MIN Creative Writing Exposition 2010
November 17, 2010
By: Leana S. Wen, MD MSc
"He's baaaack!"
I looked up as a skinny man in an orange jumpsuit was wheeled
from triage. Metal clattered as he strained against the handcuffs,
yelling, "Picasso! Rembrandt! The artist is here, mon!" He stopped
hollering long enough to flash a toothless grin at a young nurse's
assistant, who pressed herself against the wall in shock. "Calm it
down," snapped his companions, three large well-armed police
officers. "Can't you see that everyone around here is looking at
you?"
Indeed, the noise in the Emergency Department (ED) had fallen
several decibels as patients and staff alike strained to see the
commotion. I sighed. This was Jake. Jake was a 30-something
Jamaican man who had been in the Boston penal system for some time.
He tended to create quite a stir whenever he came to the ED, with
his colorful dreadlocks and even more colorful language and
stories. What he was in jail for, I didn't know, or ever wanted to
know. It must have been something pretty bad, since he always had
three officers with him while most other prisoners came with a
complement of one or two.
I didn't want to know what he did because Jake was, frankly,
rather entertaining. He came frequently to the ED with lame
attempts at being hospitalized because, compared to the prison, our
hospital had "hotter food and hotter women, mon". In my short time
in residency, I had seen him twice already. The first time, a
couple of months back, he claimed that an errant cactus pot fell
from a shelf and hit his face while he was sleeping. "Doc, you
gotta rescue my beautiful face!" he pleaded with me. He had a tiny
lip laceration and a few cactus spines stuck in his cheeks;
judicious use of forceps and he was good as new. He managed to sing
all the way through my spine-extrication, and remains the only
person to have serenaded me on his knees with shackles on both
ankles.
The second time, he seemed to have learned that certain symptoms
bought him a longer length of stay. He came in complaining of
crushing chest pain that began while he was raking leaves. The
symptoms, in combination with his history of diabetes, meant he
would receive a much longer workup. He cackled when I told him
that, indeed, we had to wait for a second set of labs to come back.
"High-five, doc, high five!" he cried, throwing up both arms as far
as they would go and shaking his full head of locks for emphasis.
Whenever I came in to check on him during that shift, he would
provide me with some amazing medical aphorisms, such as that "the
worst kind of pain is a screwdriver through the right eyeball" and
"the cure for a stroke is pineapple skunk." One of the guards
muttered under his breath, "con artist", and Jake latched on to the
latter part of the phrase. That last time, Jake signed his
discharge paperwork "Jake, the arteest" with a flourish.
This time, the chief complaint on the triage note was "altered
mental status". This will be fun, I thought. Jake at baseline was
pretty out there; Jake altered should be something else to behold.
The note that accompanied him was from the prison nurse, and stated
that he had been in isolation for a week after a fight with fellow
inmates. Two days ago, his guards noticed "bizarre behavior" that
consisted of not responding to his name. The nurse saw him today
because he refused to eat. A urine tox there was negative; his
fingerstick was 150; he had no documented trauma, and his physical
exam only commented on intermittent lethargy and manic behavior.
QUESTION MALINGERING was written in large letters at the bottom of
the prison note.
The noises had died down in the exam room by the time I walked
in. From the door, I could see I that Jake was lying on his back,
hands stiffly folded across his chest, eyes squeezed shut. The
nurse had unsuccessfully attempted an IV; one of Jake's hands would
shoot out and smack the nurse whenever she came close. The three
guards collectively rolled their eyes at me as I walked into his
room. "Can you believe this joker? First he's yelling like a
banshee. Then he's some mute pretending to lie in a coffin," one of
them jeered. Another grumbled, "No offense doc, but this is such a
waste of our time."
"Jake, can you hear me?" I called. No response. I shook his
shoulder gently. "It's Dr. Wen, remember me?" No response. I tried
again. "Hey artist man! Got some pineapple?"
This time he stirred. He sat bolt upright and stared at me,
rattling on his chains loudly with both arms and legs. "Get me the
f*** out of here! I'm the ARTEEST! ARTEESTS do not belong in the
jail, mon!" As the guards stood to restrain him, he crashed down
loudly on his back again, squeezed his eyes shut, and folded his
arms tightly over his chest.
To the snickering of the guards, I tried, unsuccessfully, to
elicit further words or a cooperative exam from Jake. Though I
couldn't assess orientation, and he certainly was not behaving
normally, I thought his neuro exam, in addition to the rest of the
physical, was fairly unremarkable. His cranial nerves appeared
intact, he could move all extremities, and he had no abrasions or
contusions or any tenderness to palpation.
What to do with the artist? The guards had their own idea: send
Jake straight back into isolation and call it a day. They had their
own incentives, but also some legitimate reasoning: one of the
guards claimed to have known Jake for the entire five years he had
been incarcerated, and said that this was a twice-monthly
occurrence; apparently we were not the only ED they brought him to.
Besides, he had been in isolation with a 24/7 guard duty for a
week. If his blood glucose was fine, and he couldn't have gotten
any drugs or been in any trauma, what could he have?
The nurses were similarly inclined. "The artist is back?" they
chuckled. Some had much longer histories with Jake than I did. One
nurse told us that he had come in last year alleging that he had
excruciating testicular pain. On exam, they found that he had
painted his scrotum green, black and gold-the colors of the
Jamaican flag. It was Jamaican Independence Day after all, and he
wanted to celebrate it in the company of women. This nurse threw up
her hands when she found out that Jake was back. "It's not
independence day again, is it?"
The other members of the medical team, too, expressed
ambivalence about getting labs and imaging studies. They thought
that letting Jake "settle out" for a few hours was the way to go. I
was not as convinced. His strange neuro exam and multiple past
admissions certainly suggested malingering, but every time before,
his strangeness manifested itself in an entertaining, flamboyant
way. Something wasn't right this time.
In fact, as I went into convince Jake to let the nurses draw
blood, I found him moaning, barely able to open his eyes. A STAT CT
of his head showed bilateral acute on chronic subdural hematomas,
with evidence of midline shift and cerebral edema. Finally that got
people's attention! The guards finally snorted their defeat. They
still muttered, though, that the con artist finally found a way to
do this to himself. The nurses shook their heads and said, who
knew, one day when the boy cried wolf there actually was a wolf. I
remember feeling vindicated on Jake's behalf. Ha! This is why we
should avoid prejudging our patients!
Alas, I never got to preach my lesson. The night of
presentation, Jake was admitted to the neurosurgical ICU. He was
intubated for airway protection, and the guards were sent away in
anticipation of a long hospital course. The ICU team weaned his
sedation to better follow his neurological status. A few hours
later, Jake's bed was empty and he was nowhere to be found. The
artist had finally fled the coop.
One thing about Jake's stories is that they always had a good
punchline. So it's a fitting end that perhaps Jake was malingering
after all. Maybe he didn't even know about his expanding brain
bleeds; maybe he had just wanted to come to the hospital to get out
of jail for a bit, then saw his opportunity and took it. Maybe he
really was unwell, and left in a state of delirium.
We'll never know. Once Jake was reported missing, police were
dispatched to search for him. According to their reports, he was
found dancing in a bar a few miles from the hospital, draped in a
flag of green, black, and gold. As the police were arresting him,
he collapsed; by the time EMS arrived, he had died. The artist was
gone, leaving us in as colorful of a way as he had lived.
