The King

They called him "The King", a patient so notoriously known to the medical service that residents bragged about the number of times they had admitted him over a one year period. For his part, he was remarkably polite, and with a fantastically amicable personality: "I assume you gonna stick my veins", he asked me matter-of-factly when I met him in the Emergency Department, turning his neck to one side. Like most sickle cell disease patients, the King had, though his many hospitalizations for pain crises, been effectively turned into a human pin cushion. His veins had become sclerosed from multiple cannulations by cold, sharp needles. They now protrouded from under his dark skin, tortuous and rubbery to the touch from the fibrosis that occurs when veins heal themselves after the iv catheters are removed.

I asked him about his sickle cell pain and about his recent heroin relapse. "I ran out of pain meds, so I used". Lucifer himself couldn't have come up with a more nefarious confluence; take a population that is already economically disenfranchised (namely inner city baltimore) and add to it a high prevalance of a disease (sickle cell) that requires large amounts of narcotics and you've got yourself a perfect storm of sorts. A lot of sicklers don't have the necessary resources (insurance, transportation to/from clinic, money for co-pays) for close follow-up of their sickle cell disease, and with a substance far more effective than any legal narcotic available just outside their doors, the desire to put up with ten, twelve hour waits in the ED only to be seen by a 25 year old intern from Kentucky who doesn't know the first thing about the sickle cell pain or heroin and then wait for hours while being transferred to a floor before getting pain relief is understandably low.

I attempted to cannulate his external jugular vein on his neck. Once, twice, but with no success. The veins were so rubbery that it was hard to even pierce their outer walls. He was remarkably patient with my bumbling attempts to acheive accesss. "Try the one in the back", he suggested, sugesting that I try one of the branches of the EJ, one that perhaps wouldn't be so sclerosed. The third try was the charm, as we achieved a good flash and I threaded the catheter in, my back pulsing with pain from bending forward in the same position for over an hour . Earlier, while attempting to hide my incompetence in gaining access, I engaged the King in conversation: "Do you work?"
"No"
"Is it because of the sickle pain?"
"Yeah"
"What would you do if you could?"
"I've always wanted to work with animals. Maybe in a vet office"

His neighbor, another sickler I admitted earlier that day, chimes in:

"Eh, doc, how much you make, man?"
I chuckle: "How much you think?"
"Eh, I bet you make 40, 50 thou"
I was impressed with his accurate assessment of resident salaries.
"I like to draw, too", The King continued. I had heard about this. In the resident work room hung beautiful pictures of wildlife and other scenery. I always assumed that this was the work of a multi-talented resident or one of the other staff but in fact, they were the King's work; he often sublimated his sickle pain into these drawings. This night, before I subjected him to my poking around his neck, he had been working on a picture of a large cat, a puma or panther or some sort. It looked like something out of a zoology text.

"I prefer Dilaudid with a basal rate of 2", he continued. He was so familiar with the treatment of his disease that he practically managed himself. He told me when to go up on his fluids, when to change his pain meds. Pain management is often the hardest part of managing sickle cell but with the King, you simply asked him. "Tomorrow, let's go down to 1.5, doc", he told me the next day. I nodded, smiled, asked him about his breakfast, and then moved on to the next patient.

This was his life. Over the last year, he had spent more time in the hospital than out of it. His life consisted of episodes of pain control in the hospital followed by going back out to the street, staying on pain meds for a while, lapsing into a pain crisis and ending up back in the hospital. His toxicology had been negative for a few visits, so I was optimistic about his ability to stay away from heroin, but I didn't dare entertain images of the King beating this sickle cell thing, settling into a quiet neighborhood and start working at a vet's office in suburban Baltimore.

Two weeks after I discharged him, I was on my way up to the office when I saw him sporting his signature EJ IV line, walking in the lobby towards the smoking area. No doubt another intern had inserted that line last night. Another young doctor was now running around this campus thinking about how if he could just get this new patient's pain under control, he just might beat this sickle cell thing and not have to be hospitalized ever again. Three weeks ago, that young doctor was me, now it was somebody else's turn.