by Robert J. Lanz, LCSW
I seldom worked the day shift or weekends, having settled into what I considered a great schedule of four ten-hour shifts running Monday through Thursday evenings, with three days off to recover. In my opinion, the night shift crew was simply the best. Best doctors. Best nurses. Best all-around staff working like a well-oiled machine, usually under the worst of circumstances.
The day shift folks were a little more conventional and the weekend guys were often part-timers, since the regular staff liked to be home with their families on weekends, too. Before the establishment of twenty-four hour social work coverage in the ER, it was common for the overnight shift to hold certain patients for evaluation and disposition by the morning social worker, and there was always a rogues’ gallery of interesting and bewildering individuals awaiting whoever it was had the misfortune of showing up for work at eight a.m. Stacked like cordwood in the hallways where they could be watched, the patients slept fitfully until the morning social worker arrived to wake them. On the rare occasions when I worked the morning shift, it was the charge nurse’s responsibility to bring me up to speed on each one of them, so of course I got hit with a array of complications as soon as I came through the door.
“Room Five needs his psych meds refilled. The doc is okay with that but wanted you to do a drive-by first. That drunk guy in the hall, bed six needs some fresh pants, a bus token and a referral to AA. Louie’s in Room Nine sleeping it off again. He needs a full set of clothes and some shoes if you’ve got ‘em. Don’t ask. And Mr. Johnson in hall Bed Four needs an eval. The doc wants you to touch base with on him and he probably needs a taxi voucher. He’s still a little stoned from last night.”
The nurse broke into a slight grin as she gave me the final referral. I wondered what that was about.
Mr. Johnson was sleeping soundly, and my policy is to let the sleeping dogs lay, so I planned to see him last.
The guy who needed the psych meds really did need his psych meds, as he had missed his appointment at the clinic where they gave out free prescriptions. Without his meds he would just end up back here or in jail because he was already starting to decompensate. His was a chronic problem. Poor self care, leading to some set of psychiatric symptoms severe enough to get him readmitted to the psychiatric ward at about $1,500 a day where he would be stabilized and released. Or, I gave in and helped create a way for him to get his meds without actually going to the psych clinic and seeing his psychiatrist. Big dilemma. Some docs were okay with it and some weren’t. On my regular shift, they often deferred to me, and if I knew the patient well enough, we’d go ahead and give him the meds and leave a message for his psychiatrist. Worked for me. Scratch one off my list.
Louie was sober enough to get a full hose down, some fresh clothes and some old shoes. I declined his offer to take me to breakfast, on my dime, but I did give him some coffee and cookies because he was nice. He was always nice, although seriously self-destructive. He always mistreated himself but never us. Louie got a decent Eddie Bauer flannel shirt and a few bus tokens so he could go visit his mother, who sometimes called the ER to see if I was there so she could ask if Louie was there. Technically, it was a violation of the patient’s rights for anyone to release that kind of information, but Louie had once told me it was all right. Besides, his mother was probably the one constant in his life besides drunkenness and the ER, and she may have offered some stability for him at some point. At least that was what I hoped.
“Okay, Louie. See you next time. Here’s some bus tokens. Go see your mom, huh?”
“Yeah, sure Bob. Thanks for the clothes and shoes and the coffee, too.”
One more guy. One more pair of pants and one more bus token and it was time to wake up Mr. Johnson.
I never went to see a patient without checking his medical chart first. Too many things could go wrong, so I always read the patient’s chart no matter what the docs and nurses told me. I walked up to the chart rack and looked for Mr. Johnson’s paperwork.
Couldn’t find it.
“Hey nurse. That dude in the hall, Mr. Johnson. I couldn’t find his chart.”
That grin again. “Well, Johnson’s not his real name. Johnson’s his medical problem.”
She handed me the chart and walked off. Mr. Johnson’s real name was not Johnson. Johnson, a well known euphemism for penis, was used because he had an injury to his, well, his Johnson. I read the chart-all the information was there, all that he had told the triage nurse when he came in, whispering it, I’m sure. All that he had told the doctor, and the treatment the doctor had rendered was on the chart, too. At the end was a note from the doctor requesting that the social worker see the patient for a brief evaluation before he left. Here’s why:
Mr. Johnson’s night had started reasonably well. A married man and an apparent heterosexual, he decided to stay out all night in the company of another man and a transsexual with all his male parts still fully functional and with his female parts surgically enhanced. The patient had fantasized about being a star performer in this bizarre threesome, so he brought along his porn star performer kit. That kit included several Viagras, a gram of methamphetamine and a device commonly referred to as a “cock ring”. Let’s go through the list one-by-one and I can explain the physiology.
Viagra is a vasodilator. That means it opens up your blood vessels to increase blood flow. Since a penis is designed to engorge with blood in preparation for sex, the vessels open wide and the blood rushes in. Vasodilation can make you light-headed due to dropping blood pressure.
Think of those corny commercials on TV that feature an unlikely group of guys sitting around talking about their non-functioning “johnsons,” and the spokesperson offering a warning to talk to your doctor before engaging in sexual behavior. And be sure to call your doctor if you have an erection that lasts more than four hours. (More on that later.)
Methamphetamines have just the opposite effect from that caused by Viagra. Meth speeds your heart rate and raises your blood pressure through vasoconstriction, making your blood vessels smaller. Another common effect of the meth is euphoria to the point of agitation, frequently accompanied by bizarre sexual fantasies, which due to his stimulated state, gives the user all the energy needed to pursue them. Can you see where this is headed?
