By Omar Nabil Metwally, MD

Earlier this week Oskar wrote up Russ Pelletier’s theory of cricket fighting: you catch a calm insect, tie a strand of your own hair loosely around its neck, shake it until it’s furious, and drop it into an arena with another insect prepared the same way. Russ was describing malpractice litigation. He thought the cricket was the doctor.

Russ has never been a patient at a Level I trauma center. I’d like to submit the following chart for his review. All times approximate. Vitals stable throughout.

The secret to American healthcare is this: if you want to be healthy, physically and mentally, stay out of the hospital. American hospitals are where people go to get sick, suffer, and die. And if you really do need healthcare, book a flight to a civilized country that has an actual working healthcare system. STAT.

15:00

Patient arrives. Polite. Professional. Shaved. Rolled in semi-conscious with pain and still says “thank you” to the greeter, which the greeter notes, since it’s rare. Patient has come to see an orthopedic surgeon about a hip, a thing he has been trying to do for months through the proper channels, and has concluded that the proper channel is the one with the ambulance bay. Patient is an internist of fifteen years and a graduate of this institution, twice, which he mentions to no one, because he assumes the building will recognize him on its own. The building does not. The building ties a loose plastic strand around his wrist and places him on a stretcher in a hallway, under lights calibrated for surgery, and walks away.

17:29

The hospital texts the patient. Unprompted. It says it understands waiting can be difficult, that the care team checks on people at intervals, and, in a sentence the patient will think about for the next eight and a half hours, “Please know we haven’t forgotten you.” Nobody had accused anyone of anything. The institution’s only spontaneous communication of the night was a denial of the thing it was about to do. The text closes with “Reply STOP to stop texts,” which is, across the entire night, the only exit the institution will offer. The patient does not reply STOP. He is afraid it will work.

18:00

Patient is making jokes about peristalsis. This is the first clinical sign. A man who arrived capable of small talk is now explaining to a group text that triage is a lumen and he is in the jejunum. He is holding a Whole Foods bag of his own MRIs on compact disc. He has been x-rayed again. He told the tech he was well done. Nobody charts this, because nobody is looking, which is the point of a hallway.

20:00

Patient has stopped reading and started listening, because in a hallway you don’t get to choose. He now knows the name, charge, and theory of defense of the man in handcuffs across from him. He has opinions. The deputies have a chair. More people are arriving in custody. The emergency department is beginning to resemble a precinct, except a precinct has a vending machine and we have a sign explaining why ours is out of order.

22:00

Patient has been shaken for seven hours. In cricket terms he is ready. In clinical terms he is “resting comfortably,” which is what you write about a man you haven’t seen. Patient is at this point quietly composing a proposal to convert the cardiovascular center’s glass atrium into a dispensary. He believes this would be the highest-value addition to the hospital. He has told a nurse this. She didn’t laugh, which he’s decided means she agrees.

23:59

A diet order appears. This is the first order of any kind on the patient. For nine hours he has been NPO, not for a procedure, not for a scan, not for anything, but because nobody wrote the sentence that would have let him have water. He has been fasting in preparation for nothing, which is a very pure form of fasting, the kind monks train for. He began asking for water around hour six. Each nurse, in turn, said she had messaged the doctor. There was no doctor. There was a future doctor, somewhere in the building, who would at some point be assigned, and the messages were accumulating in an inbox that did not yet have a person attached to it, like letters to Santa. By hour nine the patient’s mouth is parched and his urine is the color of a good bourbon, which he knows because he is an internist and because they’ve had him collect it. Nobody has looked at the cup either. A keystroke at midnight ends the fast. Nobody brings the water. The order was the point.

For the record, the texts kept coming, and together they form the only complete account of the night, because the robot was the one member of the care team who never stopped checking on him. An X-ray has been ordered. Complete your registration online (from a stretcher, with no water, one-handed, the other hand on a bag of CDs). You have been moved to room HF07/F7, which is a hallway, but a hallway with a room number, which is how a hallway gets billed. Erion has been assigned as your nurse. Grace has been assigned as your nurse. Grace; Sara has been assigned as your nurse. The nurses were assigned the way crickets are assigned: in rotation, each one shaken a little, none of them told why the box was there. At 22:42 a medical provider was assigned. At 23:46 a supervising physician was assigned. The future doctor had arrived, by SMS, seven and a half hours in. Nobody came to say so. The phone did.

