José had a 4.5 cm laceration on his palm. His “friend” brought him in stating that José was cutting a metal band on a bale of hay when it whipsawed into his hand, a common enough mechanism of injury. I remember cutting those black steel bands holding together loads of lumber during the summer of 1970. I can still hear the shears snap, the whiiiirrrr as the bands tension-bullwhip the now-steak knife sharp ends through the air.
Steak knife, right. We are all made of steak, so to speak. I often explain back muscle pain to patients by saying, “Imagine you have a piece of steak, especially if it is still in the cow or maybe in your back, and you pick up that transmission and sneeze at the same time. The steak (your back) gets all kinds of little tears. It hurts, right?”
Everything else can be explained as part of a car, the SA and AV nodes as the distributor, etc.
José doesn't speak English, and he looks at his “friend” as we examine each MCP, PIP, and DIP joint individually. No apparent flexor tendon injury. José is deferential, and sheepishly looks down as his “friend” promises he would self-pay for José. The friend, in fact, is José's boss, and José is an undocumented immigrant. His boss runs a huge chicken factory farm, and José has chicken excrement on his shoes. This interplay of José and his economic relationship with his boss is not explicitly discussed — is not to be discussed. The boss smiles at me; he sees I understand. He is relieved I know better than to bring it up. José just wants his hand fixed and out of here. We make eye contact.
I inject lidocaine. José doesn't wince; his face shows nothing. I irrigate, explore the wound with fingers through ROM, no apparent tendon injury. The whiiirrring whip of the metal band end got only soft tissue. I use the palmar creases to align the wound and suture. The boss and I talk about chicken farming. I joke about that TV commercial about the egg farm and the farmer who shows his laying hens, who aren't meeting production quota a bucket of chicken, threatening to “diversify” if they don't get moving on the egg numbers. I think about the hospital administrators I've had over the many years, the LOS numbers, the Press Ganey metrics. I bend my head down to meet José's impassive gaze, trying to catch his eye.
Suturing is done. The palmar creases are lined up. What would José's palm tell a palm reader? How long has he been here? Who pays for him if he needs his appendix out? How much does he get paid? Does he have a wife? Children? Are they here, or does he send them money back home in Mexico? What is this like for him, being a virtual slave to this boss who laughs about egg production and diversifying, and who is happy that I don't ask him the questions I am thinking? What is it like to run a chicken farm with humans in your captivity? What stories about economic reality does the boss tell himself?
I hope José can read my eyes, that he can tell I care about him, about his wife and children. I don't know if he has any. If he does, he is doing his best to care for them. The boss wants to get going. He probably thinks it is impolite of me, my attempts to chat and be friendly with his farm machine. The boss grins like a Southern sheriff on the chain gang. He beckons with a tilt of his head for José to get up off the gurney.
My responsibility to José as an emergency physician goes beyond just fixing his laceration. I take care of everyone who comes through the door. As a citizen I am responsible for the economic and political conditions that hurt my patients. One thing I know: I respect and honor José. If the economic and political conditions, the price of chickens and so forth, is such that José's boss can only make it as a chicken farmer by means of exploiting undocumented immigrants like José, well, then, I am responsible to change that also. If not now, when?