The Striker.

Looking back now, I had just come on shift and I think I was looking for...well, for someone sicker. I came to work psyching myself up on Eminem's Eight Mile soundtrack. I began scanning the electronic patient tracking screen looking for the sickest patients. When the ER is busy, you look at the board, make a plan, sign up for patients, map out the rooms in your head, and calculate the most efficient route. There are no pit stops. No water coolers. No chit chat. No deviations from course. You go all in, right from the beginning...

You acclimate to walking through chaos - through patients wailing, moaning, and retching. I must've walked past his room several times. At the start of my shifts, I am always looking for an adrenaline rush. A 31 YO male with "multiple complaints" was not only uninteresting, but would likely sap the little motivation I tried so hard to build at the start of my shift. It wasn't until the third time I passed the room that I noticed that he was a pallid, young Hispanic male. It was 11 o'clock at night. His brow was heavily creased and more than worried, he looked nervous. In retrospect, the whole scene looked wrong. Furthermore, there are some age and ethnic patient permutations that we almost never see in the ER... and when you do, they're always bad.

I opened up his triage notes. These summary notes often help encapsulate a patient's major concerns - "Pt complains of leg swelling. Pt pale. Interpreter assisted nurse with triage. Alert and Oriented x 4. Pt ambulated to ED with c/o sore throat and was told he had infection in mouth. Pt also c/o dizziness, vomiting when eats, R knee swelling x1 month. Pt states went to clinic approximately 2 weeks ago while in Florida. Pt was given prescriptions for Benzonatate, Loratadine, Amoxicillin, and Ibuprofen." Sometimes these notes are really helpful and help cater the workup. Unfortunately, not his...

As I walked into his room, I sat down and introduced myself. I had barely sat down, and he spit out two words: "spanish interpreter". It was already a busy tonight. I already had four patients to see. I looked at him with a kind of exasperation, and said, "Okay but you'll have to wait..." and marched out. My Spanish is good. I ran past the nurse and told her to get the interpreter so we could begin. An hour later, I was back in the room and learned that he had progressive leg swelling for 3 weeks. He had a large, smooth fleshy mass along his distal thigh. We also ran through his dental pain and his prior visit to a clinic in Florida where he was prescribed antibiotics for a throat infection. The dental pain. Leg pain. Dizziness. Vomiting. None of this made any sense... The more I asked, the more symptoms he reported. Finally, I shut up and asked to examine him. When in doubt, look at the patient right? When he opened his mouth, I had a 'Kobayashi moment' (Note: Usual Suspects reference). His gums were an angry, raw red and immensely swollen. They seemed to swell around his teeth. The crevices between his teeth were caked with dried blood. He lifted his chin and I could feel the chains of lymph nodes like marbles under the skin of his neck. The hollow of his right collarbone felt like the striker, the largest marble, was neatly tucked into it for safe-keeping.

There are times when you want to say so much. Often however, it's when nothing you say matters. When you want to explain how you're sorry for circumstance. When you want someone to forgive you your indiscretions...a long wait, a callous demeanor, a skeptical glance. Unfortunately, these empathetic epiphanies only come on the heels of great tragedy. This wasn't gingivitis. He had cancer. Likely Acute Myeloid Leukemia. He was severely anemic. His platelet count was dangerously suppressed, which was why his gums were gushing with blood. The swelling on his leg was a large hematoma.

As I opened my mouth to explain in my broken Spanish, I stopped, and went off to find the interpreter. This was gonna be a long night...