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Homeless Elvis
By Birdstrike M.D.
Homeless Elvis, as he actually preferred to be called, came in to our ED at least once per day, for 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. His last know job was working as an Elvis impersonator. He falsely listed his address as “3765 Elvis Presley Blvd”. 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. Homeless Elvis had chest pain every day. He had a bad heart; an extremely bad heart. He was told than after a heart bypass, repeat bypass and multiple heart stents, that there was absolutely nothing anyone could do for his heart. 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 a heart attack, sometimes it wasn’t. More often Homeless Elvis wanted food, clothes, or shelter from the heat, cold or rain 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 would never turn down a shot of morphine for the pain. Most of the physicians would give it to him, because he had real disease, real pain (most of the time) and was essentially (but not formally) a “comfort care” patient. He never asked for it by name, never asked for a second shot, never asked for pills, or a prescription, but if he didn’t get his shot of morphine, without saying a thing he’d get up, walk out the door and leave. He must have politely signed hundreds of “against medical advice” release forms. He never argued with anyone or caused any trouble. He had been coming too our ED for years, longer than most of the people working there. The guy was like 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 Homeless Elvis. He’ll grow on you. Like mold.”
Not surprisingly, Elvis also had depression, in its most chronic form. The only thing that helped his mood other than a warm blanket, meal tray and something for his pain was his amitriptyline. He had been on it for years. Nothing else worked. Sometime 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 weird way, a routine and comforting break during many a chaotic shift. He was an easy patient, really. Others got irritated, especially if they didn’t know him, and especially when the ED was busy.
One shift, we were destroyed, 30+ patients waiting with 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: “Chest pain”. I purposely let my new partner Mike see him. Mike was new to our ED and had just finished residency. “No better time for him to get to know Elvis,” I thought to myself.
About an hour later I looked in Elvis’ room, expecting to see the usual finished meal tray, tattered boots and lump of a person, head covered under a pile of blankets sleeping. “What happened to Elvis?” I asked my new partner, Mike.
“He walked out of here,” said Mike. “He wanted pain medication. I didn’t give it to him. He refused to have his heart worked up.”
“Oh, I should’ve filled you in on him. He comes here all the time. We usually do give him some pain medication. He has horrible untreatable coronary disease and really, nothing helps him other than pain control and an aspirin. Cardiology has actually endorsed giving him an aspirin, a shot of morphine and sending him home. They’ve said there’s absolutely nothing they or cardiothoracic can do for him. 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 has literally fallen 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 about that then. I told him not to come back for this chronic stuff unless he has an emergency and that he’s abusing the ED. I had social work fill a month’s worth of his amitriptyline for him, though. On the way out the door he said, he wouldn’t be back.”
From the waiting room, “HELP! OUT IN THE WAITING ROOM! SOMEBODY BRING A STRETCHER! CODE IN THE WAITING ROOM!” someone yelled.
“What the…?” I wondered as we ran through the double doors to the waiting room. “Get the patient in here”, I ordered. One of the techs hopped on the stretcher, started chest compressions as we wheeled him down the hall to one of our code rooms. “Oh, my God, it’s Elvis!” I said aloud. His heart must have finally given out. It’s amazing it ticked on for the 75 years that it did, I thought to myself. Into “code mode” we clicked.
Pulse: none.
Monitor: V-tach.
“One, two, three….charging!”
POOF! Went jolt of lightning through Elvis’ heart.
“Look, we’ve got a rhythm. I can’t believe it. Check for pulse,” I said.
“Got one!” said a nurse.
“Let’s get a 12 lead. Let’s see his MI,” I ordered.
His EKG was bizarre. There was no ST elevation, whatsoever. There was no MI. His QRS was wide, really wide. According to the computer it was 165. “That’s weird,” I thought out loud. “Let’s just run a continuous 12 lead. I’m sure his ST segments will go up any minute.”
“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?”
“Ami--, amitrip—something. I don’t know how to say it,” he answered.
“Amitriptyline?” I asked.
“That’s it,” said the tech.
“This is not an MI. He overdosed in our waiting room! Damnit!” I said. “Okay, we need some Bicarb. Now! Before he arrests again! Get Mike in here.”
“Yeah, what’s up?” said Mike.
“This is your patient, Homeless Elvis,” I told him.
“Holy crap, seriously? That guy I just discharged? He coded from his MI in the waiting room? That’s not good” he asked, shocked. “Good thing I had him sign out AMA.”
“No, actually he arrested after taking the whole bottle of amitriptyline you gave him. We got him back. For the moment,” I explained.
“Wow. That’s crazy, really crazy. The ED is a crazy place, isn’t it?” said Mike, shaking his head.
Homeless Elvis was the last patient of that shift for me. 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, maybe. I don’t know why, but despite that, I felt that I had failed, and miserably so. I needed to get the hell out of that ED and get home. Off to the ICU Elvis went and I drove home having no clue if Elvis would live, die or be a vegetable. The last I heard is that for some reason they had to transfer him to our nearest tertiary referral hospital. A few weeks later somebody made a phone call to try to track down what happened to him and nobody seemed to know or care. We never did find out. All anybody knows is that he never came back to our ED again.
