By Birdstrike M.D.
I think every Emergency Department has a patient like this. Homeless Elvis came in to our ED at least once per day, for many years. Sometimes he’d see each doctor, on each shift in an entire day. By sheer numbers the amount of uninsured ED visits he accumulated over time was unbelievable. None of us ever knew his real name, because he never had ID, and he insisted we call him “Elvis.” His last known job was working as an Elvis impersonator, and due to his uncanny resemblance, this would have been no stretch. We all knew “Elvis” had no real home, other than possibly our ED. On one particular day, he surprised us all.
I had taken care of the guy, probably 500 times. He had an extremely bad heart. He was told that after a heart bypass, repeat bypass and multiple heart stents, that there was absolutely nothing anyone could do for it. It was amazing he was even alive. He would come to the ED, every day with the same complaint: “Chest Pain.” Sometimes he actually had chest pain, sometimes he didn’t. Sometimes his chest pain was from a heart attack, sometimes it wasn’t. More often, Elvis wanted food, clothes, or shelter from the elements and most of all, company. In our ED, he almost always got it. He would routinely agree to an aspirin, EKG, and sometimes labs. Almost never, anymore, would he agree to hospital admission, or stress testing, let alone a heart cath. He must have politely signed hundreds of “against medical advice” release forms. He never argued with anyone, made any demands or caused any trouble. He had been coming to our ED longer than anybody that worked there. The guy was a fixture of our ED and part of its soul and personality. Some of us spent more Christmases, New Year’s Eves, and other holidays with Elvis, than with our own families. I once overheard one of our veteran nurses tell a new employee, “Oh, don’t worry about Elvis. He’ll grow on you. Like mold.”
Not surprisingly, Elvis also had depression, in its most severe and chronic form. Whether his situation led to his depression, or his severe depression rendered him unable to function, it is hard to say. Rumor had it that he was married with children at one point and that they had left him and that he had lost all contact. He refused to talk about any of it. The only thing that helped his mood other than a warm blanket, meal tray and something for his pain was his antidepressant medication. He had been on it for years. Nothing else worked. Sometimes he had a little bit of money to buy it, sometimes he didn’t. Sometimes he’d get samples, sometimes he didn’t.
I actually liked seeing Elvis as a patient. I knew him well and I knew exactly how to take care of him, since I had seen him so many times. Seeing him was, in a strange way, a routine and comforting break during many a chaotic shift. He was an easy patient, really. Others got irritated, especially if they were new and didn’t know him well, and especially when the ED was busy.
One shift, we were incredibly busy with 30 or more patients waiting and only two doctors on duty. The acuity was high. We had traumas, and we weren’t a trauma center. We had STEMIs and we had no cath-lab. We were buried.
In comes Elvis by ambulance, with his usual chief complaint of “Chest pain.” I purposely let my partner Mike see him. Mike was new to our ED and had just finished residency. There’s no better time for him to get to know Elvis, I thought to myself. Doctor Mike signed up to see Elvis and went in to see him.
A couple of hours later I looked in Elvis’ room, expecting to see the usual finished meal tray, tattered boots at the foot of the bed and a lump of a person sleeping with the sheet pulled over his head. “What happened to Elvis?” I asked Mike.
“He signed out against medical advice a couple of hours ago,” said Mike. “He completely refused a cardiac workup. We gave him a bus pass and he asked if he could wait in the waiting room for a couple of hours. He said he would never come back.”
“Oh, I should have told you about him. He comes here all the time. He has horrible, untreatable coronary disease and really, nothing helps him other than an aspirin, some morphine for his pain and maybe refilling his prescriptions. Cardiology knows him well and agrees. They’ve said there’s absolutely nothing else to offer him surgically. They can’t believe he’s still alive. He’s actually a sad case. He’s homeless and lonely most of the time. We’ve tried to set him up with social services, primary care, everything. He’s just one of these guys that fell through every single crack in the system. There’s no getting rid of Homeless Elvis. He’s here to stay. He’s harmless, really.”
“Oh, really? I actually feel a little bit bad then. I told him it’s not appropriate for him to be coming here three times every day for non-emergencies. I had social work fill a month’s worth of his antidepressant for him, though.”
Interrupting us, somebody yelled from the waiting room, “HELP! OUT IN THE WAITING ROOM! SOMEBODY BRING A STRETCHER! CODE IN THE WAITING ROOM!”
We ran through the double doors to the waiting room. There was a person lying on the floor, motionless. “Oh, my God, it’s Elvis!” I exclaimed. We lifted him onto a stretcher and one of the techs hopped on and started chest compressions as we rolled quickly down the hall to one of our code rooms. His heart must have finally given out, I thought to myself. Into “code-mode” we clicked.
“One, two, three….charging!”
BAM! We sent a jolt of lightning through Elvis’ heart.
“Look, we’ve got a rhythm. That was quick. Check for a pulse,” I said.
“Got one!” said a nurse, as we shot through ACLS protocol.
“Let’s get a 12-lead. Let’s see this MI,” I ordered.
His EKG was not what I expected. There was no ST elevation, whatsoever. There was no MI. His QRS was wide, really wide, and definitely much greater than 100 ms. That’s weird, I thought to myself. “Let’s run a continuous 12 lead. His ST segments have to go up.”
“Hey doc, check this out,” said one of the techs holding up a pill bottle from Elvis’ pocket. “It’s empty.”
“Empty?” I asked, “What is it?”
“Am—, amitri— something. I don’t know how to say it,” he answered.
“Amitriptyline?” I asked.
“That’s it,” he answered.
“He ate the whole bottle? He overdosed in the waiting room!? What the….?” I said, shocked. “We need some Bicarb. Now, before he arrests again. Get Doctor Mike in here.”
“Yeah, what’s up?” said Mike.
“Remember Elvis, your patient that signed out AMA about 2 hours ago?” I asked him.
“Yeah, what happened? Did he have a heart attack in the waiting room, or something?” he asked, shocked. “Good thing I had him sign out AMA.”
“No, actually he tried to kill himself. He went into cardiac arrest after taking the whole bottle of amitriptyline you gave him. We got him back, though. For the moment, anyway,” I explained.
“You’ve got to be kidding me,” said Mike, shaking his head in disbelief.
Elvis was my last patient of that shift. I felt like the life was sucked out of me. I felt like I had coded a family member. Many times we had kept Elvis alive, whether by providing a meal, treatment for his heart, or simply made his life better by providing pain control or shelter from the elements. This time we saved his life in dramatic fashion. I don’t know why, but despite that, I felt that I had failed, and miserably so. Elvis went off to the ICU alive but in critical condition. I went out the door and on with my life.
A few days went by and we didn’t hear anything about Elvis. Then someone said he got transferred to the local University Hospital. A few weeks later we called trying to find out what happened. Nobody there seemed to remember him or know what happened. They wouldn’t give us any information. “HIPAA,” they said. Did he take a turn for the worse and die, or remain in a coma? Did he survive and take what Dr. Mike said to heart and refuse to come back to our ED? Nobody knows. All we know is that we never saw our Elvis again.
This author does not divulge protected patient information or information from real life court cases. Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients. To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional. Any opinions expressed here are of the author alone and not those of epmontly, WhiteCoat, my employer or any of the hospitals with which I am affiliated.