Wednesday, December 30, 2009

All Bound Up

After much holiday nostalgia, a silly, absurd, self-deprecating story.

Recently at work, I got myself into serious trouble. I mean big time. Trouble with a capitol "T". Trouble that almost made me a patient in our ER.

On that fateful day, I arrived for my 7 a.m. shift. After taking patient sign-outs from the overnight ER doc, while I was getting my computer workstation ready, I noticed a pink emesis basin sitting in the station. These bins double well as serving bowls, so I was eager to see what the overnight snack was. I peered inside to find that it contained about fifty pieces of banana- flavored Laffy Taffy. Supposedly, the night shift had snacked on a full bin of Laffy Taffy, leaving only the yellow-wrapped ones behind.

What? Are you kidding me? Who in their right mind doesn't go for the banana-flavored taffy first? Is apple or cherry or grape really that much better than banana? I don't think so, my friend.

Well, banana taffy and I, we're like an old married couple. I guiltily unwrapped what I swore would be my one and only piece at about 7:15 a.m., thinking that the rest could wait until at least after lunch. After proclaiming my undying love to the yellow gooey stuff, I plopped it in my mouth. Do you think I could savor it, roll it around on my tongue a little bit, enjoy it? Oh no, not moi. I chomped into it three times and swallowed it whole. Okay, just one more piece. I'll savor this one, I told myself.

That was wishful thinking. By 11 a.m., the bin was empty, my fingers were stained yellow (despite multiple washings), and my stomach was lurching at anyone who approached me. How do you possibly tell your stomach to remember its manners? Mine was blatantly rude, speaking out at every opportunity. I know I ate most of the candy, but I swear I didn't eat all of it. Did I?

One glance around the ER and I found my answer. At the far end of the nurses' station, sitting on a small stool in front of her computer, sat one of the new nurses. She wore a grimaced look and was rubbing her belly as she tried to concentrate on her screen. My partner in crime. I wanted to go up to her and tease her, but I am not a stupid man. Those nurses stick together and I knew that whatever I threw at her would come back tenfold to me. So, hard as it was, I let the moment pass and just shrugged off our conjoined misery.

Well, the following week was a long one. And not just for me, but for those around me. I was miserable. Completely and utterly unbearable. From my end (pun intended), the misery stemmed from the intermittent cramping, the spasms, and the constant rumbling that I could not conquer. For those around me, I'm sure, their misery was mostly from their pained ears--ears that bore the brunt of my constant complaining. I swear, after the third day, I didn't have one friend willing to say more than "Hello" to me before turning around and high-tailing it out of there. I couldn't blame them--I'd be the same way.

After a few more days, my wife got involved. "What's wrong with you?" she teased. "Take care of this already. You are a doctor, you know."

Yeah, yeah, I know. I also know that I should not have eaten forty to fifty pieces of Laffy Taffy (did I mention that it was banana-flavored?) in one sitting, but I did anyway. I refused to let the words "Fleets Enema" be mentioned in my presence.

I would like to take this opportunity to thank the kind, elderly woman, a complete stranger, who heard me out in the cereal aisle at Wegman's while I searched for some Rice Chex. "Um," I confessed to her bewildered face, "my name is Jim, and well, I haven't had a BM for almost a week."

Of course that didn't really happen, despite my wild imagination willing it to. I really did walk up and down the cereal aisle three times, though, begging for an angel of mercy to come and put me out of my misery. If not an angel of mercy, at least someone wearing a Depends diaper who could point out the best fiber cereal for me.

Despite lots of water, prune juice, mineral oil, fiber cereal, and fiber drinks, I still had no success. I decided to be really aggressive. It was time for (drum roll, please) magnesium citrate.

For those of you not familiar with this miracle drink, it comes in a ten-ounce bottle and looks like Sprite or 7-Up. Unfortunately, it sure doesn't taste like it. Trust me, drink it fast and drink it cold. And only one bottle. After drinking it, it passes through your intestinal system, pulling water into your colon. This increases peristalsis and provides relief within one to four hours.

I called our charge nurse, Julie, in the ER and asked her to place a bottle in a brown bag for me to pick up. "And please, Julie, don't tell anybody that it's for me." Yeah, right. I should have known better.

I drove to the ER and walked in. Before locating Julie, she had found me. I heard her before I saw her.

"Dr. Jim," I heard her loud, familiar voice yell, "here I am." I turned to find Julie wearing a big grin, standing in the middle of the crowded nurses' station. Don't do it, Julie, please.

She continued. "Here's the bottle of "mag citrate" you called in for yourself. I sure hope it works for you." Ugh. She gently held my brown bag above her shoulders and did a slow 360', showcasing the temporary trophy that was in her possession. Bad girl, Julie, bad girl.

I had forgotten that magnesium citrate can be purchased over-the-counter for a dollar. A stinking lousy dollar--the cost of saving me my dignity. But at that moment, I had no pride.

Well, I am happy to report that I am a magnesium citrate success story. I am a survivor of acute constipation. Starting next month, I will be the new spokesman for magnesium citrate (I said no to the prune juice company), so look for my commercial on a Japanese television station near you. Soon, I hope to have brown wrist bands finished to bond all of us who have braved similar success stories. I hope others will step forward to share their courageous stories and inspire you as I know I have.

Okay, enough. Thanks for bearing through my obscene level of silliness. I am proud to say, however, that I have not had one piece, nada one, of Laffy Taffy since that 7 a.m. shift. Whenever I get the urge, I just slap on another Chex patch and I'm fine.

As always, thanks for reading. The next post will be Friday, January 1. Please take this fluffy post as intended...I hope you smiled. Feel free to comment if you are a banana taffy fan! LOL

Monday, December 28, 2009

Why Medicine?

One of the more frequently asked questions I face is "Why did you become a doctor?"

Trust me, that's a question I have asked myself on more than one occasion. In fact, I think the last time I asked myself that question, it was 4 a.m. and the obnoxious, drunk guy had just finished puking on my new running shoes. Why exactly did I become a doctor? It certainly wasn't so the kind people at Dick's Sporting Goods would know me on a first name basis.

I come from a large family, both immediate and extended. I am the fifth of seven kids, three of us boys. On my father's side, every male is or was involved in the forestry industry. This includes my father, three paternal uncles, my two brothers, and multiple cousins. Since I was a young boy, around age five, I have strong memories of waking up before the morning darkness dissipated, jumping with my father and brothers into one of the company work trucks, and heading out into the pristine Pennsylvania woods. It was expected that I, like my brothers and cousins, would someday pursue a college education in forestry and then continue in our family's international business.

