It started, as plenty of my cases do, when the paramedics delivered a woman who was blackout drunk and spitting up blood. It was six AM and my shift was almost over. People glided through the muted beeps and crackly overhead pages of the ER. A new patient popped onto my screen: “Wander, 39 y.o. F, ETOH Problem and Hematemesis.” I clicked on her name.
Hematemesis is the clinical term for vomiting blood, and it hits all the high points for why I went into medicine. It’s a problem you can chase down, explain, and hopefully fix. It encompasses a spectrum of conditions that range from imminent death to being a dumdum who likes red Gatorade. And it’s a tasty word, right up there with “hemoptysis” and “epistaxis.” I feel like they could all be pharaohs in a dynasty of bleeding orifices.
I went into the room and did my Minnesota nice “Knock knock! Hi there, I’m Dr. Rosen. You can call me Adrian.” The nurse was already in there, tapping away on his computer. My scribe (that’s the premed indentured servant who does my charting) was awkwardly navigating his own wheeled computer into the room. The patient was a sallow woman who looked ten years older than her stated 39. She reeked of cigarettes and liquor, the pickled, dying smell that emanates from people who live hard and die ugly. Her upper arms were wasted, the right bicep looped with a faded thorns-n-roses tattoo.
She was covered in bruises of breathtaking randomness and severity. Skin usually tells a story. You see a diagonal stripe across the chest when someone crashes their car with the seat belt buckled; you see evenly spaced circles in the shape of an abusive boyfriend’s fingers on a woman’s thighs or neck. Ms. Wander was a watercolor in ugly purples. No pattern. They were all fresh. Something had happened to her, and recently.
She held a large popcorn bucket with regal drunk nonchalance. I peered over the lip. “Coffee ground emesis” is an ickily literal term for what digested blood looks like when it’s thrown up. Ms. Wander’s bucket had a few streaks of red, but most of the contents were gritty and black.
“I read your chart,” I said. “When did you start having bloody vomiting episodes?”
She calmly coughed a glob of red into the bucket and wiped her mouth.
“Since the change. Happens every time. Didn’t wanna come but I woke up in the ambulance and,” she swallowed, “guess I’m here.” She swayed and gave me an accusatory look. The pale green hospital gown slumped off one shoulder and her left boob was perilously close to popping out. She made no move to correct this.
“What do you mean by ‘the change?’” She closed her eyes and wobbily shook her head, so I pulled a nurse’s tiny wheeled stool over to the bedside and sat down next to her.
“You’ll think I’m crazy.”
“No, I won’t.” Oh yes, I will, I thought.
“Mm. Don’t want t’talk ’bout it.”
“Are you sure?”
“Hon, how did you get those bruises?” I asked. She chuckled wetly and spit.
“Don’t worry ’bout that shit I’ll be fine in like, a day.”
“Do you have any bleeding disorders?” I waited for an answer and didn’t get one. Enough alcohol will wreck a person’s clotting capabilities. “Okay then, can I give you a quick physical?”
“Mm.” Her face looked like she was saying yes. I stood to examine her. The nurse was almost done in the room; I could tell he was waiting around for me to finish up and make a plan. For all her bruising, she didn’t seem to hurt anywhere. Good range of motion, sensation, brisk reflexes. Stomach soft enough that it wasn’t obviously filling with blood. Everything normal on a person who looked like they’d just crawled out from under a collapsed building.
“Have you been drinking tonight?”
“Prob’ly a pint? And a half.”
“Of vodka?” I asked, taking a guess based on everything about her.
“Is that how much you usually drink in a day?”
“It’s how much I usually drink for today,” she slurred. I made fleeting eye contact with the nurse his face twitched.
“Okay,” I said. “Any drugs tonight? Weed? Meth? Gravel? Wet?”
“Just a little meth.” Just a little!
“Thanks for letting me know.” I was about to ask her more questions about the vomiting, but then I shined a light in her mouth and the case went from mildly fucked up to considerably fucked up. I’ve seen a lot of bad teeth in the ER. I’ve seen a lot of good teeth.
I had never seen a human being with fangs.
Her canines, both upper and lower, were roughly three-quarters of an inch long. They were yellowed as the teeth around them and visibly sharp. Her gums were bleeding. I prodded one of the fangs with a gloved hand and felt her jerk upwards. I know the difference between real pain and someone faking it. This was real pain. I clicked off my flashlight and sat back down.
“Have your teeth always been that way?” She put a fist up to her mouth, swayed there for a few moments, swallowed, and then unclenched her fist. She dragged a hand through black hair rendered haylike by multiple bleachings and re-dyeings, eyes closed and mouth hooked up in a lopsided smile.
“They’re always the last thing to change back. And they hurt like a bitch.” I could hear my scribe typing furiously in the background. I hoped he was getting direct quotes. The woman slouched to her side and scooted up on the bed, propped on one elbow and spooning her popcorn bucket. The fluorescent lights buzzed faintly.
