This time he presented with a large area of induration and erythema in the upper arm. Small pinpoint scabbed areas appeared to be the epicenter of the inflammatory process. The surgeon recommended surgical debridement in the OR.
"I don't want to feel anything," the kid said.
"You won't," the surgeon replied. "You'll be asleep."
"What about my pain now? That morphine doesn't do shit...."
"I'll take care of it. I can order the dilaudid. You'll get dilaudid and some percocet after the surgery."
The young man shakes his head. "Yeah but that other doctor will change it. He always changes it. "
"I'll put in the orders myself."
The man won't look at the surgeon directly. He sits on the edge of the bed, eyes darting side to side, left leg pumping up and down off his toes. His face is sharp edged and narrow, not quite gaunt. His eyes never seem to open all the way, not sleepiness, rather a squinting distrust of the world.
"Whatever man. It's always the same here. You all say the same thing."
"All right man. Try not to eat or drink anything, ok? I'm going to try to get you on the afternoon OR schedule."
"Whatever." He looks off into the nowhere distance. Clenched-jaw scowl and slumped shoulders. He looks like he may have been a wrestler (maybe 152 lb class) a long time ago. You could even convince yourself that he may have once even been handsome, a catch for some local girl----an athlete, one of the popular guys. But not anymore. Already a mouth full of blackened rotted out teeth. Scabs and scars running up and down his arms. Hair falling out in asymmetric clumps. A sheen of street filth permanently etched into the creases of his palms and fingertips. Those hollowed out eyes dark as holes.
In the OR, two small counter-incisions were made and purulence was liberated. The surgeon looped a Penrose drain through the skin openings and sutured the ends together. The wounds were packed and a Kerlix/ace bandage pressure wrap was applied. He received three phone calls that night from nurses about disruptive behavior and pain medication issues. Just give him another dose. I don't care if he just got some an hour ago. He needs more.
The next day, the surgeon saw the man pacing the halls around the nursing station. He wore his ubiquitous scowl. He stared down at the tiled floor as he marched, dragging his IV pole along like a disinterested caddy. He saw him out of the corner of his eye.
"Hey doc. Doc, I gotta get out of here. I have to be at an appointment at noon. "
"I'll be in. I'll meet you in your room. I have to take down that dressing."
"I need my medicine first."
The surgeon flagged his nurse and she drew up another mg of dilaudid. He gathered dressing supplies as she injected the patient. The addict perched uneasily on the edge of the bed, rhythmically bobbing forward and back.
"Listen man, I have to be at my psychologists office by noon. It's part of the program. I don't show and I have to start all over again."
"I understand. We should be able to get you out shortly. Let me look at that arm."
Very carefully the surgeon positioned the young man's wrist against his knee and then he started to cut away the layers of gauze and bandages with an old pair or trauma shears. He gently pulled the soiled dressings away like a split cast. He dabbed away the old clotted blood with moistened gauze. The cellulitis and induration had regressed markedly.
"Does it hurt like yesterday?"
"No. But I mean.... it will later. I don't need to be judged. I know what works. That tramadol doesn't do shit."
"I'm not here to judge or not judge. Here, hold your arm higher. Let me put some clean bandages on."
The surgeon reinforced the wounds with fluffed clean gauze and then he proceeded to wrap the entire upper arm with two rolls of soft Kerlix. "You don't need that ACE anymore. We'll get you some dressing supplies. I'll need to see you in the office next week. I'll remove the drain then."
"Will that hurt worse than this?"
"No. That part is easy. "
"Yeah. I'm sure. " he looked off over the surgeon's shoulder again, far away beyond the walls.
"What's happening with you? This is no good, coming in here like this all the time. You ok? You have a place to stay?"
"No, man. Homeless. Sometimes the shelter. Sometimes my grandma's cousin lets me crash for a few weeks."
"No other family? Mom or dad around here?"
"I don't get along with them. My family all had enough of me. They all judge me. I can't take it. And every time I tell some doctor I need some pain medicine I get judged and they send me out with the same useless shit."
"No one in this room is judging you."
"Maybe not you. Everyone else." He continued to bob forward and back, like a metronome.
"I will make sure you have plenty of pain medicine. Those wounds hurt. I'll make sure you have enough to get you through the weekend. I promise. It's Easter weekend, you know. I know there's someone out there who probably misses you....who loves you. "
"No." For the first time the man looks up at the surgeon. He squints his eyes like he's looking up at the sun. "No one loves me," he says. "I realized that a long time ago."
"Nah. You're loved. We all need that. You don't have to fight it. You can fight everything else in life. But not that." The surgeon puts his hand on the young addict's shoulder. "Make sure you see me in the office. I don't want that drain getting infected because it's been in your arm for 3 months. Alright?"
"Be kinder to yourself. It's ok to hurt. I'm not here to judge any man's pain."
The younger man looks down. His body goes still, at last. His eyes are closed.
"OK," he whispers.
The surgeon returns to the nursing station. He sits down to write out the prescriptions.