I always knew, though, that I was made from a different cloth. My paternal grandmother, our family matriarch, encouraged me to pursue my dreams, even if those dreams did not include the forestry business. She knew I had a different calling and I loved her for her easy acceptance of this. As much as I enjoyed the beautiful woods, the fresh air, and hard work that came with my family's business, I needed something different.

So, until then, during summer vacations and on Saturdays during the school year, I could be found in the woods carrying a Stihl chainsaw or steering a John Deere skidder loaded with freshly cut logs down a narrow path to an accessible landing where logging trucks would pick them up. Smiling. And ducking behind the occasional tree, convinced that I had seen Bigfoot yet again.

When, then, did I discover my illuminated path toward medicine?

I'd like to say I had one defining moment where it just popped with me, that I would be a doctor, but that wasn't the case. During my tenth grade year in high school, however, multiple happenings occurred in my life that exposed me to medicine and reinforced my belief that I would be a doctor someday. That year, I lost both of my grandfathers to medical illnesses, and I was a firsthand witness to their struggles. I also witnessed my father's leg, crushed in a freak logging accident, be saved by incredible surgeons who refused to look at amputation as an option.

Personally, before these deaths and my father's injury, I also sustained an injury that reinforced my pursuit of medicine.

Chainsaw lacerations were very common in the forestry business, at least before protective chaps gained widespread use. This injury did not spare me and, as a result, I had my first and only ER experience as a patient when I needed a laceration repair.

Right after lunch on that death-defying summer day, I was trimming some obstructing tree branches to reach a felled log. Suddenly, my saw kicked back and cut into my thigh just above my left knee. At first, I thought the pain was just another tree limb poking at my leg. When I looked down and saw my cut denim pant leg outlined with a circle of red blood, though, I knew that I had just been initiated into the Lacerations Are Us Forestry Club.

Trying not to panic and fighting off the dizzying angst of near-death that accompanies a two-inch superficial laceration, I quickly ran out of the woods and jumped onto the skidder, driving it without abandon (yes, 10 mph on a rocky trail) to find Louie, one of the crew guys. Louie, not known for his strong work ethic, was only too happy to drive me to the local hospital's ER. I still don't know to this day how he could eat his bologna sandwich (with ketchup) and listen to Paul Harvey while I sat beside him in the pickup truck, hemorrhaging. And now, page two. The kid sitting beside you in the truck is bleeding to death, Louie. Put the bologna sandwich down and drive faster.

By the time we arrived at the ER, the bleeding had slowed considerably and thoughts of my family catering to my every whim after such a tragic accident waned. As Louie called my Dad from the waiting room, I was placed in an ER room, given a gown to change into, and waited for my Dad's arrival. When he arrived, he was, of course, sympathetic. His face was a hard read, though, bordering between pride for my initiation and disappointment that it wasn't worse.

What happened next for me was nothing short of a miracle. Within minutes of Dad's arrival, the doctor walked in and repaired my laceration. He was kind. He was normal. He was compassionate. And he was thoughtful enough to ask me if I wanted to watch him repair my cut. Absolutely, I said. He propped a pillow behind my back and lifted my cot upright to 90 degrees.

With precision, the doctor explained every step of my laceration repair, from numbing the wound edges with lidocaine to how he would close the laceration in two layers--the buried, dissolvable stitches that would hold my muscle together followed by the external sutures that would closely approximate my skin. Fifteen stitches later, he was done. The nurse, lacking any dramatic flare, applied a big, bulky dressing and antibiotic ointment and I was discharged to home.

Needless to say, I had seen the light. I had experienced medicine. I had been snatched from the jaws of death by the brilliance of medicine (and fifteen measly stitches). From this experience to how the rest of that year played out, I had no doubts about what I wanted to do with the rest of my life.

Is that enough to explain why I went into medicine? I hope so, although at 4 a.m. with that fresh puke all over me, I sometimes wish my personal revelations to pursue a career in medicine held more flare.

So, if you are in my ER in the middle of the night and I smell like bile, please do me a big favor and ignore the stink. And if you see me rubbing my scar above my left knee, don't pay me any attention. I'm just remembering why I went into medicine. Again.

As always, thanks for reading. I hope everyone is having a great holidays. Thanks for all the kind holiday wishes. Next post will be Wednesday, December 30. Until then...

Monday, December 21, 2009

The Family Room

It's in every emergency department.

Empty, it's just another shell of a sparsely decorated hospital room, lacking vibe and energy.

But when you fill it with nervous, hopeful family members awaiting news of their critically-ill family member, it is transformed into a room that can barely contain every possible extreme of human emotion.

It is The Family Room.

So, you ask, why is this room known as The Family Room?

This is the room where the families of the most extremely sick patients are placed while the medical team uses every available effort in their medical arsenal to save a life. It's a place for family to be alone, to comfort themselves in the face of adversity. These may be families of trauma victims, heart attack victims, stroke victims, or any other critical illness. Because the family room is usually situated on the edge of the department, it is usually quieter, more calming, and private. A far cry from the commotion that usually accompanies the room in which resuscitating a patient is happening.

Don't be fooled, though. This is no ordinary room. Physically, it may look like any other decorated hospital room, with a few extra vases and boxes of tissues thrown in, but that's where the similarities end. It is a room that demands and deserves respect. It is a room that I imagine as my friend, absorbing and buffeting and protecting all within it from the swirls of anger and the clouds of desperation. Sometimes, just sometimes, the mood is joyful. More often than not, however, this is a room where dreadful news is delivered to a family not prepared for such news.

Our own family room is just as I described above. It sits in the corner of our department, nestled between our waiting room on one side and the entrance hallway to our department on the other. It's painted beige and coral with a flowery border at the top--comfort colors, I guess. Short shag navy rug. Two of the corners hold lamps, usually lit for better ambiance. The furniture consists of two love seats and two wing-backed chairs, a couple in dark blue floral patterns, the other in pink and coral. Slightly better quality fabric and stuffing than the standard hospital furniture, but not by much.

How do I know these details? It's amazing the small things that I notice when I'm trying to blink back my own tears in sharing a family's misery. Sometimes I'm transported back to tenth grade when I counted Christmas tree ornaments on our church tree during my grandfather's funeral, all in the hopes of distracting my impending tears. 157 ornaments on the tree closest to the Virgin Mary.