“What do you mean they’re the last thing to change back? What is it that’s changing?” Ms. Wander put a hand up to her face and slowly wiped downwards. Her palm everted her lower lip as it went, pulling the blood coating the inside of her mouth over her chin in streaks. Blood in movies is dark, thick and transparent. It looks like black cherry syrup. Blood in real life isn’t like that. It’s bright red, surprisingly opaque even in a narrow rivulet. It’s thin enough that when you hear someone bleeding to death it sounds like a watering can being poured out onto the ground. She wiped the scarlet smear off with the back of her hand.
And then she began to laugh.
There’s a point in an ER case where you can tell that a patient is turning violent. Ms. Wander was unusual in that I sensed danger too late. I jerked my head at the scribe to get out right fucking now, glanced up at the nurse and nodded when he mouthed “SECURITY?” He slipped out after the scribe, already in not-panicking-speed-walk mode.
“Ms. Wander? Ms. Wander, what do you mean by the last thing to change back? You’ve got to be honest with me here.” I was still sitting by the bed, every muscle tensed to bolt up if she moved. Her laugh tapered to a snigger. Rusty bubbles popped at the corner of her mouth. She absentmindedly ran a thumb over her left upper fang as she quieted. She looked like she was considering something.
“D’you really wanna know?” I glanced out the window of the exam room door. I could see my nurse at the end of the hall, walking back to the room with security.
“Sure, I do. Is someone hurting you?” She shook her head and reached toward me. I started to stand up and move away. Suddenly, her hand shot out and she had my right arm in a grip that was far too strong for her tiny, ruined body. Her hands were dry and rough, skinny fingers with nicotine stains and chipped black nail polish. She looked up at me and her face twisted into an evil, nauseating smile. Her eyes glittered.
“Find out for yourself, bitch.” Her grip tightened. She yanked my arm straight, bent down and sank her teeth into my inner forearm, tearing tracks in the skin and fat beneath. I froze, stuck in a flood of stupid racing thoughts about what I could use to beat her off. She let out a muffled groan that I couldn’t mistake for anything other than animal pleasure.
That was when security busted into the room and four corn-fed Minnesota boys with neck tattoos and black polyester uniforms piled onto the woman, pulling her flat on the bed and grappling for restraints. She lay there like a ragdoll as they strapped her down and grinned at me with her sharp red mouth. Someone had handed me a towel and I was holding it to the wound, curiously relieved that it only hurt a lot. I stood back and let the scene turn into a flashbulb memory, loud and flat and detailed. She ignored security and looked at me. She licked her cracked lips and giggled.
I stepped out of the room and into a silent semicircle of staff who’d stopped to see what the commotion was about. I didn’t blame them. I would have been rubbernecking, too. I murmured “I’m fine” and slipped past. No one stopped me. I locked the door behind me in the bathroom, closed my eyes, and leaned against the wall until I was sure I wasn’t going to cry.
I got patched up by my most grandfatherly coworker, kept a stiff upper lip, spoke to a polite sleep-deprived cop in what I’m sure was a weirdly colorless narrative and then walked home after doing a mountain of employee injury paperwork. The morning sun was high on the Mississippi as I walked over the water, away from the Minneapolis skyline. I was mercifully alone in the elevator. My arm throbbed dully. The lidocaine was wearing off. I looked down. Blood was seeping through the clean white gauze taped over my sutures. I got off on the sixth floor and let myself into my apartment. My place is forgivably messy and appointed with new, cheap and comfortable modern furniture. In true cat lady fashion, I decorated in caramel and cream to match my orange tabby, Mr. Macaroni. He trotted toward the door with a friendly, expectant trill. Breakfast time.
“Yeah, yeah,” I wearily said. I reached into a cabinet and pulled out his food, dumped a scoopful of kibble into the hilarious child-art dish that my nephew painted for Mac. He sniffed at my bandage as I bent down. In an exquisite feline mix of affection and ruining everything, he gave me one gentle headbutt right in the stitches.
“Oh, son of a bitch,” I said. Mac turned away to crunch on his food while I opened the refrigerator. I pulled out a half-full bottle of Chenin Blanc and emptied it into a plastic water tumbler. It took three long swallows for me to remember that I hadn’t finished writing up the case. I logged into the hospital’s records system on my laptop and scrolled down to type a summary paragraph, already starting to feel rubbery and unhurtable.
Ms. Wander is a 39-year-old female who presents to the Emergency Department with abnormal dentition, contusions of unknown mechanism, and coffee ground emesis. Differential diagnosis includes gastric ulcer and traumatic esophageal perforation.
Her sly, demented laughter. Her patternless trauma and improbable strength. I hit delete a few times.
Differential diagnosis includes gastric ulcer, traumatic esophageal perforation, or other occult pathology.
In medical terminology, “occult” refers to anything hidden. An occult fracture doesn’t show up on X-ray but it’s still there, pulling bone apart and taking the tender nerves with it. Western medicine flounders outside a very narrow set of parameters, and as a result I invoke occult pathology often. It means there’s been a shift both real and nameless.
It means that something’s gone wrong.