In which I put on a new cap.

During orientation week, one of my co-interns gave all her fellow interns custom-made scrub caps with our last names embroidered on top, in cheery school-color fabric. I had never worn scrub caps much in medical school. The kinds of people who wore scrub caps seemed much busier than me — usually surgeons on consult, or time-tested nurses who kept their nails short and their words shorter. I quickly learned why some people preferred the scrub cap on, though.

I started intern year in the MICU, where patients were so intubated and sedated, each nested in their tangle of wires, that I barely had to touch each patient in their evaluation. When I returned to the ED, the closeness of it — undressing and staunching a pulsing artery, mopping up stomach acid from a dislodged G-tube, milking pus out of an abscess — made me reconsider protecting my hair. In my first week back in the emergency department, I had been splashed with peritoneal fluid (the liquid that one’s intestines float around in), blood, pus, and urine. One patient had come in with a clogged and infected Foley catheter (a thin tube that drains urine for people with giant prostates). My task was to help the nurse flush out the tube to unclog it. We pumped in almost 500 mL of saline, which looked highly uncomfortable for the patient, and then when it was time to drain out the fluid, the nurse’s thumb slipped and a high-speed jet of pus-tinged, blood-tinged urine spurted out. She aimed it, naturally, away from her, which happened to be directly at me. I was splashed from my hair to my shoes with pee sludge.

Needless to say, now I wear a scrub cap.

There are side benefits, too. For anyone who has ever been in a hospital, there are a disproportionate number of female Asian employees, from the administration to the doctors to the nurses to the pharmacists. I’ve started to get a reputation as “the one with the hat.” On days I don’t wear it, some of the nurses don’t recognize me. I also get fewer comments about looking too young to be a doctor. Maybe with the cap covering my forehead it’s easier to imagine a few wrinkles.

It’s been a while since I’ve told stories about patients. As a medical student, you see so few patients that each story stands out. As a resident, I’ll come home venting about all the weird folks that made my day interesting, but when sitting down to think about what to write, I draw a big blank.

One patient came to the emergency department at 2 AM. His records indicated that in the last month he had gone to the ER at least once a day, each time requesting IV antibiotics. He had gotten at least seven different types of oral antibiotics from other hospitals for flimsy indications, probably from doctors just trying to mollify him. His symptoms? A sore throat from two years ago. His throat was currently not sore. After more probing, I discovered his real issue was that he had been wrongfully incarcerated two years ago and caught some kind of pharyngitis in jail, and since then he’s been obsessed with the idea that he caught some kind of supergerm from the other inmates. He looked at me furtively, saying, “I’m not like the other black guys.” I asked, “What do you mean?” He said, “You know the jail, it wasn’t clean. I was exposed. Who knows what was in the food? I need these antibiotics to clean me up inside.” I talked with him for almost an hour about why we couldn’t risk giving him powerful intravenous antibiotics for an infection he no longer had, but he would not be convinced. He pulled out his phone multiple times, saying, “I have a very good source on WebMD that says I should get IV rocephin or oral vancomycin.” I reminded him that I was the one trained in medicine, and he did not have any symptoms of infection that qualified for either antibiotic (the latter of which is reserved for c. difficile colitis). By the end of the visit, he was irate. “It’s my body, it’s my right to take on these risks of getting the antibiotics, so that’s why I want to take them. You have to give me the drugs I want. That’s why President Trump signed the law letting us take hydroxychloroquine and ivermectin. You and the CDC got it all wrong, you’re trying to make us take this vaccine to end the virus but you don’t want us taking ivermectin to cure the virus.” It escalated. “You’re not a good doctor,” he told me, standing over me. “My ENT doctor is way smarter and better than you, and he told me I should get these IV antibiotics.” I had checked his records — that doctor did not recommend antibiotics. I ended up having to firmly tell the patient to leave, something I had never done. It’s hard staying detached and clinical when someone is spitting flecks into your face, but at some point it was liberating to just step into the role of a kicker-outer. I’ve always known the script. “I hear your concerns, but based on my best judgment for your safety, I’m not giving you antibiotics. That’s the end of this conversation. We don’t have any treatment we can offer you. If you do not leave, I will have to call the sheriffs to escort you out.” He left on his own, dragging his cart of belongings with him.