I rarely deliver news alone to a family waiting. Either the ER social worker or the supervising nurse accompany me, sometimes both. I wear my long, official white coat to respect the gravity of the situation.

Imagine that moment right before walking into the family room with bad news. I hesitate at the door, take a deep breath, and remember that my words and support will be paramount to the family. I open the door, usually to be greeted by several anxious family members either pacing or sitting well beyond the edge of their chairs. After introductions of myself and my team, I ask them how they are each related to the patient.

Then, the hard part follows. I sit close to the spouse or family. Sometimes, I am offered a hand to hold and I eagerly take it. If the patient has already died, I make it a point to not linger and share the news almost immediately. It is important to be blunt but heartfelt, using the words "dead," "expired," and "we did everything we could." It has been shown that a family needs to hear several variations of the word "dead" so that the news sinks through their despair. Reassurances are given that everything possible was done.

If the patient is still alive, I review with the family everything being done to save their loved one. I explain any prehospital treatment, what we are currently doing for the patient in the ER, and give the family a brief opportunity to ask questions. We sometimes need to review the patient's living will or DNR status and to what level efforts should be pursued. Family members may even be invited to witness the resuscitation.

Through all of this, I don't lose eye contact. I focus on each person in the room, letting my eyes say something different from my words. "I'm so sorry" is the most simple and heartfelt offering.

As an ER doctor, I have a protective shell around me that I can usually maintain. But in the family room, I am different. It is not rare for me to leave with tears in my eyes, and that does not shame me. It is my privilege and blessing, really, to accompany a family through some of their darkest moments. I appreciate their acceptance of my presence during their misery. Who am I to bear witness to their profound loss?

I have been told by several staff members that my greatest gift is how I interact in that family room. But, for whatever I bring to that room, it is but a feather compared to the weight I carry away from it each and every time I meet another family.

I am humbled by this part of my job. And respectful of the family room's role in our ER.

Thank you, as always, for reading. I am grateful...may your week go well. Next post will be Wednesday, December 23.

Friday, December 18, 2009

Meeting Candy

It was early morning, 4 a.m., the first time I met Candy. I had been on the job for about a year. Not having any idea what I was walking into, I slid Candy's curtain to the side to enter her treatment room. What I walked into was better than a shot of espresso.

Candy was running her fingers through her nurse's long blond hair.

"Honey, what I could do with your hair if you let me," she was saying to Mo, who was being an awfully good sport about it. I'm not sure I could let some stranger caress my scalp and hair in this manner.

"Yeah, yeah. Thanks, Candy," Mo answered, "that's what you told me last time, too."

So, Mo already knew Candy. I later learned that everyone who works in our ER knew Candy.

Candy, as it turns out, is a transgender male-to-female. These terms can be confusing, but transgender simply means that a person is living cross-gendered without sexual reassignment surgery.

Candy was known for handing out brutally honest fashion advice to our staff during her treatment time. I was only too happy to watch her interaction with Mo play out.

"Yes, honey," Candy continued as she held tight to Mo's hair, "you need to cut it a little shorter, get some highlights, and have it frame your face better."

"Um, okay, thanks Candy. I'll get right on that," Mo answered, still the good sport. "You do remember, though, that it's four in the morning, right? I'm sure not getting gussied up for an overnight shift."

"Ugghhh," Candy continued, ignoring Mo's defense, "and your split ends! Girlfriend, how could you? Go get me some scissors and I'll take care of this mess right now."

Mo extracted herself and her hair from Candy's grip. And then noticed me standing by the entrance.

"Oh, Candy, look who we have here! One of our doctors is waiting to see you." I do believe that Mo had just thrown me under the bus!

I stepped forward with my hand extended and introduced myself to Candy, feeling her eyes bore into my every fiber.

"Well, well, well," she said thoughtfully, "what do we have here?"

Nope. I'm first. Let me describe Candy to you. First, her outfit. She was in a white with black polka-dot mini-skirt with white tights, humongous red heels capping the ends of her lower extremities. Her shirt was sheer, white and black zebra-striped, hanging loosely over her skirt. She had a five o'clock shadow, a prominent Adam's apple, and thin scraggly hair that hung limply to her shoulders. Her makeup was very loud, despite the facial contusions and abrasions from the assault that brought her to us this night. She was sitting upright comfortably in her cot, one leg bent under her thin frame.

Okay, now your turn, Candy.

"Hair, good. Body, good. Nice eyes. Nice lips. Wow, look at those cheekbones!" Yes, I was really liking this Candy character, but made a mental note to myself that I should probably check her vision on this visit. Mo, who I thought was leaving the room, decided to hover to see what advice I would be receiving. She was leaning against the wall, arms crossed, smirking at me, thoroughly enjoying me being in the hot seat. She must have known it was going to get ugly soon.

"Wait. Oh yes," Candy exclaimed, pointing at my mouth, "look at that tooth!"

Shoot. I can't believe she narrowed in on my tooth. I think I have pretty nice teeth, barring one slightly off-colored one on my right upper front. And even this tooth isn't so bad. I had gotten knocked in the mouth playing basketball a few years ago, resulting in this tooth turning slightly off-white. My dentist had thought it would die and I would ultimately need to get it pulled, posted, and replaced. However, the darn thing didn't die off completely, and now I was stuck with a half-living tooth. Kind of like tooth purgatory.

Eventually, I knew I would have to get the tooth addressed, but it didn't bother me, and you had to look really hard to see it. At least I thought so. Thanks, Candy, for looking hard.

"Yeah, sugar," Candy continued, Mo now in a full-bloom smile, "get that thing taken care of, would you? Jesus H. Christ! Why would you walk around looking like that?"

How can you not smile? I started laughing, but Candy was just getting warmed up.

"Honey, can you spell manicure? Because you need one bad. Look at those bitten-up nails!"

I looked down at my hands, appreciating my nails, actually thinking that they looked pretty good to me. Now, though, I was feeling the need to apologize. "I'm sorry, Candy, I can't help it."

"Well, help it. You're a doctor, right? There's no reason you shouldn't be getting yourself some manicures (she said it like "man-neeeee-cures") and pedicures." She shuddered and continued. "I can only imagine what your feet look like!"

"Do you want to see them, Candy?" I asked, now enjoying this immensely. I had on hospital clogs, it would be easy to accommodate her.

