NPO

Bearded. Pungent. Sour smelling clothes stuck in places well beyond the expiration date.

“If you people don’t give me some god damn graham crackers right now I’m leaving!” His voice carries across the room, down the hall to the nurse’s station.

“You’re here for an amputation, sir. Your surgery is scheduled in less than two hours.” My delivery is flat and matter-of-fact.

“I don’t care about surgery! You’ve been starving me to death for two days and I want something to eat! NOW.” He is definite. “After I eat, then I’ll go to surgery,” he argues, as if to bargain.

Education regarding the risks of aspiration while intubated is delivered. Anesthesia is the bad cop, while I play the innocent messenger from internal medicine.

“God damn you people! I’m hungry!” The grey beard streaked with tobacco stain, an hombre look gone completely wrong, bobs up and down. Whiskers sprouting from an edentulous mouth. Profanities are slung around the room. The neatly groomed third-year medical student cringes as the patient pulls the sheets over his head. A clear signal he is done with us. Having obviously failed with my educational inservice on aspiration risks, I opt for a more practical approach.

“Sir, where exactly would you go if you don’t get the surgery?” I’m cautiously curious.

No response. I fill the space and remind him his foot is dead and the amputation with vascular surgery would be life saving. Crickets. I wait shifting my weight from one high heeled shoe to the other.

In one fell swoop, like a bird of prey about to pluck its dinner, he rips off the covers. I lean backwards away from the bed while still maintaining my balance. He looks up at me from the tiny island of a hospital bed. For all his big talk he’s a frail old man losing more than a limb, he’s losing his agency.

“Ma’am,” his voice is softer, almost quiet. I lean in towards the bed to hear better. Careful not to get too close. “I’ll go home and take care of it myself.”

“How?” my voice cracks.

“Well, I’ll just pretend like I’m an animal in a trap. I’ll take my buck knife and saw through the muscles and then the bone.” He makes gashes though the air with his hand wrapped around an imaginary knife.

Knowing what landed him an extended stay on 2-East, I believe him. Having recently been discharged from the hospital after being treated for a diabetic foot infection, he’s back not three weeks later. The wound vac carefully placed by the podiatrists to suck out drainage and encourage the crater in his foot to remember how to heal made it all of four days. Having fired the home health nurse at the front door, he removed the wound vac himself since “It really didn’t work anyway.” Then with fishing line he sutured “that son of a bitch shut.” His foot is now a black crater of oozing pus.

I stare at the man in front of me demanding to break his NPO status. Our gazes lock. Who will blink first in this no-guns-on-campus, gun slingers show down. I give the universal signal to the team we’re done here. In my most commanding of voices bark out the following orders.

“You aren’t eating anything until after your surgery. Those are your orders and I expect you to follow them.” In my most confident, respectable, “That’s doctor, lady doctor, to you” turn on your heels and exit stage right, I head for the door.

The sheets are now back covering his head.

“You know what you are?” says the taunting voice from behind sheets.

“What’s that?” I freeze.

“You’re just a bunch of Republicans!”

And with that the OR calls for my patient.

On my own rounds the following day I notice his name on a different floor. He’s now followed exclusively by the surgeons, medicine benched to the sideline. I pop my head into his room.

“Well, what the hell do you want?” he bellows from the bed. He is supposed to be working with physical therapy and I’m a distraction.

“I knew they were starving you to death so I just wanted to make sure you got something to eat.” I’m genuine, maybe he can tell.

“Yeah, I got dinner last night and breakfast this morning.” He’s less edgy, not exactly kind, just not hollering through sheets.

Another pause. We stare at each other. He’s lost a leg, but he’s already learning how to transfer, pivot and, most importantly, he’s regaining his independence. I smile as I turn to go.

“See you later, alligator,” I call.

“In awhile, crocodile,” he responds.

And just like that we patch it up.

Amy Cowan, M.D. is a full-time hospitalist and educator at the Veterans Affairs Medical Center in Salt Lake City. She loves tackling tough topics and impolite subjects through improv on the wards and group discussions. She loves rock climbing and dead lifting and bringing waffle bar to work.

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2019 Essay, "NPO"