. I saw a middle-aged lady shuffling down the hall, in no respiratory distress at all, followed by a doting daughter and her baby. This is a total waste of time, I thought to myself. I bet if I wait on it they’ll forget all about it. I wheeled back into the office and reclined against the dirty wall. Pedi ER’s therapist came in and joined me in blissful repose, and we sat in the office and tried not to move for a few minutes.

Our reveries were interrupted when the door to the RT office was bashed in. An enormous man in green scrubs printed Hospital Property stomped into the room. I jumped a little but maintained my composure and my posture. He was a tall man and he stomped right on into our small office until he was crowding both the other therapist and me.

“Hey! Didja get me that blood gas yet?” he bellowed in a long Texas drawl. He stood in an impatient posture and glared at the two of us.  I assessed the situation and tried to think of the best reply.

“Um…no. Is the patient critical? I saw her walking to the bathro–”

“OF COURSE she’s critical! I’m only waiting on YOUR LAB to admit her! I need it!” He was not quite yelling, but he was not quite using his inside voice. His tone was that of someone who is used to people asking how high? when he says jump and on those grounds I immediately felt a clash with him.

“Well then, I’ll go ahead and get that for you.” We locked eyes, I planted firmly in my rolly chair and he planted firmly into the tiled floor of our office until he turned and stomped out of the room. The Other Therapist and I exchanged a look.

“What an asswipe,” said Other Therapist to me. “Who does that?” We made some more choice comments about the shouting doctor, and just before I could get up the door smashed open again and the doctor barged in bearing a chart.

“Hey! It’s this lady right here!” He pushed the chart right up into Other Therapist’s face and opened it to the page with the patient labels. “How many do you need? Huh? How many?”  I slipped in behind the angry man and grabbed two stickers.

“Just two,” I said quietly. He turned and wordlessly stalked from the room. Other Therapist and I again sent each other a look: what the hell was with this guy? I left the office and went to get the gas. As I expected, it was normal, perfectly 100% normal.  I printed the test results and walked around until I found the doctor, then I slapped it on the counter in front of him.

“Here’s your stat gas. It’s perfectly normal.” He grunted at me and I turned and walked away from him. When I got back to the office, the night shift had arrived and were settling in.

“Man, that guy’s a total ass,” I said. I repeated the incidents of the last hour to the night therapist who was replacing me.

“Wait a second,” he said to me. “This is a tall guy, green scrubs? Was his name Dr. Melted*?”

“Yeah, that’s him. I don’t think he was happy with us…” Other Therapist interjected at this point. “Yeah, he probably thinks we’re really lazy, I think we looked like the guys from Delta Delta Delta or whatever the frat was in Animal House.”

The night therapist looked at us with an expression of mixed horror and humor.

“Um, I hate to be the one to tell you this…but Melted is the director of emergency services here. He owns the ER. You just mouthed off to the director of the ER. You may as well have gone and pissed on the CEO’s desk.”

Needless to say, I was shocked by this bit of information. Had I known of it previously, I may have been a little less jerky towards the doc.

Whoops.

*close to but not actually his real name

Wow! According to some amazing new research, government programs for the needy place an undue burden on emergency services. Who would have possibly guessed it?

Now, before I get a thousand snippy comments from people who are angry that I am suggesting that the poor should be denied emergency services, let me clarify this. The reason that so many of these destitute bums* wind up coming to the ER is that they lack any other options. As I understand it, Medicare and Medicaid don’t typically pay well enough for private physicians to be willing to accept patients whose only means of payment is through those programs. This means that an enormous percentage of these people have no primary care physicians to do things like monitor chronic illness or manage minor ailments, and as such these people wind up presenting to the emergency room with bullshit complaints. People who aren’t in the field don’t seem to get this: our Fearless President recently stated that he thought it would be okay for people to just go to the ER rather than see a private doctor.

Now, even if we reformed Medicare/Medicaid and made it possible for the destitute* to go and see primary docs, we’d still have a fair number of problems in the ER. We’d still get the dumb-asses who come in pretending to hurt just to get drugs, the people for whom the question “what number from one to ten is your pain” is an invitation to suddenly drop their 200-dollar cell phone and pretend to writhe about in agony, screaming “it must be a twelve!” The only ways to get rid of these people are to either shoot them (generally considered unethical) provide them with terrible service so they don’t come back (frowned on by paper-pushers) or to perform large numbers of punitive diagnostics such as spinal taps and blood gases with 14g needles (also unethical.) I’m a believer that enough documented abuses of the ER should be grounds for refusal to treat; plenty of people get snotty and whiny about this, but they’re not the ones dealing with whiny liars all day.

