Grady Memorial Hospital, right in the pelagic heart of The City of Atlanta. It is just as functionally dysfunctional as the city itself, full of dichotomy and synergistic contradiction. Grady may actually be much more like its patients, actually. They are both a wonder. How are they still standing, still going about the day through sheer force of willpower and ignorance?
We have a prison in the emergency department. A PRISON. Staffed by armed guards. In the proper ED halls the (also armed) Atlanta PD patrol to keep us caregivers safe. Mostly safe from the unruly "thug" who isn't getting the specific med they demanded or some tweaker freaking out. Occasionally, a gang member comes into the trauma bay to finish off what was started. Shots have been fired inside the ED far too many times… despite the metal detectors at all entrances. This is where I got real comfortable with trauma, real fast. Mainly the physical damage I'm treating in my trauma patients, but also some of the other myriad definitions of the word. More crazy stories than I will ever remember could be spilled from my time there. Some painful, some simply absurd, almost all taught me something… but I'll never forget the lesson I learned from my first patient that I ever (without supervision) did a trachesotomy tube change out on.
She didn't seem too different from the normal "Grady Patient". Oddly dressed for the weather, but what the hell do I know about city style.? I have a hard enough time distinguishing chic from homeless. She seemed to have a little bit of both vibes going on. A bit malnourished sure, but not on death's door by any means. COPDer almost certainly, looking at her clubbed digits and hearing her prolonged expiratory phase. (I just can't untrain my ears… once a respiratory therapist, always a respiratory therapist.) Oh, another clue I picked up on was the plastic trach tube in her neck. It was poorly cared for. Grime in all the creases and missing its inner cannula, I was a bit worried about how long she'd had it in. Once I was in the room to examine her, I realize it must be pretty gross on the inside too. The high pitched whistling exhalation and observable work of breathing on the patient's part wasn't entirely due to her lung disease… she was trying to breathe through a coffee stirrer. Gunk has no doubt built up inside the tube, narrowing it. I got the greenlight to swap it out for an identical (but brand new, clean and likely much more patent) model. The procedure is straightforward when the patient's stoma - the hole - is well established from long term use. Most of the time at least.
I've done a few myself, but always with help right at hand, just in case. There typically aren't issues, and even if there are they aren't usually too emergent. Yeah, you could technically rupture the tracheoinnominate artery and cause the patient to bleed out their entire blood volume into their lungs… leading to a horrifically bloody, sputtering mess of a death. But it's super rare, and usually has warning signs. I'm pretty sure.
Hers turns out to be perfectly uncomplicated. The old one comes out easily, although it's disgusting. The new one slips right in place with nary a cough from the patient. Either she's a tough ol' gal, or I did a decent job. Shortly after, I'm outside the patient's exam room, chatting with her nurse about how well it had gone.
The nurse informs me, "She's been through much more… uncomfortable things."
"Eh? Do you know her?" I ask.
"NO. I can just tell…"
At this point, I'm a little puzzled. I'm nodding along and agreeing as one does when one is out of their element or depth, which I often was during my time at Grady. Is this a cultural thing? Am I being the naïve white guy again? My gears are turning.
"Wait, what are we talking about?"
The nurse leans in and whispers with a smirk, "She's a prostitute. You aren't the only dude puttin something in her tonight."
Well, a bit crude perhaps, but it sure got the point across. I was being the naïve white guy again. Or the nurse is screwing with me. I've done a damn good job making myself an easy mark amongst the salty lifelong Grady nurses.
"Bullshit. She's no prostitute." I say confidently. I won't be had again. "There's no way a guy's gonna pay to have sex with a girl with a TRACH." But, evidently, I announced my thought a bit too resolutely. From inside the exam room, I hear the sandpaper rasp…
"SWEETIE…" -inhale- "GET IN HERE."
OH SHIT! SHE HEARD ME!
My mind racing, I debate all the possible ways to react to this situation. Ignore her request and act like I couldn't hear her? Run? I mean, I have completed all of the care that she needs… I could just bail. The urge passed as quickly as it had pounced upon me. No, that isn't right. I was being rude, and carelessly loud with my comments to boot. I deserve whatever tongue lashing she has planned for me. Well, not exactly "whatever tongue lashing"… but you get the point. Man up and go in there. Apologize. She deserves the same human respect we all do.
"Miss, I'm So-"
"NO." -inhale- "Don’t." She growled out, sharply intaking breath and then covering the open tracheostomy tube with her long, skinny index finger when she wanted to speak. (This routes the exhaled gas out the normal route, past the vocal cords.)
​
"I know" -inhale- "you prolly don't understand" -inhale- "the way I live my life." -inhale- "That’s good for you" -inhale- "Really hun, it is." -inhale- "You didn't have to live" -inhale- "the life I did." -inhale- "But lemme explain somthin to ya…" -inhale-
​
Now I can only imagine the kind of wise anecdote that this weathered old soul could impart on me. Surviving against the odds, using what talents you have to overcome, perseverance, how far any of us could fall, compassion for fellow man. The list rolodexing through my mind would have kept on going had she not so very abruptly cut straight to the point.
"Listen here sonny"
-inhale-
"I'm the only girl"
-inhale-
​
"walkin' them streets"
-inhale-
​
"don't have to come up for air."
Let that sink in.
I will never forget my little urban snorkeler.