"Ugghhh," she said, "find somebody else with a foot fetish. That ain't me, honey."

Ouch! She was tough. Clinton and Stacey from "What Not To Wear" held nothing on Candy.

Well, I'm happy to say that Candy turned out alright that night. Just some bumps and bruises. Interestingly, she had been working a corner in one of our less-desirable neighborhoods and had been picked up by four college boys for her services (this was her version). Less than a mile later, when they found out her true gender, they assaulted her and threw her out of their barely stopped car.

I'd like to think it wasn't her gender that bothered them as much as her fashion critiques. Can you even imagine? "Honey," she'd start out as she bent to get into the car, "what's up with all those pimples on your face? And you," she'd continue, looking at another one, "what's up with that greasy haircut you're sporting?" Yep, out the door she went.

I've seen Candy in the ER a few more times since then and always enjoy her wisdom and our conversations. Most recently, I was out to a dinner party at a local restaurant that was having a simultaneous gathering of transgender/transsexual localites. As my party followed the waitress to our table, we passed the gathering and there was Candy, sitting at a table with three other members, laughing and smiling and being quite animated.

Her hair is still scraggly. My tooth still isn't fixed.

You go, Candy!

Thanks for reading, as always, and have a great weekend. Next post will be Monday, December 21.

Wednesday, December 16, 2009

Please Make Her Comfortable

During a recent shift, I was witness to a family's struggle and courage in facing their mother's illness.

Their mother, age 96, had broken her hip a week prior. Because of significant health and social issues, the family and patient concurred with the orthopedic team that it wouldn't be wise to operate.

The patient was sent to a local rehabilitation facility. Prior to the transfer, the patient and her family had discussed at length a living will and to what degree heroics were to be performed in the event of a medical emergency. They opted for no intervention whatsoever--no CPR, no medical testing, no antibiotics, no intubation, no resuscitation efforts. Basically, they wanted only comfort measures for pain and anxiety relief.

A very difficult decision, of course.

Within a week of being transferred to the rehabilitation facility, unfortunately, the patient started to have a cough. Soon after, she began to have a harder time breathing.

The facility, despite their best efforts, eventually sent the patient to our ER when it was discovered that she had very low oxygenation levels. They were not equipped for this.

I walked into this patient's room and after introducing myself to her and meeting her family, consisting of two sons, a daughter, and a daughter-in-law, I began to sort out what I could do to help this patient and her family.

On exam, this patient was obviously struggling and appeared to have pneumonia. She had a fever and very low oxygen levels. When I listened to her lungs with my stethoscope, she had classic findings for infection. She was starting to get very fatigued and was not as mentally alert as her family knew her to be.

Normally, with a patient in this situation, we are very aggressive. She would have been intubated and received three, sometimes four, antibiotics intravenously. She would have gotten a very thorough workup that would have included x-rays, blood work, and possibly a CT scan of her chest to make sure she didn't have a blood clot in her lungs, a possible consequence of her hip fracture.

However, upon review of the patient's paperwork sent from the rehab facility and the family's personal request at her bedside, we did none of this. We respected their wishes and this patient's living will.

I did order this patient some low doses of morphine and valium which made her more comfortable. The family was quite appreciative. Although the patient was critically ill, she was not yet near her end. After another discussion with the family, we came to a mutual decision to admit their mother to the hospital and continue her comfort care. The family was uncomfortable taking the patient home with her hip fracture. I called their family doctor and he graciously came in and handled the admission.

During the admission, I was stopped by the daughter in the hallway. She was very tearful, as any of us would be, and second-guessing their family decision of no heroics.

"Mom lead an amazing life. I know it's time...but this is so hard to watch. I feel like we should be doing something more."

I put my arm around her. "God Bless your family," I said.

"Well," she sighed, "this is how Mom wanted it, so I guess we have to respect her decision."

I nodded at her words. I have several times witnessed these decisions reversed, but it seemed that this family was not going to follow that route.

The daughter, though, still needed to reconcile the decision with her anguish.

"What would you do?" she asked me suddenly.

Her question caught me off-guard. It was a question that I couldn't possibly answer for her. Her family's decision was made after weighing many specific circumstances, circumstances that I knew nothing about. So no, I couldn't give her a direct answer.

I explained this to her. "But," I continued, "does the rest of your family still support this decision?"

"Yes," she said, "and I think I do, too."

I decided to open up to her. I shared with her how several years ago, my beautiful mother, after courageously fighting and beating back leukemia for several years, decided that it was time to stop. It had been an extremely difficult decision, fully supported by my father, my six siblings, and myself. Because Mom knew. And despite all the setbacks, her faith had never wavered and her spirit had remained unconquerable. She had fought the fight and had benefited from that fight. But, unfortunately, her disease had come back with a vengeance. After several failed attempts to reenter remission, she chose to stop all further treatments and go home to spend her remaining days enveloped in our love.

"So, yes," I said, "it was very hard to watch. But it was the right thing for Mom and our family."

Now, the daughter nodded at my words. After a moment or two, she spoke. "Mom did have an amazing life, but yes, it is time."

I squeezed her hand in support and she leaned in and gave me a hug.

"Thank you," she said as we parted.

No, I thought to myself as I walked away remembering my mother's beautiful spirit, thank you.

Monday, December 14, 2009

What Do I Know?

One of the hardest parts of being a physician is that people expect you to know everything about everything. And I have to be brutally honest here. That ain't me. But, thanks to a great residency and medical school, I do know my medicine.

Heck, though, I'll be the first to admit that I've never known much about plumbing. Or electrical work. Or car engines. Or how to cut an onion without crying. Or rectal foreign bodies.

Whoa, back up! What did I just say?

Yes, you heard me right. Rectal foreign bodies. As in having something in your behind that shouldn't be there. If you need to squat over a mirror to look, then chances are something is wrong back there. Seriously wrong.

So, imagine my surprise when, in my first year of residency, I discovered that our hospital's ER, being centrally located among several prisons, got it's fair share of rectal foreign bodies.

"Wait a second, people," I wanted to scream out, "I didn't sign up for this part of the job!" As long as I was making a list, I didn't sign up to do internal pelvic exams on eighty year-old ladies with blue hair, either. Unfortunately, though, in the ER you simply don't have a choice. Besides, I was a first-year resident. That's about as low as you go on the medical totem pole. Who would have listened to my concerns?