At some point the patient texted the robot back. He typed the name of the nurse in pink, on the theory that the hospital’s most responsive employee might want to know. The robot replied: “We couldn’t process your request.” Which was, he noted, exactly what he’d been told in person, only faster.

02:00

Patient gets off the stretcher and walks to the clerk. He has three questions, in escalating order. Is there a physician on my case? Am I still in a hospital receiving medical care? Or is this a social event, and I was seated at the corrections table?

The clerk looks at the screen. The screen has the one thing worse than a bad answer, which is nothing. Patient has not been triaged, forgotten, or discharged. Patient has been set down. Somebody picked up the box eleven hours ago, put it on a shelf, and went to do something else, and the patient has been getting shaken by the HVAC.

02:03

A nurse in pink scrubs, who could not be older than the patient’s residency, makes a beeline across the nurses’ station to raise her voice at him. Not at the man in cuffs. Not at the clerk with the blank screen. At the cricket, for walking to the edge of the box. Nine hours lying quietly under the lights: unremarked. Thirty seconds standing at a desk: a situation.

This is not recorded.

02:04

Patient raises his voice back. Patient says a word. I won’t repeat it; it’s in the chart. It is, in fact, the only word from the entire night that’s in the chart. The provocation was spoken. The response was documented. That is how, between a hallway and a door, a man with a stable heart rate acquires a psychiatric diagnosis authored by the person who caused it.

Patient asks to speak with Risk Management. He is informed that Risk Management is home sleeping.

Risk, it should be noted, was not.

02:08

Security arrives. Two young men who look like my nephews. They are, without competition, the kindest people the patient has encountered since 15:00. They have clearly made this walk a hundred times and know before they arrive that “agitated patient” means a tired middle-aged man asking why nobody’s seen him. Nobody tied anything to them. Nobody shook them. They are the only two people in the department without a chart to protect, so they have room to be decent. The hospital has outsourced its kindness to security.

They turn on their body cameras. And so, eleven hours in, enough time to fly from North American to Asia, the first impartial record of the patient’s care is created, by accident, by the people sent to remove him. The footage does not contain 15:00 through 02:03. It does not contain the stretcher, the lights, the blank screen, or the beeline. It contains a man in a hallway being loud. Footage with no history, like a diagnosis with no history, is a very clean document. The camera turned on after the arena was finished with him and pointed at the cricket.

Patient feels bad for the guards. This is also not charted.

02:15

A room opens. Not because of the questions. Because of the mop. The room has a door. The door is the great luxury of American medicine: a place where you can’t hear what’s wrong with anyone else. The patient is placed inside it the way a bar at closing time places a man on the curb: lights up, bouncers out, the bartender who started it wiping down the counter like nothing happened. Last call for medical care. You don’t have to go home, but you can’t stay in the hallway.

An attending appears, a real one, and the patient’s main anxiety is that after eleven hours composing hospital satire in a hallway he no longer presents as a colleague but as an Internal Medicine Physician Emulator, and that the attending will conclude he’s a simulation. The attending asks how he can help. The patient says: I came here to see an orthopedic surgeon about my hip, and I’m not leaving until I do. The attending is dry about it. Everyone’s dry. Nobody’s had water since three.

03:00

A calm, sweet nurse takes over the patient’s care, after the fact, the way a cleanup crew takes over a parade. She asks if he has any feedback. He does. Constructive, even. Put cameras at every station. Big ones. In everyone’s face, nurses included, running all night. Then, when an incident happens, you’ll have footage of the events leading up to it, which is the part that would let you prevent the next one, instead of two body cameras aimed at the customer’s response. She nods and writes it down. The patient suspects it goes in the same inbox as the water.