Now for the “cock ring” part. If you don’t like graphic visual descriptions, I suggest you stop right here and just forget you ever started reading this ode to lunacy.
A “cock ring” is simply a constricting device placed at the base of the penis that keeps blood from flowing out once it has flowed in. Arterial blood under pressure going in, venous blood under a lot less pressure coming out. A constricting ring will allow the user to maintain an erection when it would otherwise go flaccid. It’s rare to have a “cock ring” presentation in the ER because the devices are usually made from leather with some type of a fastener, or simply a rubber band or something like that which can be easily removed. The literature illustrates that the rings are quite effective and variations are used as medical devices for those with erectile dysfunction.
However, I don’t recall reading anywhere in the medical literature that it would be a good idea to ingest Viagra and meth (and most likely lots of alcohol), and then slip a heavy brass ring around one’s penis. I’m sure that the warning about the four-hour erection eluded Mr. Johnson. Probably all of that meth and alcohol got in the way of any sort of good judgment he may have possessed to start with. This was a patient who obviously should have stayed home and just had sex with himself and gone to bed.
By the time the patient realized anything was wrong, he was well past the cut-off time to avoid penile endangerment. No doubt, for a moment he thought he was a star, never having seen his penis so big. No doubt, he took full advantage of that increase in size in ways I don’t even want to think about now, or any time in the future, for that matter. Suffice it to say his member wasn’t going to win any beauty contests by the time he got to the ER. Thanks to the Polaroid camera we sometimes use to document evidence and interesting injuries, there were several pictures of Mr. Johnson’s Johnson, and the only competition he was going to win with that pulsating purple wand was as a prize eggplant in a vegetable growing contest. Next time you go to the market, head on over to the produce section and your worst produce nightmare will be envisioned.
In any case, with that engorgement, the cock ring had all but disappeared. With a leather strap or rubber ring, we could have just cut it off. And on that rare occasion when a patient has arrived with a similar condition, called priapism, the docs can just drain the engorgement—aspirate is the medical term—with multiple pokes from a large bore needle. It hurts my own Johnson just to describe the procedure.
Of course, a sane patient can refuse a medical procedure even if it is in his own best interests. I guess they couldn’t get a psych eval at four in the morning and didn’t want to wait for me to come in to give my opinion on the patient’s ability to make an informed consent. Thank God for small favors.
No matter, since the patient refused the needle aspiration, the only thing left to do was to try and cut the ring off. We did have a small tool, actually called a ring cutter but I don’t recall ever having it used for a cock ring before. It isn’t very big and has a hook and round wheel with sharp teeth that will cut through metal jewelry pretty easily. I’ve seen that done a lot of times when a finger has been injured and we need to get a ring off before it becomes too constrictive and restricts circulation. Of course, most jewelry is made of silver or gold, relatively soft metals, where brass is an alloy made of copper and zinc and is a lot harder. Brass is usually used for door knobs and in some plumbing applications. Maybe this cock ring was a component of some plumbing application. I don’t know much about that. The ring cutter didn’t do much to the brass and the brass wore down the teeth on the cutter so badly that the nurse had to throw it away.
It was then that the doc did what he probably should have done in the first place, contact the urologist on call. Urology is a fairly routine specialty and most nights the urologist on call slept through the night like nothing would happen because it rarely did. The Viagra guy on TV doesn’t even show up in the ER as far as I know. The most common treatment for the priapic nightmare is the aspiration cure.
“Well, I already tried that,” our doc told the urologist on call, “but the patient refused the procedure.”
“Give him a lot of pain meds and ask again. He’s going to need them. Good night and thank you for this most interesting consultation.”
So the patient got a lot of pain meds but still refused to have the needle aspiration, apparently finally finding something he wouldn’t do with his Johnson. That decision propelled the ER doctor into a creative mode of thinking, and I have to say it took a lot of bravado to make the next move.
“Nurse. Call Ricardo over in maintenance. Tell him to bring his bolt cutters.”
I’m sure, when Mr. Johnson woke up from his drug induced stupor and saw Ricardo straddling him with giant bolt cutters, he finally realized what a huge mistake his whole night had been. The way I heard it from the doc later, it didn’t help calm Mr. Johnson down when Ricardo asked, “Shouldn’t we at least try to sterilize this thing first?”
“A little late for that now,” the doctor replied. “Try to keep a steady hand.”
That was when Mr. Johnson finally got a good grasp on reality, likely a rare occurrence for him, and yelled uncle. He got a little more pain meds and then the needle aspiration procedure. When it was finally over, Mr. Johnson was in decent spirits and told us he wanted to go home. He wasn’t crazy and he was no longer under the influence, so I couldn’t stop him. When I asked if he wanted a free taxi ride he declined and said he wanted to walk home. Hard to believe after all that he’d been through. I guess he had a lot to think about. In any case, he got what he needed, medically, the doctor’s bolt cutter ruse providing the final impetus for the patient’s decision to get the needle, rather than the Ricardo From Maintenance Intervention.
“Welcome to the day shift, Bob,” the nurse said. “Do you think we’re different than the night shift?”
“Oh yeah,” I said. “On the night shift, no one would ask the social worker to go see Mr. Johnson.”
I let that hang in the air for a moment.
“The night shift nurse would tell me to go see the goofball who couldn’t even do a cock ring right. Mr. Eggplant. Room Five.”