Failure

"Lauren," my female co-intern said.  "I'm sorry to have to do this to you, but I just picked up this sexual assault case a half hour ago, and I still have to finish up some laceration repairs before I go.  Do you mind taking her?"


"No problem," I replied.  "I'm happy to help."  I quickly reviewed the face sheet she had started about the patient, scanning the sparse details of the 6-day-old assault, location of her cuts and bruises, and basic vital signs.  She was homeless and newly arrived from California and had not yet found work.  She had already been given a hefty dose of IV Dilaudid in the emergency department and apparently was asking for more. 


"Why did she wait so long to come in?" I asked, knowing at this point that a critical 72-hour window had passed.  Our highly specialized, sexual assault response nursing team could no longer conduct a thorough pelvic exam and collateral investigation that could be dissected in any legal proceedings she may have wanted to pursue.  The evidence, so to speak, would have been washed clean so far removed from the attack.


"She was raped in January," my colleague shared.  "She went through the formal exam, and it sounded pretty traumatizing to her, so much so she didn't want to repeat it this time."  


"Makes sense," I offered.  "I just can't imagine ..." 


"I know," she nodded. "I appreciate you taking her.  I just haven't had the chance to spend much time with her, and she keeps wandering the halls asking for pain medications, a warm blanket, soda.  The nurses are growing a bit impatient, but it's been nuts down here."  


"No worries," I reassured.  "It's not like you've been sitting around twiddling your thumbs!"  


I glanced at the infamous board, a massive flat screen monitor situated across from the fishbowl and near the charge nurse's station that continually updated the patient roster ... those trauma cases that had already arrived and been triaged and managed and those that we anticipated rolling in any given second from the nearby environs to those due in a few hours, being flown or driven in from the expansive recesses of the WWAMI region.    Harborview Hospital, as the only Level One trauma center for the entirety of Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI), operated at a steady hum year-round and at a high-pitched scream in the summer months, when daring and dangerous exploits resulting in harm increased in number and severity.  


As a family medicine intern, I spent two weeks on the trauma service in July, learning how to manage literal and figurative train wrecks --- motor vehicle accidents, gunshot wounds, stabbings, shaken baby syndromes, bicycle and motorcycle spills, overdoses, wood chopping and woodworking mishaps, bear attacks, crush injuries, drownings, hangings, vertebral fractures from falling out of trees, children who found and played with their father's guns, suicides, homicides, and buffalo "gorings" (although not in my rotation).  The Harborview ED also provided care for rape victims ... the most chaotic of places to discuss the most intimate of intrusions.


"Why don't I introduce you to her?" my friend suggested.


"Great idea."  I replied.  We walked together in to her room, as stretchers and paramedics scurried by.  Sirens wailed in the distance.


She perched on the edge of her bed, her hands shoved between her knees, rocking gently back and forth.  Her dirty brown hair fell in matted chunks against her face; her arms were littered with cuts and bruises of different ages, colors, and sizes.  Her few possessions were wadded in to a bright, orange bag sitting behind her on the bed.


I squatted down and took her hand in mine, noticing her dirty, split nails, caked blood, and years of calluses.  


"Ma'am, this is Dr. Hughes," my friend began.  "As I shared with you earlier, we change shifts now, and Lauren is taking over for me."  I asked her a few questions to clarify what I had already learned, allowing her to share the story in her own words.  


Our patient's eyes welled with tears.  "I don't ..." she trailed, biting her lip.  "I, I don't want to be a burden ..."


I broke in, perhaps a bit more swiftly and sternly than I should have.  "You are not a burden to us," I said, looking her directly in the eyes.  "No one deserves to have this happen.  You are in good hands here, and we are going to do our best to care for you."


"Okay, doctor," she said.  "But, but I'm in a lot of pain.  Can I get something for it?"  


"Let me take a look at what you have already received tonight, and we'll go from there," I replied, standing to leave.  


"But, hurry, please," she pleaded, swaying a bit faster.  "I hurt ... I hurt so much ..." 


"I will be back soon."  I touched her shoulder and exited with my colleague.  