But even if we got rid of the financial burdens and the lying whiners, we’d still be stuck with a big problem in the ER: overdiagnosis. By this I mean the overuse of expensive diagnostic exams for no real reason other than the ER doc feels like it or the ER doc fears a lawsuit if he doesn’t get this diagnostic. I was the victim of many useless diagnostics in a recent ER shift in which I performed 16 blood gases and four arterial lab draws with BGs in twelve hours. Of the 20 blood-gases I ran that day, maybe three of them were indicated: one on an unresponsive intubated patient, one on a decreased LOC, and one on a diabetic in DKA. The other 17 blood gases were drawn and analyzed mainly because one of our ER doctors orders them on everybody who comes in for no relevant reason. Now, a blood gas analysis costs somewhere around 200 dollars, so if you add it up I billed for 3,400 dollars in useless diagnostics over twelve hours. This is a problem in other departments, too: an enormous percentage of our patients get things like CT scans simply because people are out of ideas and want to feel like they are doing something. After all, even an unindicated useless exam is more something than nothing. Incidentally this is a clear violation of Rule 13, which I will be essaying about at a later date.

Anyway, the point I am driving at is this: the emergency medicine system is badly broken. No longer is it a system in which people having genuine emergencies are seen and treated by physicians who only use evidence-based medicine to solve simple and complex medical cases. It has become a catchall, a safety net in which the dregs of society are caught and given treatment based on either (a) the preferences of aging physicians who don’t believe in evidence or (b) the fear of lawsuits from irate patients. Genuine emergencies still come in frequently, but they are sadly overlooked and forced to queue with the patients who are in the ER just because they have nowhere else to go. Only if we can solve the problems of government healthcare, whiny liars, and overzealous physicians will the emergency room be returned to its proper place in the hospital: a place for patients in crisis to go and be treated.

Any ideas?

Busy, busy day in the ER today.

Four suicide-attempt overdoses, all intubated. One who vomited casserole all over, one who was fighting underneath her sedatives, one who was speaking in tongues and one who just laid there staring into oblivion.

One elderly man found down in his home, evidently there for several days. He had an abcess that you could lose your watch in on his backside. He was a bit leaky from most of his orifices, and even when all of them were corked up with various tubes and hoses he managed to leak around them. I felt bad for him but didn’t really want to get any of him on me, so I tried to keep my distance. When (shortly after intubation) he was found to have a pH of 7.01 (normal 7.4, his was way acidotic) the nurse told me to hang out because we would be bringing him upstairs soon. She called me later and told me we were going to transport “right now!,” so I tracked down my favorite supervisor and asked her to help me move him. I hooked up the BVM to the O2 and began to bag while my favorite supervisor took the ventilator upstairs for me. Something was amiss.

The nurse. She was gone. She came back, left, came back, left, and so on. Eventually I surmised that in her head, transporting “right now!” means transporting “in about half an hour.” So I bagged, and changed O2 tanks, and bagged some more until we went upstairs.

In addition to those five, we also had one patient who came via family. Her family mentioned that she was just acting unusual and breathing a little hard, and much to my surprise her ABG showed her CO2 to be a whopping 150 (normal 40…150 would be deadly in most people.) So we intubated her and took her upstairs eventually.

In addition to that we coded a skeletal old lady, consciously sedated a whole bunch of people, and did dozens of stacked “asthma” nebs.  All of this happened between about 1130 AM and 330 PM, and then we had a twenty minute lull.

And then a couple of guys decided to flip their SUV and so we had to take care of them, in between transporting our other intubated patients upstairs.

My ass is kicked. It’s time for a beer.

In my time as a respiratory therapist I have heard many excuses from patients. Typically the patients do not take their control medication; their excuses range from “I can’t afford the medication” to “I just forget to take it every single day until I come to the hospital…three times a month.” But today was the newest and my favorite excuse thus far.

I was working for most of the day in one of our ICUs, which was suspiciously calm, which I’m sure will not last long as tonight it is literally storming here. Towards the end of the day I got a frantic SOS from the therapists assigned to the ER, who were drowning in work. I responded to help them along with four or five of my comrades and was sent to the pedi ER, where a young man was wheezing away on a bed after not taking his medication for several weeks in a row. As he chugged down a fast nebulizer, I asked his mother about why he wasn’t taking his control medications.