I had a patient, 6 years old and intellectually disabled, with veins so difficult to access that his chart opened with an automatic alert: “Call [A] and [B] service for assistance with placing IV, patient is a HARD STICK”. I went into the room hoping nothing would require blood, but of course he ended up requiring an infectious workup and an inpatient admission with IV fluids. The parents were internally conflicted on their stance with medicine, I think. When I asked whether the patient was delivered vaginally or by cesarean, the mother immediately replied, “He was a home birth.” I knew the answer to my next question, but I asked it anyway. “Any vaccines?” “No, we would never give our kids vaccines.” They were an organics-only family, no vaccines, no chemicals. He was also struggling to breathe from RSV, a common winter cold, and we had to spring to action to make sure he didn’t have epiglottitis — a life-threatening entity now made rare by the advent of the H. flu vaccine (he didn’t, because karma isn’t real). But anyway, back to the IV. After both A and B service had tried and failed to get an IV, it was my turn with an ultrasound and the tiniest little IV I could find. As I was squinting at the fuzzy vein on the screen, the patient was raptly watching a video, and a familiar Korean chant played over and over again to the sound of gunfire. It was unmistakable. The 6-year old who wasn’t allowed to get vaccines or eat GMO broccoli was watching Squid Game. And loving it.

In medical school you learn an exam for the unresponsive patient, but you never really learn it. My first ever rotation in medical school, I was on the Neurocritical Care ICU, and none of my patients were awake. I tiptoed around them, pinched their fingernails to see if they had a response, but most of them didn’t. Last month, I picked up a completely unresponsive patient who rolled into the ICU, and I felt like no time had passed. “Mr. X?” I tried rubbing his shoulder. “Mister X?” I ground my knuckles into his sternum, hard. “Hey. Hey, can you hear me?” Still nothing. So I called my senior resident to come and assess. Altered mental status is a serious matter. If the patient was truly unresponsive, I’d have to intubate him to protect his airway. The diagnosis is time sensitive for bleeds, cardiac arrests, drug overdoses, seizures, metabolic derangements, hemorrhage, etc. My senior stepped into the room, glanced at the patient’s wristband, and yelled, “ARNOLD!” I had never heard her shout that loudly before. The patient, who looked dead to me, cracked his eyes open and made a low moaning noise. My senior turned to me. “You just gotta yell louder. Call me when you’re done assessing.” The nurses and I undressed him for a full examination (a crack pipe, freshly blackened, rolled out of his pocket. I tucked it away in his belongings to make sure he didn’t lose it). I bellowed my neurological exam at him. “WIGGLE YOUR TOES!” “OPEN YOUR MOUTH!” “STICK YOUR TONGUE OUT!” Every so often when he fell back asleep I’d yell his name again. Finally after I determined that nothing much was wrong with him except a little too much crack, I left the room. The patient had begun snoring at full strength. So much about concern for his airway.

There are two types of patients who come to the ED: the ones who walk in and wait for hours, and the ones whisked in by EMS and immediately get assessed. On an especially clogged waiting room night, where a heart transplant patient with covid had been waiting for 8 hours outside struggling to breathe, a mom and baby were brought in flanked by two paramedics. The problem? “My baby is only drinking two ounces of formula every three hours. She usually drinks four from my breast but I haven’t been breast-feeding because I’m taking cough medicine.” The nurse at this point, out of sight of the patient, threw up her hands in the air and walked away. “What cough medicine?” I asked. “Mucinex.” I ducked into the pharmacy corner. “Hey, is mucinex ok to take while breastfeeding?” I got a weird look. “Why wouldn’t it be?” “I don’t know, could you help me find out?” After a little Googling, we discovered it was perfectly fine. “Ma’am, no problem! Why don’t you breast feed your baby right here so we can make sure she’s ok? Then you should be good to go.” It’s hard not to be frustrated at the poor allocation of resources, but in the end, everybody who shows up in the emergency room is having what feels to them to be an emergency.

I had another patient brought in by paramedics late at night. She was just one year younger than me, and had metastases from her breast cancer all over her body. One poked out of her sternum through her skin, and as metastases do, it was bleeding a slow trickle for the last few weeks. But that night, while her husband was in another room, he heard a loud thud. The patient had collapsed. When we processed her blood tests, we found she had a hemoglobin of 3. For context, a normal woman has a hemoglobin of 13. Someone actively hemorrhaging would require transfusions at a level of 8. It was a miracle she was even awake and talking to me. When I went to talk to her about her results and get her consent for a transfusion, I did my best to modulate my voice and make her feel normal. A hemoglobin of 3? Just another Tuesday for us, don’t worry! She wasn’t very convinced; she was trembling, on the edge of panic. “Hey, Ms. Y-. You’re okay. We’re here with you, and we’re keeping a very close watch on you. No matter what happens, we’re here.” I had considered saying, “It’s going to be okay,” or “you’ll be okay.” But if I were being honest, I don’t know the answer to that question. She began sobbing, saying, “I may get this transfusion and be fine for today. But after all of the chemo and surgeries and radiation, is this the beginning of the end?” I didn’t have an answer for her.