Severed and Indifferent

This post features graphic images. They are attached at the bottom. Not appropriate for children

It can take months to get accustomed to a new hospital. The Emergency Department is naturally a maze of people, rooms, and tools. You know the medicine, but every shop has its own flow, its own staccato rhythm that you have to learn and settle into. There are obvious skills to learn; where things are, what can be arranged, and which consultants to avoid. But there is a much more subtle pulse to each ER that needs to be measured if you're going to survive. Mastering this flow is extremely comforting, because you know that the whole department has your back when needed. I'm exceptionally bad at doing this, and it often takes me much much longer to settle in then most people. This transition is almost mandatory for you to be able to enjoy where you work, so I always have a...turbulent start anywhere new. 

And it was no different in this setting, it took a whole 6 months before I felt that the department worked for me and I worked for it. Together we were like an efficient machine, doling out patient care and heavy doses of sarcasm in equal amounts. I was fresh in this new found groove when I encountered this specific patient. 

It was an ordinary day, a blessing because ordinary days are extraordinary mostly, and we were moving patients at a respectable clip. Splints were applied, crutches were supplied, and wheelchairs arrived at regular intervals. This gentleman was not especially sick, he wasn't extraordinary in any way. His chief complaint was thumb pain, and thumb pain comes in exactly two varieties: extremely boring and slightly interesting. I've learned to expect the boring, so that when something slightly interesting shows up, you get to have more fun with it. This gentleman had essentially destroyed his right thumb. The most useful finger in his dominant hand. He'd applied a liberal amount of alcohol to the mundane task of operating a wood shredder, and was now sitting in front of me, far too comfortable for the injury he had sustained. He didn't let his injury affect his mood, smiling quietly as he soaked multiple layers of gauze dressing. I did my work, examined him and told him the next steps. 

There was a possibility that his thumb might be eligible for re-attachment. A chance, though slim, that he could come out of this situation with minimal dysfunction, but it required immediate transfer to a facility that could perform the procedure. After getting the patient's pain under control I presented the option to him, getting the necessary paperwork in order beforehand. I expected this to be a quick disposition, the patient would no doubt like to retain the function of his thumb. My own thumbs were working furiously, calling the appropriate hospital to arrange for transfer, because time was of the essence. 

Eventually, I came back to check on the patient, to confirm that medical transport was available and that the procedure was still a possibility. I told my nurse how to package up the destroyed thumb, and how best to get the patient transported over. I was saying goodbye to the patient for the final time and requesting his signature (while acknowledging how difficult that would be) to consent for transport. The patient looked apologetic, licking his lips as if he was preparing to tell me some bad news. He took off his baseball cap and held it in his good hand. He was not interested in the procedure. There was too much daylight left in the day, and...he really hadn't planned on being here this long. If it was alright with me, he'd rather that we complete the amputation have him on his way.

I started talking about how important thumbs are, how they really aren't like the rest of your fingers. You can't really be a movie critic without them, hitchhiking is impossible, and you look ridiculous in a pair of gloves. I started questioning his sobriety and decision making capacity, but ultimately he was able to verbalize to me that he really didn't value his thumb that much. He just wanted the bleeding to stop, and his wound to be closed so he could continue on his way. This was bizarre to me, but ultimately we reached a compromise. He would not allow me to transfer him to have his thumb saved, but he would allow a shorter transfer to a location that could perform a more cosmetic amputation. We were at an understanding, and he was on his way. 

This encounter was enough to sabotage our otherwise smooth operations that day. In medicine we deal in shades of gray, with only occasional chances at a "clean" kill or save. This was a chance at a clean save. A new injury with the potential for a poor outcome, but with appropriate management there was a chance to rectify it completely. The nurses, myself, and the rest of the department were on the same page, moving in a synchronized way to fix this tiny catastrophe; the only one not on board our soon to depart ship, was the patient. He wasn't having it.

I still think that there is no better seat from which to examine society then from the position of a healthcare provider. Even though a severed thumb no longer fazes me, I still have a strong reaction to the lives of my patients. My own life has been shaped by my particular circumstances, which are entirely different then the lives of others.  I have the privilege of seeing the truest cross-section of my society, and that ever changing picture continues to amaze me.