“He don’t never feel like it! Fo’ real. He always sayin’ that he don’t need no medication because he feel good! He even tryin’ out for the football team.” The mother nodded at her son, who nodded to confirm her story.

“Well, I understand that he feels better. But if you stop taking the medicine, you’ll get sick. It only works if you take it. People often think they can stop, but if you don’t keep taking the medicine, you’ll wind up…well…like this. Do you have an inhaler or some albuterol at home for him to take? I mean, he needed to come to the ER right now, but do you have anything at home in case he gets sick?” The mother looked at me and laughed. A cigarette lighter and a fabric cigarette case dangled from her belt loops over dirty working boots.

“He ain’t got nuthin’! We used to have one of them things (here, she jerked her thumb at the nebulizer), but then somebody stoled it!“

:::

I know that there are criminals out there, but what kind of dumbass steals a nebulizer? You can’t do anything with it: it’s just a shitty air compressor with some tubing on it. I guess people could use it to make those “air shots” or whatever they’re called when you aerosolize alcohol, but a home nebulizer is so slow and powerless that it would take longer to nebulize than to drink. I suppose you could use it like drug paraphernalia, but…why a plastic cup? I guess I’m left in awe of the criminal mind, but from what I’ve been told the denizens of this county are known for their lack of intellect when it comes to stealing things.

Mielikki has written what may be the most deliciously punny take on talk-like-a-pirate day ever. It’s entitled…“C-P-Aaargh.”

It gets better from there. Just go read it.

:::

In the ER today we had a patient who ingested something like 130 pills of various sorts. He had recently been discharged from a local psyche facility, where they had prescribed him an enormous amount of medicine and no supervision. In the spirit of evidence-based medicine, I’m going to go ahead and say that the evidence suggests that the processes at the psyche hospital are probably not up to snuff.

In other ER news, I met my nemesis at the hospital today. No, it isn’t the ever-worrisome Sumdood: he is far too much nemesis in one package for me to handle. Instead, my nemesis seems to be a physician who I will be nicknaming “Doctor Dork.”

Doctor Dork is about five-ten. He sports a pair of totally dorky glasses*, wears black jeans instead of scrubs, and has a shrill and whiny voice more typically associated with basement-dwelling nerds than with charming emergency physicians. Even all of this is tolerable: however, his total presentation…his mannerisms, his lack of interpersonal skills, and his generally unpleasant demeanor make him possibly the most dorky person in the entire world.

Doctor Dork also has the gift of being able to make a controlled, normal situation into a scene of total chaos. During an intubation today, he was sequentially yelling at the RT, the nurse, and me to do things that we had either already done or were actively doing. He turned a controlled, easy intubation into a nightmare scenario for all of us simply by being a total douchebag. I have decided that he will now be my nemesis: anybody so annoying and utterly incapable of being calm and rational should not be in emergency medicine, and the urge to subtly drive him to the edge of a stroke is very difficult for me to resist. The question is, how can I drive him to stroke without endangering patients? The argument could be made that patient safety would improve with the removal of this physician: this is a man who routinely writes orders for insane things, like arterial blood sticks for problems like lower extremity pain.

I’m open to suggestions here. Drop me a line and let me know.

I was amazed to meet another RT today who is familiar with a rather obscure patient evaluation tool that I learned in respiratory school. I had been assigned to the Emergency Room with Tall Therapist, and despite the tri-county coverage area and the local populace’s wild antics, the ER was strangely still. We were discussing some of our older cases, in a totally serious and not at all cruel or mocking way, when the subject of a certain patient archetype came up.

We all know this type of patient. They’re typically aging rebel boys with a crazy “anti-establishment” lifestyle. They grow out of discontented twentysomethings and disillusioned Republicans or Hippies; they become withered, rapidly aged men with a great many tattoos and adentitious mouths. They are known for their cockroach-like ability to survive astonishing systemic insults and major trauma.

Their survivability can be calculated with this obscure tool that I learned in Respiratory School. It is called

“The Tattoo to Tooth Ratio.”

Despite the relative obscurity of the TTR, I was astonished to discover that not only did Tall Therapist know of this ratio: she may well have invented it. Indeed, while I would like to take credit for the invention or rediscovery of this technique, Tall Therapist has been practicing much longer than have I and is therefore much more likely to deserve credit for her discovery.

