The Peripatetic Patient

“I reached some plains so vast, that I did not find their limit anywhere I went, although I traveled over them for more than 300 leagues . . . with no more land marks than if we had been swallowed up by the sea . . . . there was not a stone, nor bit of rising ground, nor a tree, nor a shrub, nor anything to go by.” – Francisco Vázquez de Coronado, letter to the king of Spain, October 20, 1541

lost on the llano

On the High Plains of the Panhandle of Texas lies the Llano Estacado, the Staked Plains.  These are the plains Coronado described.  Navigating their featurelessness proved so difficult he instructed his men to drive stakes into the ground, from which they took their bearings.

It seems many wander into the High Plains and never think to pound stakes into the ground.  Under the blue sky, they wander through their lives, unable to orient themselves, running from one crisis to another, finding only the slightest bits of respite in between.  Often those wanderings lead them to my ED.

vagabonds and ramblers

The ED is our society’s safety net of last resort.  Entry is guaranteed to all, the law requires hospitals to provide an examination and stabilization.  As such, many crises with social roots land the Emergency Department.

As a traveling doctor, I see many of these peripatetic souls.  Unfortunately, the happy wanderers and jaunty pilgrims don’t end up in my High Plains ED.

I have cared for the meth-addled, the anxiety ridden business drunk, the chronically ill truck driver who just couldn’t quite make it to the end of his run.  The elderly RVer with COPD or CHF who never seems to remember oxygen is sparser at higher altitude is a frequent visitor (they are called the High Plains for a reason).

The challenges of caring for the itinerant are many.  Treatments are often not portable. The lack of family members, who are a mainstay of support during illness, puts more burdens on the medical and nursing team.  Often the best you can do is get them patched up so they can get back to somewhere with better support.

high plains drifter

All of the above characters have parts of their stories that are touching or sad.

For instance, I once did a trauma evaluation on very stoned young man who had been driving a car that a train demolished in a collision.  I evaluated, observed, and released him unharmed, though he did annihilate several microwaveable burritos in the process.

Apparently, he stole that car two hours away and drove until he passed out, high-centering the car on the rails. Luckily he wasn’t actually in the car at the time of the collision, though his inebriation prevented him from telling us this when he arrived in the ED.

What did he do when after his discharge into a town where he knew no one and had no transportation?  He stole another car, lead the police on a high speed chase, and earned himself three hots and a cot for an unspecified amount of time.

Occasionally, something hits you like a train.

marooned on the high lonesome

On recent shift, a local foster family brought in a child for suicidal ideation and threats of self-harm.  The child was newly in foster care, less than 10 years old.  Already, it is a pretty sad story.

When the child arrived, we talked.

Me:  How are feeling, how is your mood?

Child:  Sometimes good, sometimes bad.

Me: Is it getting better or worse?

Child:  Worse

Me: Do you want to die sometimes?

Child: Yes.

He was in a new school in a new town with a family he didn’t know.  It was stressful, he was angry.  He hadn’t made any friends in his new school.

I asked where he was originally from – a state over 1000 miles away.  He had no blood relatives nearby.   I didn’t understand how he ended up in this hamlet.

Son of farmer in dust bowl. Cimarron County, OK. April, 1936. Arthur Rothstein, FSA.

As the story unfolded, he was traveling with his mother, a long haul trucker.  She stopped at a truck stop and law enforcement apprehended her for some previous violation, placing her in custody.  He went into the system.  After her release, she fled the state.  Here he stays, marooned on the Llano – no landmarks, no stakes, no family.


For now, he will continue to live with a foster family he doesn’t know, his mother having abandoned him to the wind and sky.

Me, Anemically: That must be really hard

Child: Yeah.

That, and a referral to mental health, is all I have to offer this poor kid.  It is better than nothing, yet so insufficient. This small child has rendered all my advanced diagnostic and medical technology impotent.

Like a tumbleweed on the Llano, it all seems powerless in the face of the incessant wind and limitless sky.


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