Just Do The Next Right Thing

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When burnout threatens, sometimes it’s the hardest cases that re-ignite our passion.

Around 5:30 in the morning I am called to see a patient with chest pain. In the stretcher, I see a skinny bordering on cachectic man around 50 years old. Not a great story for cardiac angina, but he is a heavy smoker with both parents having cardiac disease in their fifties. He used to take blood pressure medication and was told he was “pre-diabetic” but stopped taking medicine many years ago because they made him feel bad. Serious risk factors. He has been “stressed for several months” and reports losing about 10 pounds a month for the last few. I tell him frankly that he looks awful, and he replies, “I just have to outlive my dog” to which his girlfriend replies (because I chuckle) “He’s not kidding.” While I am listening to his lungs, I wave behind his back for his girlfriend, to meet me in the hall. There may be more than chest pain going on with this guy.

So, I pull her aside and talk with her for a while. To me, he seems horribly depressed and anxious. I want to admit him for 24 hours to rule out chest pain, but first I want to know how far I need to go down the depression/suicidal pathway. We stay pretty much focused on his complaints, and she keeps on saying, “There is more to this than meets the eye.” I think she is talking about how he looks like a multi-tattooed homeless junkie and reassure her I am taking him and his complaints very seriously but have concerns about his mental health as well. She validates this and talks about his bizarre behavior, such as how he usually breaks off the rearview mirror of any car or van they have because he hates to look at himself in the mirror and how he doesn’t really eat but smokes and drinks coffee all day.

My ED is in a tiny town in the Pacific Northwest. They are from Massachusetts and have been traveling since March. She says he sees himself as a “traveler” and doesn’t want to be settled in one place. She says her name is Susan, and she was an EMT and a social worker but has been with him for about a year, adding that she has been divorced for many years and has 3 children:  23, 22, and 19 (exactly 3 years older than my kids). They have been camping in the area for a couple of months and are vaguely working their way towards CA. They survive because he holds up signs on the highway or rest stops saying “Veteran–Need gas” and gets enough money to move on. Sometimes she paints rocks that they find and they sell them at rest stops, but he takes the money. As her narrative slowly evolves, she keeps saying, “There is more to this than meets the eye.”

I ask if she believes he is at risk. She believes he is. I finally ask if she is safe. “Of course, I’m not safe. I’m terrified all the time,” Susan replies. I find out he has taken the batteries out of her phone, so she can’t contact her kids or her friends. They keep moving around. He won’t let her read a paper or talk to people. If fact, he will be upset that we have been talking for so long. She has tried to leave before, but he won’t let her go.

At this point, Susan is crying. Fuck. I initially planned to do my routine rule out and have her help me convince him he need to stay in the hospital. Now I just think I need to get her away from him. I tell her to go to the van right now and get the phone numbers she needs to contact her friends and family while he is here, then come right back.

Meanwhile, he is getting suspicious. Shortly after she goes out to the van, the monitor on the room (camera) shows him getting restless and getting out of bed. Crap. “Call 911!” I say. We actually call dispatch directly. It is weird hearing your panic call paged over the always on scanner.

Phil, our paramedic, is in the ED helping out, and he is a big guy. The patient starts to rip out his IV and walk out. I update everyone on what is going on just before he starts to leave. Susan is still in the van, taking way too long. Phil takes out the IV before the patient rips it out and stalks out of the ED. Luckily the ambulance doors do not open, and he has to walk around to get to the parking lot. I ask Phil to go out and get Susan from the van (We don’t know exactly where the car is.) and bring her into the ED. Chest pain guy starts running from the entrance to the van, as he can see the door open. Phil starts running to the van. I’m at the door waiting for the police. Then Amber (CNA) starts running outside too. I’m on the phone with dispatch telling them not to let the white van leave then dropped the phone to the nurse and ran outside myself.

Seconds later, after the patient gets in the van (with Susan out-of-sight), the cops arrive. Crap. I had told Susan she was safe, and it would be OK and here he is in the van with her and they are leaving. NOOOOOOOO! So the cops are there talking to him, and she is outside the car with a backpack standing by the door and Phil and Amber are close, and I feel like I am watching some bad drama unfold, but nobody is making anything happen. Get her away from the van and inside the ED! Why is she still there?! Does he have a gun?!

Then Amber, bless her heart, pulls Susan by the arm and just takes her hand pulling her to our locked down ED. I come on the other side with my arm around her, then Phil follows leaving the cops to argue with the yelling patient in the van. She keeps trying to turn back, crying and saying, “He will be so angry, he can hurt people.” etc. We gently insist she keep walking away with us. We take Susan inside the ED. It’s over.

We get her breakfast. The police say there is not enough to file a warrant for his arrest, but I don’t care. I just want Susan to be safe. They escort him from hospital property and advise him not to return. He drives away. It takes an hour, but we get a victim’s advocate (two actually) to come and be with her. I buy her the bus ticket to Vermont to go to her friend’s place, which leaves the next morning. I make sure the advocates tell her we found “hospital resources” to cover it. She says she tried to leave and go there before a month or two ago and her friend sent a ticket, but she was thwarted by him.

The victim’s advocate may be able to arrange a temporary phone and battery replacement for her current phone so she can access her contacts. They are arranging a local hotel for the day/night. I buy her breakfast, which she barely eats. Hugs all around.

When it’s time for her to go, I offer up, “Just do the next right thing,” sage advice from my sister Debbie that helped me get through a crisis of my own and has become a personal mantra.

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