What is this “Tattoo-to-tooth ratio,” you ask? Simply put, the ratio can be calculated by dividing the number of tattoos present on the patient by the number of teeth remaining in the patients skull. For example, a patient with 24 tattoos and 2 teeth would be said to have the astonishing ratio of 12. A general rule of thumb is that if the tattoo-to-tooth ratio is greater than or equal to one, your patient is indestructible. The higher the TTR score, the lower the likelihood of a terminal outcome. A patient with a TTR of just two could be run over by a truck after being shot twice in the back outside of the bar in which they drank six fifths of whiskey, and shortly after admission to the emergency department they would be demanding cigarettes and sexual favors from any nearby persons.

A corollary to the tattoo-to-tooth ratio is the social contribution scale. generally speaking, the higher the TTR, the lower the number of points awarded on the social contribution scale. Hence the well-known fact that likelihood of survivability is inversely proportional to social worth.

So there you have it: a crash-course in the venerable patient assessment tool known as the TTR. Print this webpage out and present it to your supervisor for an hour’s worth of continuing education credits. And if you do, let me know how that works out for you.

::UPDATE:: William the Coroner has written about postmortem tattoo analysis here. Go check it out.

A number of months ago I promised to tell you all the tale of Incest McDrunkypants. Of course, I completely forgot to do so until just now. This is a true story that happened in the ER of Our Lady of Immaculate Grace several months ago, long before I had even begun this blog. The event was so unusual that I wrote it down, and now I will share it with you all for reasons not entirely clear to me. Enjoy!

:::

As we all know, drunk people are a source of endless entertainment. Sometimes they’re funny, sometimes they’re abusive, and sometimes they make you sad, but almost always they provide an interesting story in some way. One of the most fascinating drunks I’ve ever met was the young lady that I have dubbed Incest McDrunkypants. Ms. McDrunkypants came to be a patient of the respiratory care service for reasons not entirely clear to me. This…is her story.

It was three o’clock in the morning, the Magic Hour after bars have closed and before the sun begins to rise in which many drunks find themselves in some kind of trouble. And so it was that I was unsurprised when my pager went off and informed me that an ETOH patient in the ER was in dire need of some nebulization. I put on my blue labcoat and walked downstairs to the emergency room, sneaking in through the back room to avoid being accosted by anyone in the waiting room. I saw Grumpy Nurse at the nurses desk and asked her what was shaking.

“Nothing’s shaking. The patient in room four needs a neb. She’s asthmatic, been here before, came in through EMS.”

“Can I see her chart?” Grumpy Nurse slid the chart across the table a bit more forcefully than was necessary. “Keep it,” she told me.

I began to read the saga of this intriguing young lady. She had been brought in by Backwoods EMS after hysterically calling 911, claiming alternately to be pregnant, asthmatic, a victim of an assault, and A Fucking Angel, OK? Clearly the young lass had some issues, but according to the chart she also had some wheezing and a history of asthma. I sighed and made sure I didn’t have any stringy or sharp objects on my person and entered her room.

I knocked on the wall and pulled back the curtain. A young blonde lady lay crumpled on the bed in the fetal position, eyes closed, muttering strange things to herself. Her clothing was folded at the end of the bed and she wore two small hospital johnnies tied together to cover herself. Unlike many of our patients I could smell no alcohol on her. I was about to open my mouth to introduce myself when she opened her eyes and jerked upright. Her light blue eyes were wild under an alcoholic haze.

“Nobody…ain’t nobody believes me!” she said. I paused.

“What do you mean?”

“They don’t BELIEVE me! They don’t think I did it but I DID! I took TWO FUCKIN’ SHOTS!”

I stepped back and evaluated her, and she slumped back onto the bed and stared at the ceiling, chuckling. I took of my labcoat and hung it over a chair so she wouldn’t have anything to grab, and then I advanced slowly to the head of the bed and began assembling my nebulizer.

“I have this breathing treatment for your asthma, okay?” I squirted some DuoNeb into the cup and screwed the mouthpiece on. She opened her eyes and glared at me like a wildcat glares at a gazelle.

“You don’t believe me either,” she said, drawing out the words like a Western Movie Duelist. “But I did it. I took TWO SHOTS!” I sighed and turned on the nebulizer, handing it to her. She ignored it. “You wanna know what I took two shots of?” she asked me.