I remember well my first "something's stuck back there" patient. One of my favorite teaching physicians, Dr. Z., held a chart out for me. "Hey, K.," he said, "there's a patient in Room 12 I'd like you to see." Looking back now, I should have known his snicker was not all that innocent.

I walked into the room to find a regular Joe sitting on his cot, his feet and legs dangling off the side, looking a little uncomfortable.

Hmmm, not a prisoner. So far, so good.

"Hello, sir. I'm Dr. K. What can I do to help you today?"

"Well," the patient stammered, "I had an accident."

"What kind of accident?"

"Well," he started, his eyeballs almost rolling up into his brain to recite his rehearsed story, "I was at the gym and after working out, I got a shower. After I was done, I walked back to my locker wrapped in a towel and as I went to sit down on the bench, the guy next to me put his hairspray bottle down and I sat on it. It was an accident."

I promise you, he did not even crack a smile. It's amazing how distracting ass pain can be, I guess. Even as a first-year resident, I knew a good story when I heard one. The storyteller in me wanted more.

"So," I said, "did the bottle scratch your skin? Leave you with a bruise? What happened to it?" I, in some twisted way, wanted to hear him admit to me that as we were talking, a Clairol hairspray bottle was still missing.

He looked at me incredulously. "Look," he said, "you're new here, right?"

"Actually, yes, I am. Why?"

"Because, I've been...," he blew out an exasperated breath before continuing, "let's just say that this isn't the first time this happened to me." That explains Dr. Z.'s smile. And what gym has multiple hairspray bottle accidents in their men's locker room?

It turns out this guy had several "accidents" in his past that brought him to the ER. And, of course, they didn't really happen at the gym. He was a local celebrity of sorts. It was my privilege to finally meet someone famous, although a few years prior, I had met Cyndi Lauper. That should count, right?

I listened to the patient's heart and lungs with my stethoscope for way too long, hoping against hope that my shift would end before I had to do the rectal exam. No such luck. After feeling his abdomen, it was time "to look back there." I stepped out of the room to bring Dr. Z. in with me. After all, he was my teaching physician for the shift (plus, he dragged me into this case).

Dr. Z. walked in. "So, Joe, I see you met Dr. K., one of our new residents. He treating you okay?"

Great, Dr. Z. and Joe were buddies. "Yeah," Joe said, eyeing me up, "he'll do."

This is where my learning curve took off.

"Okay, Joe," Dr. Z. said, "you know the routine." Dr. Z. had Joe get on all fours on his cot (yes, my mouth was gaping open, too) and, after several layers of gloves, we inspected Joe's backside poking out of his gown. No scratches. No bruises. Then we tried to manually (unfortunately, "manually" meant using my fingers, not Dr. Z.'s) grasp and remove the hair spray bottle. Although I could feel the bottom of the bottle, I was unsuccessful.

I was filled with shame from my failed attempt. I had wanted this story to have an ending where I saved the day, where all the nurses would cheer for me, a measly first-year resident, and my unlimited brilliance as I walked out of Joe's room holding up the Clairol bottle like it was some sort of treasure trophy.

Dr. Z. tried his best to cheer me up. "It's okay, K. Really. This is what residency is for--to learn how to successfully pull a hair spray bottle from a patient's ass. There'll be more." Funny guy, that Dr. Z.

We sent Joe to x-ray. Abdominal films revealed to us that, just as Joe had said, there was a stuck hair spray bottle. Just beyond our reach. I blacked out Joe's name on the x-ray and made myself a copy to frame and hang over our fireplace, but my wife refused. "Don't you even think of taking down our wedding picture!" Sometimes I wish she could be a better sport about this stuff.

Unfortunately for Joe, the bottle would have to be removed in the OR. We tried one last hurrah by using a special rectal speculum and graspers, but no such luck. Yep, Joe was heading to the OR.

While under anesthesia and completely relaxed, the GI team was able to use a scope to retrieve the missing bottle from Joe's backside. I can only hope that they got the round of applause that I had dreamed about.

I often wondered what Joe told his family and friends about his hospital visits. I mean, really, what if one of them wanted to send flowers? What do you write on that card? Please let me know if you have an idea about that--I'm blanking out.

I still don't know much about plumbing or electrical work or peeling an onion without crying. However, I'm proud to say that so many years later, I know all I need to know about rectal foreign bodies.

Thanks for reading...and enjoy your day. The next post will be Wednesday, December 16.

Friday, December 11, 2009

The MoooooER

Imagine your phone ringing. You scurry around your house, rushing to locate the handset.

You finally find it.

"Hello," you say, winded, "how may I help you?"

There's a pause.

"Hello," you repeat, "is anyone there?"

Suddenly, without warning, you get your answer.


That above scenario, my friends, would be me calling you.

After my first year of residency, my wife had called me at work, quite excited, telling me she had found an amazing house for us to rent during my last two years of training.

Say what? I was surprised and didn't know we were "looking" to move from our very comfortable, two-bedroom condo just ten minutes from my hospital.

"Trust me," she reassured me, "you are going to love it."

And she was right. I did love it. Leave it to my wife to find such a great place.

The new house was about 35 minutes from the hospital, almost all country driving. It was built by Farmer Ed, an old-timer who we grew to love as family, smack in the middle of his cow and corn pastures. Farmer Ed had built this house for his planned retirement in a few years and wanted to rent it out until then. It sat comfortably on the top of a beautiful mountain range, alongside a curvy, country road where neighbors waved as you passed by. The views were endless and the sunsets spectacular. A small, friendly town sat just a few miles away.

It was not uncommon for us to wake at the break of dawn in our new house, cows milling around our bedroom window, talking to us in their language. Many a times I had dreams interrupted by Bessie's moo. Sometimes, even, it felt like Bessie and her gang were having some fun with us, staging their own version of The Sound of Music. Hey, Moo Trapp Family, go back to your hills in Austria and let me sleep!

Ashamed of myself, I must admit that I rolled over a time or two in my dreams to snuggle up to Bessie and her warm, engorged udder. "Moo," I whispered seductively in her ear. "Moo moo," she answered back, blinking her big eyes and batting her long lashes flirtatiously at me.

Okay, I just made that up. Sorry.

Anyway, my wife loves to speed walk and sometimes, on days when I was home, I would go with her. I always struggled to stay alongside her, but the country scenery and surrounding beauty did much to distract me and make the walks more tolerable and even fun.