By Birdstrike M.D.
Homeless Elvis, as he actually preferred to be called, came in to our ED at least once per day, for 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. His last know job was working as an Elvis impersonator. He falsely listed his address as “3765 Elvis Presley Blvd”. 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. Homeless Elvis had chest pain every day. He had a bad heart; an extremely bad heart. He was told than after a heart bypass, repeat bypass and multiple heart stents, that there was absolutely nothing anyone could do for his heart. 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 a heart attack, sometimes it wasn’t. More often Homeless Elvis wanted food, clothes, or shelter from the heat, cold or rain 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 would never turn down a shot of morphine for the pain. Most of the physicians would give it to him, because he had real disease, real pain (most of the time) and was essentially (but not formally) a “comfort care” patient. He never asked for it by name, never asked for a second shot, never asked for pills, or a prescription, but if he didn’t get his shot of morphine, without saying a thing he’d get up, walk out the door and leave. He must have politely signed hundreds of “against medical advice” release forms. He never argued with anyone or caused any trouble. He had been coming too our ED for years, longer than most of the people working there. The guy was like 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 Homeless Elvis. He’ll grow on you. Like mold.”
Not surprisingly, Elvis also had depression, in its most chronic form. The only thing that helped his mood other than a warm blanket, meal tray and something for his pain was his amitriptyline. He had been on it for years. Nothing else worked. Sometime 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 weird way, a routine and comforting break during many a chaotic shift. He was an easy patient, really. Others got irritated, especially if they didn’t know him, and especially when the ED was busy.
One shift, we were destroyed, 30+ patients waiting with 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: “Chest pain”. I purposely let my new partner Mike see him. Mike was new to our ED and had just finished residency. “No better time for him to get to know Elvis,” I thought to myself.
About an hour later I looked in Elvis’ room, expecting to see the usual finished meal tray, tattered boots and lump of a person, head covered under a pile of blankets sleeping. “What happened to Elvis?” I asked my new partner, Mike.
“He walked out of here,” said Mike. “He wanted pain medication. I didn’t give it to him. He refused to have his heart worked up.”
“Oh, I should’ve filled you in on him. He comes here all the time. We usually do give him some pain medication. He has horrible untreatable coronary disease and really, nothing helps him other than pain control and an aspirin. Cardiology has actually endorsed giving him an aspirin, a shot of morphine and sending him home. They’ve said there’s absolutely nothing they or cardiothoracic can do for him. 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 has literally fallen 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 about that then. I told him not to come back for this chronic stuff unless he has an emergency and that he’s abusing the ED. I had social work fill a month’s worth of his amitriptyline for him, though. On the way out the door he said, he wouldn’t be back.”
From the waiting room, “HELP! OUT IN THE WAITING ROOM! SOMEBODY BRING A STRETCHER! CODE IN THE WAITING ROOM!” someone yelled.
“What the…?” I wondered as we ran through the double doors to the waiting room. “Get the patient in here”, I ordered. One of the techs hopped on the stretcher, started chest compressions as we wheeled him down the hall to one of our code rooms. “Oh, my God, it’s Elvis!” I said aloud. His heart must have finally given out. It’s amazing it ticked on for the 75 years that it did, I thought to myself. Into “code mode” we clicked.
Pulse: none.
Monitor: V-tach.
“One, two, three….charging!”
POOF! Went jolt of lightning through Elvis’ heart.
“Look, we’ve got a rhythm. I can’t believe it. Check for pulse,” I said.
“Got one!” said a nurse.
“Let’s get a 12 lead. Let’s see his MI,” I ordered.
His EKG was bizarre. There was no ST elevation, whatsoever. There was no MI. His QRS was wide, really wide. According to the computer it was 165. “That’s weird,” I thought out loud. “Let’s just run a continuous 12 lead. I’m sure his ST segments will go up any minute.”
“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?”
“Ami--, amitrip—something. I don’t know how to say it,” he answered.
“Amitriptyline?” I asked.
“That’s it,” said the tech.
“This is not an MI. He overdosed in our waiting room! Damnit!” I said. “Okay, we need some Bicarb. Now! Before he arrests again! Get Mike in here.”
“Yeah, what’s up?” said Mike.
“This is your patient, Homeless Elvis,” I told him.
“Holy crap, seriously? That guy I just discharged? He coded from his MI in the waiting room? That’s not good” he asked, shocked. “Good thing I had him sign out AMA.”
“No, actually he arrested after taking the whole bottle of amitriptyline you gave him. We got him back. For the moment,” I explained.
“Wow. That’s crazy, really crazy. The ED is a crazy place, isn’t it?” said Mike, shaking his head.
Homeless Elvis was the last patient of that shift for me. 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, maybe. I don’t know why, but despite that, I felt that I had failed, and miserably so. I needed to get the hell out of that ED and get home. Off to the ICU Elvis went and I drove home having no clue if Elvis would live, die or be a vegetable. The last I heard is that for some reason they had to transfer him to our nearest tertiary referral hospital. A few weeks later somebody made a phone call to try to track down what happened to him and nobody seemed to know or care. We never did find out. All anybody knows is that he never came back to our ED again.
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