“Why don’t you smoke this thing and then tell me,” I said, pushing the nebulizer at her again. She took it and inhaled deeply like she was sucking down a pack of camels. She closed her eyes and inhaled the duoneb deeply for several breaths, and I leaned over to auscultate her. Contrary to Evil Doctors opinion, she sounded fine to me. I began to think. Is this a CYA neb? Suddenly she took the neb out of her mouth and screamed out:

“WOOO! Two shots of fucking JAGER, man! Two shots! FUCK YEAH!” She screamed this last part so loudly and in such orgiastic delight that I stepped back, afraid. Suddenly the mood changed. She began tExuberant laughter changed to weeping and sobbing, and she pulled her knees to her chest and started rocking back and forth. “I just want my daddy…”

I was deeply confused at this point. She spoke again, her voice escalating.

“I…want…my…daddy….” With a sudden urgency she snapped awake and looked at me. “Where! Where are my clothes, man?”

“Your clothes are right there.” I pointed at the pile of neatly folded garments. “Why don’t you breathe some more on your nebulizer? You’ll feel much better when you can breathe right.” She sat back, breathing in and out rapidly in a futile attempt to speed the treatment. She sucked in one final, deep breath and suddenly whipped the nebulizer down onto the bed.

“I need my daddy! Give me my clothes back you fucking pervert!” She ripped the top of her johnny open and jumped forward. I ducked back and stepped out of her room, actually just two curtains dividing her “room” from the hallway and the next cube.

At this point, things began to get weird. The curtain dividing her room from the next opened and a short, greasy, mustachioed man stepped in. He was in the room next to Ms. McDrunkypants with a comatose GOK overdose. I gawked at him as he eyeballed my half-naked patient.

“Sir! You can’t be in there. Get back in your own room. This doesn’t concern you.” He turned to me and smiled, and then turned and addressed my patient by her first name.

“(first name)! What’s wrong, baby?” He turned and looked at me. “I’m her uncle Waldo. Surprised Grumpy Nurse didn’t tell ya about me!” He stuck out a greasy palm, and not knowing what else to do I shook it. Truly this was bewildering. Uncle Waldo turned back to Ms. McDrunkypants and spoke to her again, sitting next to her on the bed and stroking her hair. “What’s wrong, baby? Talk to Uncle Waldo.”  He moved his hand and lovingly covered her up with her johnny again. My mental creep-o-meter began rising. I looked back at the nurses desk, where Grumpy Nurse was busily pretending not to notice any of this. My attention was directed back to the patient when I heard a painfully loud slap.

Incest McDrunkypants was standing on the floor, johnnies beside her, five feet of buck-naked fury. Uncle Waldo was holding his cheek where she’d slapped him. His face was bright red where her tiny hand had struck.

“God Damn you! This is all your fault! You and your fucking drug schemes! Why do you always fuck everything up, you ASSHOLE!” Waldo’s eyes got large, and then flitted around the room as he formulated a response. Slicker than a teflon-coated weasel, he began speaking to her in soothing tones.

“Aw, c’mon, baby…what are you talking about? You’re confused. Let me call you your daddy.” Waldo grinned, displaying rows of scary teeth beneath his ’stache. McDrunkypants began weeping again.

“Call my daddy for me. Call him, Waldo.”

“I’ll call him…I just, uh, I just need a phone book. Why don’t you let this man give you your treatment now?” Waldo motioned at the half-finished nebulizer sputtering impotently where it had fallen. It wasn’t nebulizing because it was on it’s side, and I could see about half a treatment left in there. Damn. They know it’s not done. That was my only hope.

Creepy Uncle Waldo brushed past me and left the ER by way of the waiting room, ostensibly to look for a phone book. Ms. McDrunkypants sniffled, covered herself up, picked up her nebulizer, and began to breathe. As she sucked down the oxygen-rich duoneb she began to relax, melting back into the pillow and regaining some of my sympathies. Cautiously, I reached forward and pulled a blanket over her, trying to calm her like you would swaddle a baby. Her blonde hair draped over the pillow and she closed her eyes. I stepped back and watched as she breathed on the nebulizer.

Finally her nebulizer sputtered out, and I took it from her and hung it up. I auscultated her from the front so as not to rile her up again, but it was all for naught when Creepy Uncle Waldo barged into the room. I frantically gestured for him to be quiet and go away but he ignored me and spoke, his creepy uncle voice booming out over the ER.

“I tried your daddy, baby, and he ain’t there. Ain’t answering his phone.” The patient’s eyes flew open once again and she thrashed violently under her blankets, ripping them off the bed and leaping ninja-like to her feet. I backed out of the room. Chris, a security guard, was waiting in the hallway, and he rolled his eyes at me as we watched the scene unfold. McDrunkypants screamed.

