I am now working in a community emergency Department. This emergency department is in a rough part of an inner city community and it happens to be extraordinarily busy. Every time I show up for a shift, there are at least 7 ambulances in the parking lot 40 patients in the waiting room and all 36 patient rooms are full. The minute I hit the door it is "go time" and it seems that for the next 12 hours I am constantly running from room to room fixing this, fixing that, doing a lumbar puncture here, and intubating somebody there, doing an incision and drainage here, and repairing a laceration there.
I like this emergency department because it is in a community type setting therefore when I have to call a specialist it is usually a private physician at home and not a resident in house. These private physicians at home on call are usually paid to be on call and happy to be busy or to get business. Compared to a full academic emergency department, when I call a specialist like a surgeon, I am usually calling an in-house resident physician who is not paid any extra for the extra work I am about to give him or her. So you can imagine the difference in the environment when working in a community emergency department as compared to an academic emergency department.
For example, one time in the community emergency department I had a young patient who was suffering from an apparent appendicitis. I called the private surgeon who was on call at his home being paid to be on-call as well as being paid to perform surgeries. I remember calling him at 2 in the morning and saying hi Dr. sorry to call you so early in the morning but I have a young patient here who has what I believe to be appendicitis. There was a pause on the other end of the phone and I was preparing for a verbal beat down or some sort of explanation as to why I should call a different specialty because that is the normal response in an academic emergency department when I'm calling resident specialists. However, in this case because I was in the community emergency department the private surgeon responded with; thank you for calling me I appreciate the business, do you think this is appendicitis? I answered, yes the patients symptoms seem pretty classic for appendicitis. He stated, great I will be in in 5 minutes don't worry about getting a CT scan that sounds like classic appendicitis I will take care of the patient please let the family know I am on my way. By the way what do you want on your pizza. Thank you for calling me I appreciate all you guys do.
Needless to say there are some differences in working in an emergency department in a academic center versus a community center. This post however is not about the politics or differences of academic medicine versus community medicine! This post is simply a post about a man who knew better who should not have tried to be a Hero.
This man was in his 30's and had a great job as an accountant for a big city firm. He was educated and had a wife a 3 young children. He had been out with his friends watching a football game and drinking and upon returning to his home at about 5 in the morning he was approached by a person wearing a hat and a mask pulled over his hat. The individual stated "empty your pockets you are being robbed". Somewhat intoxicated and somewhat scared the young accountant started to put his hands towards his pockets to empty out his pockets and give the items to the thief, when he noticed that that thief was not paying attention. Foolishly the young accountant decided to take this opportunity and punch the burglar in the face. The burglar was obviously not expecting this punch, and dropped to the ground when he was punched.
The accountant felt like a superstar as the adrenaline pumped through his veins. Suddenly however, the account felt someone or something jump onto his back and take him to the ground. A wrestling match ensued with the second burglar and eventually the accountant was able to break free and escaped to his house. He walked into his house to find his wife and young children waking up for the morning and days' activities. To their astonishment they saw their father bleeding profusely. His wife started to scream and the children soon started screaming as well, she ran and grabbed a towel as the accountant began to try to find and see where he was bleeding from. It became evidently apparent that he was bleeding from his arm as there was an 8 inch gash on his forearm. Blood was pouring out all over their entry way floors. Fortunately his wife had her wits about her self and sent her children off to their bedrooms. She wrapped a towel around her husband's bleeding arm and demanded him into the car so she could drive him to the emergency department. This young smart, wise accountant didn't want to make a fuss and stated "it is fine just put a Band-Aid on it, I do not need to go to the emergency department." Fortunately, the wife knew the limitations of her husband's common sense and she ignored his statement and forced him into the car and brought him to the emergency department.
The nurse approached me and said "doctor you have a patient in room 13 that needs to be seen immediately, he is bleeding profusely and may have lost a lot of blood I think he needs to be seen sooner rather than later!" Great! I thought to myself what has this person done at 5:00 AM? I scrambled to room 13 to find a surprisingly well dressed well kept individual with a towel saturated in blood wrapped around his forearm. I also noticed a young wife sitting in a chair frantically making phone calls to make arrangements for her children to be taken to school and to their various activities as well as calling her work and his work to explain why they would not be there today. I introduced myself to both of them and told them I would need to take a look at the wound. I peeled back the blood soaked washcloth to expose a gapping laceration, I asked the patient; "Do you remember when your last tetanus shot was?" He smiled obviously getting my humor and I said that actually this is the least of our concerns at this point let's stop this bleeding first!
The police arrived shortly after I began to fix this laceration. After what seemed to be an hour or 2 of meticulous stitching, a full 3 layer closure, was required to completely fix this laceration and stop the bleeding. Ultimately, the patient had an excellent outcome, but will have to followup with hand surgery and potentially have physical therapy and maybe further interventions. However he was very fortunate to have come to the emergency department quickly and have his laceration fully repaired.
I asked him "how much money would you have lost if you had just given the thief your wallet and other items. He calculated if he would have given the thief everything it would have cost him maybe $500.00 - $800.00 if the thief got his cell phone as well. He actually only had $100.00 cash on his person at the time and the rest of the estimated costs were losing his wallet,and cell phone and costs associated with replacing his credit cards and getting a new licenses etc. Remember this man was an accountant so he thought long and hard about what giving in would have cost him. He was proud that his macho super powers had saved him up to $800.00. While he boasted about this great savings his wife rolled her eyes in the background and I asked him if mugging loses could be declared on taxes.
I politely asked him if he was done with his accounting estimation of the savings he had achieved by punching his attacker and not giving up his belongings. He said, "I think I calculated all the savings." I pointed out and asked what the costs were for missing 2-3 days of work for himself and for his wife. His wife chimed in and reminded him that his $300 new leather jacket now had a 12 inch cut and the arm and could now be deemed worthless unless leather vests make a comeback. His wife also reminded him that his children will need some form of therapy after seeing their father pouring blood from his extremity all over the house. She then started to calculate the cost of cleaning the carpet or replacing the carpet and wood floors. She also noted that there was blood spilled all over their car and the cleaning that would cost money as well not to mention all the other stained clothes he was wearing and she was wearing and finally she reminded him of the medical costs associated with this type of injury. I kept silent during this exchange.
I decided it was in my best interest at this point to remain quiet and not explain how physical therapy and possible hand surgery and further doctor visits as well as medications, and medical supplies would add up to significant costs and it would have just been about 1% of the full cost to just have turned over his wallet with $100.00 in it. I did point out he was lucky that the stab wound missed a major artery by about 1 cm or we would also have to ad in the cost of a funeral into the equation of costs vs savings. I mentioned this in the upmost professional way possible and we all had a laugh but he got my point.
Lesson: Do not be a hero!
Lesson Learned?: The last thing the patient said to me after hours of sewing his arm up after thanking me was : "Hey doc you should have seen the face on the other guy, I knocked him out and he definitely will remember my punch when he wakes up!"
Lesson Learned? = NO