One day, as we passed a pasture of grazing cows, on a whim, I stopped and inhaled a deep breath. Plugging my nose, from the back of my throat I forced the air out, emitting a low, guttural "moo."

"Hey," my wife said, "that was pretty good."

And you know what? It was good. I knew because the cows had stopped their grazing to look up.

I took another deep breath and mooed again. And another. And yes, another.

The cows started mooing and began walking collectively toward us. I got a little nervous, the barbed-wire fence the only thing separating my wife and me from eighty misled cows. I didn't want a mutiny on our hands. My wife, however, found this all to be quite funny.

With a little practice, I soon had the "moo" down pat. It sounded good. Heck, I'm going to forget about being humble--it was excellent!

I started mooing all the time, I think to the point where family and friends began avoiding me. I mooed on the phone, I mooed at work, I mooed at home, I mooed at parties. That would have been me who, standing alone in the corner with my drink, mooing, you carefully avoided.

I was a hit, however, with the young kids. I would get calls from our family's and friends' children to moo. Over the phone line, I'm told, my moo sounds even better. On hindsight, though, I think their parents just said this to keep me from coming over and doing it in person.

The biggest place where my moo was a hit? Easy answer--our pediatric ER.

Where I trained in residency, we had a Pediatric ER and it was here where I perfected my moo. If a child wasn't critically ill, I would have three strategies to make the visit easier: 1) Hand out stickers, 2) Hand out a popsicle, or 3) Moo. Let's face it, anyone could do strategies one or two, but three? Sorry folks, I owned that one all to myself. And truly, it was a hit. A smile usually appeared by my second moo.

So, I mooed my last two years in residency and brought my moo with me when we moooved here.

The other day, one of our residents brought his devilish, happy, handsome two-year-old son to visit our ER. He was so darn cute already, but I knew a way to make his cute factor fly through the ceiling.

I took a deep breath and plugged my nose.


At first his reaction was usual--a look of bewilderment. By the second moo, however, I had him.

"Moo," I said. "Again," he said. "Moo," I repeated. "Moo-cow," he said, clapping his hands. "Moo," I said one last time. He laughed out loud and flailed his giddy arms and legs.

As I walked away, I felt like, once again, my moo had made me the cat's meow. I was all that!

Unfortunately, three patients were peering out of their rooms, wondering why there was something mooing in the ER hallways.

"It's okay, folks," I said, "go on back in your rooms, please."

At the nurse's station, I overheard one of our newer secretaries on the phone. "Yeah," she said, "some idiot is out in the hallway mooing-can you believe that?"

I almost bent over to moo in her ear from behind, but I restrained myself. Instead, I went to my telephone and called home.

"Hello," my youngest daughter answered, "how may I help you?"

A pause.

"Hello?" she repeated.

I took a deep breath and let it out.


"Oh, hi Dad," she said nonchalantly. Then I heard her yell, "Mom, it's for you. It's Dad and he's mooing again."

I could have sworn I heard my wife's faint response. "Tell him I'm not home."

As always, thanks for post will be Monday, December 14. Have a safe and enjoyable weekend...

Wednesday, December 9, 2009

No Second Chances

In residency, I was fortunate to train at a university hospital that had a burn center, one of approximately 125 centers in the U.S. As a result, we treated victims of all types of burns. While some burns were minor, many were quite significant, requiring months of both physical and psychological treatment. Death was the result of the worst of these burns.

I was working a twelve-hour shift when an ambulance called in. They were bringing us an elderly woman from her nearby residence. She had been drinking and had fallen asleep while smoking a cigarette. A fire ensued. Both her nightgown and couch had been extremely flammable, resulting in very serious burns to her body.

"It's bad, Doc," the paramedic said, ending his call.

Within minutes, the ambulance arrived. Our trauma team was activated and between the ER and trauma teams, we were ready to treat this patient.

Remarkably, this patient came in talking and not in much pain, which was worrisome. "I want to go home!" she said emphatically, obviously intoxicated.

Her injuries were profound. The skin on her arms, her legs, and her torso, both front and back, was either charred or translucent gray, indicative of full thickness burns. She had minor redness and blistering to her face and anterior neck. Her hair and eyebrows were singed.

It's daunting to see a patient so badly burned and not in significant pain. Very disturbing. The smell of her burnt skin and hair permeated the ER.

If I may, I'll briefly explain burns. They are classified by the type and by the depth of burn. Types include electrical, contact, steam, gas burns, thermal, etc. This patient sustained thermal fire burns. Unfortunately, she also sustained secondary contact burns, where the couch and her nightgown melted into her skin. Depths of burns are classified into three categories: superficial (or first-degree) burns, partial thickness (or second-degree) burns, and full thickness (or third degree) burns. Superficial and partial thickness burns, which this patient had on her face and neck, result in pain. Full thickness burns, the worst of burns, extend through the skin and soft tissue beneath it, burning, among other things, nerve endings. Thus, the reason this patient wasn't in extreme pain.

This was bad news. She had partial and full-thickness burns to at least 70% of her body (a morbid percentage). She was going to die from these burns.

Another grim fact was that most of her burns were circumferential, meaning that they completely circled, or wrapped around, her torso and extremities. With serious burns, there is significant swelling and edema. Circumferential burns, in essence, are a tourniquet, preventing the skin from expanding and compensating for this edema. With increasing pressure from the edema, the deep blood vessels are compromised and blood flow is diminished, initially to the extremities and ultimately to the vital organs.

I knew we only had minutes to talk to her and explain the gravity of her injuries. She was in disbelief. I explained that her injuries were-life threatening and how the swelling from her burns would quickly advance to her throat and close her airway.

"I'll do whatever you need if you can just call my daughter," she said, the morbid news settling in. "And can I have a smoke? I'm nervous."

No smoke, but my attending gave me permission to quickly call her daughter. The nurse ran and got a portable phone and I dialed the out-of-town daughter's number. A woman picked-up. Thankfully. It was her daughter. The patient told me to "tell my daughter everything," so I did.

I quickly introduced myself. "Maam," I said, "I'm sorry to call you with this news, but I'm standing at your mother's bedside in the emergency room. She's been involved in a serious burn accident and her injuries are life-threatening. She asked that I call you."

"Will she be okay? Was she drinking?" the daughter asked hurriedly.