“God Damn You!”

With a fierce lunge, she flew naked through the air and tackled Waldo full-on. He fell to the floor with a thud, and McDrunkypants’ nails scrabbled all over him as she tried to bite his throat. An elderly patient across the ER looked on in terror as the security guard and myself approached McDrunkypants. Chris was able to get her off of him before she could rip open his jugular vein, and Waldo crab-crawled backwards away from her. Much to my dismay, she hadn’t even injured him. Grumpy Nurse had arrived by now and took the patient, womanhandling her back into her bed. Chris confronted Creepy Uncle Waldo.

“You need to leave.” Waldo looked around Chris’ bulk, trying to make eye contact with his niece. “Bye now baby, I love ya!” Waldo blew her a kiss and I considered throwing up on him just to demonstrate my feelings on creepy fiftysomethings blowing kisses at young women, but my dinner was firmly rooted in my stomach and wouldn’t cooperate. Chris took Waldo’s arm and escorted him out of the ER, Waldo’s eyes fixed on the young lady as he was marched out into the waiting room. Grumpy Nurse had another patient to attend to, and zipped across the ER. And so it was that I once more found myself alone in a room with this strange patient. She looked at me, her blue eyes drifting in and out of focus. She showed minimal signs of recognizing me.

“Hey. Hey you. Where are my clothes at? I want my pants back now.” I once more pointed at the foot of the bed, and I took my exit before she could strip naked again. Last thing I needed at this point was a homicidal angry naked drunk girl trying to dismember me.

Back at the nurses station, I spoke to Grumpy Nurse and Evil Doctor.

“What is her problem, anyway? Is she on drugs or something? PCP, LSD, coke, anything?” Evil Doctor shrugged, feet up on the desk, hands behind his head.

“Negative tox report. My best guess is that she’s just a live wire.”

“Are you sure? She’s insane. You saw all that, right?” At this point Grumpy Nurse interjected.

“She’s always like that. She was here a few months ago, same exact thing, except without the creepy dude. How did she sound?”

“She’s fine. She didn’t need that treatment in the first place, you filthy weasels. Unless you need me for something real I’m going back upstairs.”

The patient began shouting at us. I looked at her. Her pants were on backwards and her shirt was buttoned, albeit incorrectly.

“Hey! Don’t be fuckin’ around behind my back! Stop talking about me!” She stepped forward a little and glared at us all before turning around and shuffling back into her room. Evil Doctor stood and stretched.

“She can go. I’ll just go look at her so I can chart something.” He ambled off, and I took my leave of the ER. It was coffee time in the ICU.

Not five minutes after my arrival upstairs, the pager buzzed against my hips again, and I swore as I saw the number of the ER flash across the screen. I walked back downstairs. Before I even got to the ER, I could hear the screaming altercation between her and the ER doc.

“What now?” I asked Grumpy Nurse.

“She blew a .03 on her breathalyzer and she wants to go. We can’t keep her anymore. She’s not dangerous, just a pain in the ass. But Evil Doc thinks she needs one more treatment for the road.” Just as she finished that statement, Evil Doc stalked past me, fists clenched. A voluminous FUCK YOU followed him across the room. My ears hurt from the force of the shout. Evil Doc turned to me and gave me his you-die-now look.

“She needs another treatment. She still sounds bad to me.”

“Are you insane? She wasn’t that bad to begin with. I’m not doing it. She’s going to hurt me.” I glanced at her out of the corner of my eye as she ambled the perimeter of her room. She caught my eye and glared.

“I know you’re talking. About ME! STOP talking about ME!” She kicked at the bed, drawing a glance from Chris.

“Look. If she can scream that loud she doesn’t need it. I’m not doing it. You can call my boss if you’re that upset about it.” With those words I turned on my heel and left the ER.

::

Later in the morning, after shift report, I walked out of the hospital past the ER. I glanced in and saw that bed four was empty, and breathed a sigh of relief. She must have gone home. I turned to walk out the glass doors–

–and bumped directly into the patient. Her nose hit the center of my sternum and she looked up at me. I quickly backed up.

“I know you. And I know you were talkin’ about me all last night.” Her eyes narrowed. She stabbed a finger into the center of my chest.

“And I ain’t gonna forget it.” And with those words, she turned and stalked across the parking lot, angrily ambulating in the direction of the bus stop, five feet of female fury unleashed.

And that is the sad tale of Incest McDrunkypants. Just another day at Our Lady of Immaculate Grace.