07:08

The phone buzzes. “A consultation has been ordered.” Sixteen hours after the greeter, the sentence the patient came for. He reads it twice. It doesn’t say which consultation. It doesn’t have to. Reply STOP to stop texts.

Discharge

Diagnosis resolved. Not treated; resolved, the way a hair resolves when somebody unties it. It will not be mentioned at discharge, and it will follow the patient to every emergency department he walks into for the rest of his life, where it will be read before his name, and he will be shaken accordingly. The footage is retained. The nurse’s last name is not released. Risk Management will review the incident at 9:30, over coffee, and conclude that the system worked.

Addendum, for Russ

Here is what the arena doesn’t tell you. The nurse in pink is a cricket. Young, shaken hard and early, and she crossed that station because something in her own hair got pulled. The clerk is a cricket with a blank screen. The nursing supervisor who eventually appeared is a cricket; she said so, more or less, with her face. The resident who finally came through the door is a cricket on hour twenty-something. Everyone in that building was tied and shaken by the same hand, and the hand was home sleeping.

Russ thinks crickets fight each other. They don’t. They get put in the same box and told it’s an arena. The only unusual thing about last night is that one of the crickets had spent ten years inside this particular building, walked in assuming it would know him, and stayed awake long enough to watch it not.

Nobody asks the cricket. But they do film it.

A note, before anyone forwards this to Risk Management

This is meant as reflection, not prosecution. Nearly every person I met in that building over sixteen hours was excellent. Truly, measurably above average: the techs, the clerk with the blank screen, the two security guards, the calm nurse who took the feedback, the attending who was dry with me because I’d earned it. Even the nurse in pink was good at her job; that’s what makes the beeline worth writing about. None of this is good cop, bad cop. There are no bad cops in this story. There is a box, and a hand that isn’t in the room, and a lot of very tired crickets being decent to each other at two in the morning, which is harder than it sounds and happens more than it should have to.

It’s early. We’re all tired. I’m writing this from a room with a door, in a hospital I’ve loved since I was eighteen, waiting for a consultation that has been ordered. If you work here and recognize yourself: thank you. If you run the place and recognize the hallway: that’s the part I’d like you to read twice.

And one ask, for everyone with a badge. Give the patient a break. You are in the position of power. You have the keys, the water, the chart, the cameras, and the door. The patient has a wristband and a paper bag. When he finally gets up and walks to the desk, he isn’t challenging you. He’s asking whether he still exists. The answer to that question costs nothing, and it’s the only thing in the building that does.

I know the argument. He raised his voice. He said a word. But think about who got to decide when the clock started. The patient was polite for eleven hours, and that counted for nothing, and then he was loud for thirty seconds, and that became the record. That’s not a judgment about him. That’s a description of power: the side that writes the note decides which thirty seconds matter. If the roles were reversed, if a nurse had been left in a hallway from three in the afternoon to two in the morning, without water, without a doctor, listening to custody cases, and finally walked to a desk to ask whether anyone knew she was there, every one of us would call her raising her voice reasonable. We’d call it the first sane thing that happened all night. The patient doesn’t get that reading, because the patient doesn’t get to write anything down.

Every hospital and clinic in America now has the sign. You’ve seen it. Threatening or abusive behavior toward staff will not be tolerated. I used to nod at it. I’ve had patients yell at me; I know what it protects. But read it again from a stretcher. The sign only faces one direction. There is no sign that says leaving a patient in a hallway for eleven hours without water will not be tolerated. There’s no sign that says crossing a nurses’ station to raise your voice at a man asking if he’s been forgotten will not be tolerated. There’s a text message that says we haven’t forgotten you, and then there’s the sign, and the sign is for him. An institution that posts rules for the powerless and texts reassurances to itself has told you exactly who it thinks the threat is.

So when the tired person on the stretcher finally snaps, the question isn’t what’s wrong with him. It’s what took him so long, and what you’d have done at hour six. Give the patient a break. He’s the only one in the room who can’t give himself one.

Go Blue.