On the Road Again


Morning folks.

Let’s talk about travel today. 

We have an interstate highway system in the United States, conceived and built back in the nineteen fifties during the Eisenhower days. I’ve heard tell it was originally devised as a network of roads that could most efficiently and quickly mobilize a column of military vehicles from one part of the country to the other in case of attack or invasion (or get Dwight David from one golf course to another with the least amount of effort and Secret Service protection). If you look at a big map of the country and squint just a little, it looks like a big arterial system, nowadays bringing goods, services and millions of Amazon.com packages to people all over the nation.

An arterial system moves blood, and the lifeblood of modern-day America is her people, pure and simple. This system of four-lanes-and-up highways moves, when it’s all said and done, people from one place to another. 

In the emergency department, this phenomenon manifests itself as the itinerant patient, the traveler (not to be mistaken for the Travelers, the life insurance company or the Travelers, a group of Irish folks who patch driveways and paint houses for oddly large amounts of money). He (and he is usually a he) shows up in the EDs that happen to be close to the interstate highway system. Which reminds me of that old question: Why do Civil War battlefields always seem to be close to exit ramps off major interstate highways these days? But, I digress.

This peripatetic fellow is usually on his way down south when the cold winds blow up north and winter is coming (cue Game of Thrones music and awesome, awesome opening sequence-I’ll wait), and traveling back up stream like a spawning Chinook when the stifling humid heat of a southern summer is gripping the lower tier in July (coinciding with another Game of Thrones episode coming up in Season Four, titled The Interns Beyond the Wall)

He gets to us in one of several ways. He is sometimes found by local law enforcement sleeping on a park bench or living under a bridge. He is sometimes brought to the ED by a well-meaning soup kitchen volunteer who sees the nasty, festering hole in his lower leg (battle scar from a late night run-in with an old metal carnival tent stake left in the ground in a field) and says “You really need to get that looked at”. 

He is sometimes picked up by EMS after he unceremoniously passes out outside a local WalMart, dehydrated and not even able to sweat to cool himself against the southern heat wave any more. Sometimes, he hitchhikes, getting himself to the place with the bright red cross glowing in the night like a beacon (Bring me your poor, your tired, your masses yearning to breathe free and get a meal and a place to crash for the night. I can’t remember exactly how the tattoo under Lady Liberty’s left arm reads, but that’s close enough for this post), sure that he will find a kind doctor, a pretty nurse, an IV with a banana bag, and a couple of Lortabs there before the sun rises the next morning. 

This guy is the dirty, smelly, rode-hard-and-put-up-wet guy in Bed Three. He is “not from around here” as they say. He is a traveler, a gypsy in the broadest term, a guy who uses the health care system like his own personal chain of Motel 6’s, knowing that in every big city and little town, somebody is always leaving the light on for him. (Good night, Mr. Bodett, wherever you are)

He’s not really an unpleasant guy, at least after he gets a shower. He smiles, jokes with the nurses (male and female), is respectful of the doctors (male and female), takes the medications ordered for him, eats the food offered with nary a peep about the shade of green of today’s Jello, and sleeps when told to sleep. He asks for nothing special, gives the staff no problems, and is the subject of not more than two lines in the nurses’ morning report (Mr. Jones slept well all night, has eaten 100% of his breakfast tray, and has no complaints today). 

So, you’re asking me now, as you tire of my early morning, I-haven’t-had-enough-coffee-yet blog humor, why is this guy in the ED? Is he for real? Is he sick? Why don’t you just kick him to the curb? He’s wasting taxpayer dollars! He’s a malingerer

Well, Kemosabe (you hear the Johnny Depp in my voice, don’t you? C’mon, go with me here…), yes, and no. No, and yes.

My opinion? As a shrink?

Sometimes these guys really are sick. Just because you travel the eastern seaboard via Trailways and not by air-conditioned SUV doesn’t mean that you can’t develop DKA from untreated diabetes or have your blood pressure spike or have a seizure. Remember when I told you that a good doctor will take the same critical approach to working up a smelly, unwashed, slightly obnoxious patient that she will in dealing with a perfumed mother of three who has gold bracelets dripping from her arms as she tells you about her migraine? Yep. That.

Sometimes they need three hots and a cot. Really. They have no family. They have no money. They have no job. They are truly homeless. What would it feel like to be that guy? At Thanksgiving? With the snow starting to come down and the warm lights in warm houses going up and the smell of pan dressing cooking in the oven pervading the den where Dad is pretending to watch the Lions lose again behind closed eyelids? Put yourself there, in that situation, for just a moment. 

Sometimes I think they crave human contact. I really do. I have heard more fascinating stories from these traveling symptom shysters than from almost any other group. They can tell you where all the soup kitchens are, the best VA hospitals to get admitted to at Christmas time, the bus schedules in North Carolina, and the airspeed of an African or European swallow. Okay, I made that last one up, but the others are all true. I swear. 

These guys are just one more in a a group of special patients you’ll find in the emergency department. 

You may not find much wrong with them physically or emotionally. You may spend a few bucks out of the health care budget working them up and feeding them overnight. You may send them on their way feeling like you haven’t really done that much to help them.

But, you’ll never forget them.

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