Back in the fishbowl, I reviewed my plan with the ED attending --- find the pelvic cart, locate a private room in which to perform the pelvic exam, and discuss shelter options with social work, as she had expressed worry for her own safety if discharged back to the streets.  


"Sounds good to me, but I'd run your thoughts by trauma doc, too," the attending physician said.


I quickly found trauma doc, a second year surgery resident who ran the codes and was in charge of the trauma interns, including me.  For twelve hours per shift, trauma doc called the shots, placed consults to other teams, and kept patients moving along toward their dispositions --- home if not seriously injured, psychiatry if suicidal, upstairs if sick enough to be admitted, operating room if in need of surgical repair.  A full Level One emergency department was problematic in many regards.


"I'll do what I can to move her along," I said to trauma doc, after sharing my plan.  "I know we're busy, but she is a priority for me to package and send someplace safe."  


"No," trauma doc cut in, looking at me sharply.  "Your priority is trauma."  


Somewhat stunned, I watched my boss turn abruptly and stride toward the radio room to answer an air lift call.  


"Dr. Hughes," a nurse practitioner yelled toward me.  "I found your pelvic cart.  It's down by the observation wing."  


"Thank you," I nodded.  I quickly studied the board.  Ten minutes to a multiple victim van rollover.  My window of opportunity was now.  


I told my attending where I was heading and cajoled my patient to follow me to her pelvic exam with the promise of more pain medication once done.  Unsatisfied with her fragmented and dismissive ED care, I was even more unsatisfied with myself and my inability to properly understand and address her physical versus psychological pain, knowing that the latter, years in the making, was not going to unravel in any meaningful way tonight.  I just had to ensure there was not something medically dire we needed to treat that would cause her harm if left unchecked.


I managed to finish her luckily benign pelvic exam, obtain a urine sample for a pregnancy test, and begin my conversation with the social workers about shelter options for her before being summoned to the van rollover victims rolling through the front doors.  The codes kept coming, and in between patients, I swung by her room, telling her that 'soon' I'd finish finding her a safe place ... 'soon' I'd be back to talk with her ... 'soon' I'd discuss her wish for more pain control, sounding more and more hollow and less believable with each 'soon' I uttered.


In a moment of relative calm, I ran in to trauma doc in the hallway.  "How's it going?  Anything you need help with?"


"I'm doing all right," I said.  "Just drew my third hemoglobin on resus 2, bed 3.  And, by the way, I finished the pelvic exam on our lady.  Once I touch base with social work, she'll be heading out so that we have that bed free.  Just thought you'd want to know."


Hands thrust in the air, trauma doc leaned closer and growled, "Frankly, I really don't care."    


Trauma doc disappeared into the radiology reading room, and I simply stared as the door swung shut, slowly lowering my blood draw to my side, breathing forcefully through pursed lips.  I wandered in search of the social work team, who was able to find a shelter bed for her, unusual at such a late hour of night.  Despite the relatively positive news, in their conversations with her, she told them she may leave for Swedish Hospital, as she thought she may receive better care there.


As I typed her discharge paperwork in the fishbowl, I noticed my patient walking slowly by in opposite direction of the main door, dressed in her street clothes.


"Where is she going?" my attending asked.


"I don't know," I responded.  "Probably the bathroom.  I'm almost done with her papers.  We found a place for her tonight."


"Good work," she said.  "I wish our sexual assault nursing team could have seen her.  It would have made it a lot easier for us all."


I looked up from my desk to see another stretcher rolling through the main door, bound for the trauma bay.  A young toddler had been ejected from his stroller, after being hit by a car traveling 35 mph.  I grabbed my safety goggles and X-ray shield and ran.  


Twenty minutes later, I returned to the fishbowl, retrieved my discharge paperwork, and scurried to my patient's room.  Her nursing chart and ID stickers had been removed from the metal table.  A janitor quietly mopped the floor.


"Did you see where she went?" I asked.


"No, I'm sorry, doctor, but I was told she's gone.  I think she may have eloped."


I didn't move for a few moments, watching the janitor pull taut clean sheets where my patient had once sat.