Locum terror

My geriatric wiper blades were losing the battle against a late afternoon coastal storm as I turned onto the tree-lined winding road. It had not been my lifelong dream to work in a small hospital in a quaint Oregon town, but I was happy to have a well-paying weekend gig until I could find something better.

Three months earlier I had been living a frantic but enjoyable life in Manhattan. While my fiancé finished her OB/GYN residency, I was working as a hospitalist. When not on the hospital service, I focused on prolonged and moderately warped debauches. My house, or apartment to be exact, of cards crumbled the day the love of my life announced she had been accepted into a gynecology fellowship in L.A. I could come or not, it was up to me, but she was already packing.

The job market in Los Angeles was saturated. Everywhere I looked they only were hiring “nocturnalists.” The pay was great but the graveyard shift was not my idea of fun.

I thought about finishing a fellowship, but my medical school grades could be characterized as sub-prime. If I wanted to hang in there I would have to go the locums route. I chose Loco-Pros. I liked the name.

So here I was pulling into the staff parking lot of a funky old private sanitarium in the middle of stinking nowhere. I rang the bell and the creaky door swung open. A very pale and dusty nurse pointed to the staff lounge, but said nothing, though I seemed to detect the ghost of a smile. I sat down in the big overstuffed chair, closed my eyes and was instantly asleep after the long soggy drive.

I awoke with a start. A small twitchy man was leaning over me, well inside my personal space. His breath reeked of garlic. I pushed him back. He wondered, in a whispery chuckle, whether I was the new doctor or a patient. I assured him I was no patient, but Dr. Jack Kell, the locum.

I asked if he was Dr. Karl Loff, who was supposed to check out the service to me. He told me he was Peter, Dr. Loff's physician assistant, and that Loff was in the laboratory and I'd meet with him later. He rattled off brief facts about the patients who were in the facility at the moment, most of them on a long-term basis. One patient was some type of transplant, which made me nervous. Kidneys were sometimes obtained under dubious circumstances. I could see it happening here.

As I headed off on my rounds, I went up the ornate staircase, my fingers trailing along velvet wallpaper caked with dust. This place was definitely off The Joint Commission survey list. There were no hand-washing stations, no crash carts, very little modern equipment. There were more safety violations than you could shake an injunction at.

My first patient was a Mr. Cheney. I hoped it wasn't our former vice-president, as I was no expert on pacemakers. I reviewed the chart outside his door to assess the situation before entering the room. There appeared to be quite a lot of screaming inside; he was probably delirious or watching reality television. The chart described him as a 48-year-old with episodes of altered mental status, photosensitivity, and hirsutism as well as ocular and oral symptoms. Could it be acute porphyria? I thought a few blood tests would be warranted. I decided to visit the patient later.

I was puzzled by the minimalist checkout on the patient in 208, which was, by my best guess, “Creat… Lagoo… fluid.” Perhaps “Creat” was creatinine? I knocked and entered, introducing myself as Dr. Kell. I was struck by the patient's skin disease, obviously a severe case of ichthyosis or “fish-scale skin,” possibly combined with chlorosis or iron deficiency, giving him a greenish tinge. He gurgled with each breath.

I placed my stethoscope against his side. He had coarse rales and appeared to be in heart failure; his skin was cold and clammy. He might be having a myocardial infarction. I asked him if he was having any chest pain, but he only grunted and shook his head. This patient needed an EKG, full lab and 60 mg of IV Lasix. I would dry him out. I was sure what to do for this one.

Next, I arrived outside room 202. I looked at the thick, dusty chart on the door and could not read a word. It was probably the worst handwriting I'd ever seen. It looked like it was Arabic or something. No help there.

I did know that the patient, a Mr. Rom Seas, had been admitted by Dr. Canavan. When I swung open the door into the very luxurious room, I saw Mr. Seas completely covered in some kind of wrapping. I was thinking psoriasis. All I remembered from dermatology class was “If it's dry, wet it, and if it's wet, dry it.” Looking at these dried-out old wraps, I decided he must have started out really wet. The dressings had not been changed in a really long time. I began to unwrap them.

The patient did not stir. It took me a half-hour of effort to unwrap all the layers. His skin was like parchment. He did not seem to be breathing; in fact he looked quite dead. I quickly rewrapped him, and quietly left the room. I wasn't about to rock that boat. I sure wasn't going to take the heat for it and have to do all the paperwork. Perhaps I'd skip my note on him.

I headed down the next hallway. It was getting late, and I wanted to find the call room. Coming toward me was an older, distinguished man in a lab coat, unusual only in that it was black, not white. He greeted me with a sonorous “Good evening.” He was the lab tech, Lou Gozey. We discussed some of the patients, especially the one I thought might have porphyria. We went down to the room together.

On our entry, the patient was writhing in restraints. His eyes were red, his lips were thin and his teeth quite prominent, and he had an unusual hair distribution pattern. I asked Lou if he could get porphyrin studies and glucose on him. It seemed like a difficult stick, but Lou leaned right over and somehow quickly got the specimens. He told me that the porphyria test would have to be sent out to another lab, but smacking his lips oddly he assured me the patient was not diabetic.

Gozey was in the process of showing me to the call room when an overhead buzzer went off: “Code 45 in the OR. Code 45.” Lou began to sprint down the hallway with me close behind him. We entered a large OR filled with unusual high-tech equipment. Dr. Karl Loff and his assistant, Peter, were working hard to resuscitate the patient, a huge man with many scars.

Through a large window, I could see that the storm I'd driven through to get here had gained strength during the evening. Suddenly, the power went out and emergency generators provided a small amount of light. I ran up to Dr. Loff and quickly introduced myself. Dr. Loff explained that the patient had received “multiple cadaveric transplants.” I tried to feel a pulse. There was none.

Dr. Loff stood as if paralyzed. I pushed him out of the way and began chest compressions. I called for the defibrillator, but both Lou and Dr. Loff looked at me like I was crazy and told me they didn't have one. Then Dr. Loff got a sudden gleam in his eyes. The power might be out, but the storm was raging. He ran to the window, opened it, and extended through it a large metal rod and a series of coils. I rigged up two metal pads and attached them to the coils.

When the next bolt of electricity hit, the system charged, and yelling “Clear,” I shocked the patient. Nothing happened. After another bolt, though, I felt the subtle stirring of the patient's pulse. I cried, “He lives. He lives,” and collapsed to the floor with exhaustion.

Later that evening I saw the patient walk. He held one hand in front of him, dragged his leg and mumbled incoherently. I suspected there had been some neurological damage from underperfusion of his brain during the resuscitation effort, but hopefully it would improve. Lou escorted me to the call room. I wasn't all that tired any more, but after a few soothing words from him, I found myself growing unexpectedly sleepy.

The next morning I awoke with difficulty. When I stood up I felt lightheaded, like I was hypotensive or anemic. I brushed my teeth. The mirror was fogged with hot water; I could not clearly see my image. I rubbed my fingers along my jaw to see if I needed a shave, and felt two large sores on my neck, as if someone had placed and removed two central lines during the night. I had lost my desire for breakfast. I felt like lying back down and spending the day asleep.

Suddenly, being a nocturnalist on the graveyard shift seemed much less horrifying.