I stepped away from the patient and lowered my voice. "Well, yes, it appears she has been drinking. And I'll be honest with you, maam, she's probably going to die from her injuries. She insisted we call you before we place a breathing tube in her airway to protect it from her burns and swelling. She'll be hooked to a ventilator after that."

"Oh, no," the daughter said, hesitating before speaking again. "I haven't spoken to my mother in years. We're estranged."

How damn heartbreaking. "Do you have any other family?" I asked. "No, it's just me. I'm an only child, like my mother. My father died when I was young. We were never in touch with his family."

It's so profoundly sad how many cases emotionally play out this way.

I moved on. "Can you talk to her? Again, she asked us to call you. If there are any words needed to be said, now would be the time to say them." The daughter lived five hours away and it was doubtful she would make it in time to see her mother.

I heard the daughter sobbing as I walked back to the patient's bedside. "Here's your daughter," I said to the patient, placing the phone to her ear.

All around this patient, it was organized chaos. She was receiving excellent medical care--attention to her burns, aggressive IV fluid hydration, and pain medicine. Preparations to intubate her were underway.

We, however, were in our own bubble. I was only interested in one thing--allowing this conversation between mother and daughter to occur. I stood by her cot, near her head, holding the phone as close as I could. I turned my head away, in essence to give her some privacy.

The patient sobbed. "I'm so sorry, baby." "I know, I know." "I love you, too." "I'll see you when you get here."

How sad to summarize all your regrets and feelings into a thirty second conversation.

This patient had been in our ER less than five minutes, tops, but by the time we hung up from her daughter, she was already getting stridorous, a sign that her airway was compromised. We needed to intubate her. I repeated our concerns and she agreed. Her eyes searched mine and she whispered, "It's bad, huh?" "Yes, maam. I'm so sorry, but your injuries are very bad."

We sedated her with adequate medications and successfully intubated her.

After the intubation, as expected, her swelling and edema worsened. Ultimately, this restricted her breathing and compromised her blood flow. Her vital signs became unstable. Before transferring her to the Burn Unit, the trauma team performed escharotomies. These are linear lengthwise incisions through the skin and soft tissue, along the lateral sides of the patient's extremities and torso. This procedure helped to relieve the increasing pressure from the swelling. Despite this, she continued to decompensate.

I learned a lesson that day. Yes, she received excellent and necessary medical treatment. But making that phone call, well, in the end, it was that phone call that was probably the most important thing we offered this patient in her hour of need.

Sadly, she would not be a miracle patient. And there would be no further reconciliation. Her daughter arrived just hours after this patient had passed.

As always, thanks for reading...the next post will be Friday, December, 11. It will be lighthearted.

Monday, December 7, 2009

Grim Google

I walked into one of our big trauma rooms to see a medical patient who had been placed there because of overflow.

After introducing myself to the patient and his very pregnant companion, I asked him what brought him to our ER.

His chief complaint was as big as the room.

"Doctor, I'm dying of colon cancer."

His exact words. And as he spoke, his words were accompanied by his companion's eye-rolling.

I think now is a good time to describe the patient. He was 25. Yes, 25. He looked very nervous but otherwise normal appearing, short brown hair, 6'0", 220 lbs. Pure muscle. I think he ate a side of beef for lunch every day.

"Why do you think that?" I asked, suspicious I might already know. "Do you have a family history of colon cancer?"

"Well, no. I don't think anyone in my family ever had it--until now. But," he hesitated, choking back his emotions, "every time I go to the bathroom, you know, from behind, I see blood in the toilet and on the tissue."

"Bright red?" I asked. "Yeah," he replied.

What twisted human nature compels each of us to look in the toilet when we are done using it? I am reminded, though, of reading that if you put just one ml of blood in a toilet bowl, most people would overestimate how much blood they were actually seeing. I doubt this patient was an exception.

His concern for his health was very real. And although he was not your average demographics for a colon cancer patient, he still warranted a thorough physical exam and blood work.

"So, every time you have a bowel movement, you see blood?"

"Yes, sir, for the last two days."

"Any pain?" I asked.

"Not, really," he replied, "just a little itching and discomfort."

"Have you ever been constipated?"

"Well, yeah, I have," he answered.

"And obviously, you work out a lot. Do you do a lot of sit-ups? Crunches? Core workout?"

"Yeah, how did you know?" Don't give me too much credit--like I said, the patient was pure muscle. A four-pack wasn't a far stretch of the imagination. However, the abdominal strain and pressure from those exercises could be a contributing factor to his problem.

My next question surprised him. "Do you have internet access?"

"What?" he asked, glancing at his companion.

"Well, did you 'Google' your symptoms?" I asked with sincerity.

His female companion jumped in and answered for him. "Yeah, he did. Yesterday. And since then that's all I've heard about--'I'm dying,' 'I'm not gonna see my kid be born,' 'Why me?'."

On a roll, she took a deep breath and continued. "I have to be honest. I'm 37 weeks pregnant and I have to listen to him whine? I don't think so--it should be the other way around, right? Just tell him he's okay, Doctor, and we'll get out of here."

She finished speaking, looked at the patient, and gave him another dismissive eye-roll.

I loved it. I was going to ask her to give me an eye-rolling lesson when we were done. Twenty times a day, easy, I could be using that talent. And who knows, maybe for extra credit, she could teach me to bob my head, hold up my defiant index finger, and drawl out, all with a little attitude, "Mmmm hmmmm". High-pitched, of course.

After finishing the patient's history, we moved on to his exam. I reviewed the patient's vital signs with him--all good. I performed a very thorough physical exam--all good. This included a pain-free abdominal exam. I reviewed the patient's blood work results as ordered from triage--all good. Again, this included a normal CBC (no signs of anemia). I saved the best for last.

"I'm going to need to do a rectal exam to see exactly what's going on."

This was the moment when I knew this patient seriously did think he was dying. He had no objections to a rectal exam. There are very few reasons that a 25 y.o. male wouldn't object to a medical rectal exam. Very few. So his willingness for this exam spoke volumes of how ill he thought he was.

I performed the exam. And, I'm happy to report, it was in his favor--no blood, no pain (a touch of discomfort, at most), and no unusual findings.

Well, except for one. He had two small, inflamed hemorrhoids that were the most likely source of his bleeding.

Ugh! More near-death hemorrhoids! God's joke on the human race, they are.

I explained in detail to this patient what hemorrhoids are. I explained that we treat them with sitz baths, suppositories ("you mean I gotta put one up my ass?"), creams, and stool softeners. If his symptoms continued, I explained, his family doctor may change treatment, order a colonoscopy or CT scan, or have him see a colo-rectal specialist.

"An ass doctor?" he asked. "They really exist?" Oh yes, Virginia, there is a Santa Clause. And to you, buddy, yes--ass doctors do exist. They're the ones wearing heavy cologne along with plastic face shields and cover-up procedure gowns.

During this conversation, out of the corner of my eye, I saw this patient's girlfriend trying to hold back her smile and failing miserably. And yes, she was rolling her eyes at him. Again.

I liked her. And I liked this patient. In all seriousness, his worries could have been any of ours.

Finally, after my best reassurances that he was not dying of colon cancer, the patient finally relaxed and joked a little about "his new little buddies down there." I actually think he was going to name them.

I pulled out a blank sheet of paper and wrote on it. H.E.M.O.R.R.H.O.I.D.S.

I handed it to him.

"What's this?" he asked, taking the note and reading it aloud.

"Your next Google search," I answered, smiling.

His companion laughed out loud and rolled her eyes. Again. Only this time, they were directed at me.

After the recent news report of how people are bypassing their doctors and relying on search engines to make self-diagnoses of their symptoms, I decided to flip that coin. Thanks for reading, as always. Next post will be Wednesday, December 9.

Friday, December 4, 2009

The Half-Load Predicament

My family does a lot of swimming in the summer, both recreational and competitive. And because of the amount of time we spend at the pool, we go through a lot of swimsuits.

This summer, while at a local department store, my wife took the girls and went looking for some extra suits while my son and I searched out swim trunks in the men's department.

While my son was looking at the boy's rack, I thumbed through the available men's options. I passed right by the tiny Speedos rack, since I'm neither European nor obese, and found a rack of board shorts, my favorites.

The designs were current and hip and I just knew I was going to look 20 again at the poolside.

Finding a pair I really liked, I peeked at the tag to confirm the size was the same as what the hanger read.

What I saw next was nothing less than disgusting. And hysterical. I could not believe what I was looking at.

There, inside the swim trunks I had planned on purchasing, was half a load of crap clinging to the inseam!

Obviously, someone had tried these trunks on underwearless, which is gross enough. But to actually leave this mess and put the shorts back? I was incredulous. It either had to be a teenager playing a vile prank or someone who simply failed to hold their wet fart. Either way, I couldn't even imagine what their crack looked like if this is how the shorts turned out.

Since my kids have fantastic senses of humor, I decided to have a little fun. "Hey," I called to my eleven year-old son, "can you come here?"

He came up to me as I stood in front of the trunks. "Yeah, Dad?"

"I really like these trunks but I can't read the size on the tag. Can you?"

"Sure." My son grabbed the clean waistband and pulled it back to read the tag. "Dad, it says thirty...OH MY GOSH!" He had spotted the mess.

He released his grip on the waistband and could barely get his words out. "There's...there's a load's brown...OH MY GOSH! GROSS!"

I sometimes wish my humor wasn't so twisted from working in the ER, but there you go. I could hardly keep a straight face.

"Look, Dad, I'm not kidding!" I took a look to appease him. "Well," I said reflectively, fingers on chin, "I don't think that should be there."

"We have to go tell Mom and the girls!" he exclaimed, running away from me before I could stop him.

I followed him to the girls section, where he was already in the middle of the story by the time I arrived. My wife and daughters looked incredulous. In unison, when he finished, they exclaimed "NO WAY!"

My wife and girls looked at me to confirm the story. "Really?" they asked. "Really," I said.

As my son rushed off with the girls to show them this remarkable find, my wife asked me again. "This is for real?"

"Yes," I said again, "no lie. I promise. And it's disgusting."

She caught me off-guard with her next question. "Aren't you going to take them up to the front counter?"

What? I didn't even think of that. I wasn't the one who took a dump in some new board shorts in the dressing room. And, I didn't ask for this to happen. Why should I have to take them up to the front?

"Because," my wife said, "that's the right thing to do. You don't want someone buying them and taking them home, do you?" Ugh, sometimes her reasonable thinking annoyed me. "Besides," she continued, "what if someone throws them in their cart and they have food or, even worse, a toddler playing in the cart. Then what?"

I pictured a little child, blond spiral curls, pulling those board shorts playfully over her head.

Nope, it still wasn't enough for me.

"Listen," I pleaded with my wife, "if I take them to the front counter, they'll think I did it. Who's going to believe that I 'just found them on the rack?' They'll be laughing at me the minute I walk away. Security will probably follow me on hidden cameras the rest of this shopping visit."

I could only imagine. "Hey, Nancy," the security guard would yell to the lady I handed the shorts to, "there's 'the shitter' looking at tennis balls in the sporting section. Why isn't he in the toilet paper aisle?" Then they would burst into fits of laughter, all at my expense.

No, I wasn't handing the swim trunks in. No way, no how.

My wife and I walked over to the men's section to find our kids playfully pushing one another close to the stained shorts.

"Hey, kids," my wife admonished, "be careful! And don't touch them! I don't want you getting someone else's poop on yourself!" Yes, I thought, but it's okay to have your own poop on you? Since she was somewhat annoyed with me, however, I decided not to question her on that point.

She hesitantly stepped towards the shorts and peeled back the waistband. The kids and I held our breath. "Well," she said, cracking a smile at the absurdity, "that sure is something, isn't it?"

Um, yeah, it is something. Something disgusting. Something filthy. Something funny. Something hysterical. Something unexpected. Something unbelievable. Yeah, it was something alright.

"Are you going to take them to the front? Or am I going to have to?" she asked.

I held my ground. "I can't, hon'. Seriously. I just can't do it."

She huffed. "Well, whatever then." I expected her to keep her threat and grab the shorts and take them up to the front herself, but she didn't.

She grabbed the cart handle and pushed it away from the rotten, stinking shorts. "Come on, kids. Let's get out of here and get some cookies." They had earned that much. As long as they washed their hands first.

"Wait," I challenged, "I thought if I didn't take these to the front, you were."

"I changed my mind. Let's go." Good--maybe she was seeing the light of my way.

I walked away from those shorts with a heavy heart. Why I felt so responsible for a load of feces that wasn't mine, I don't know. Darn that deviant culprit for making me feel guilty for his defecation.

On our way out, my eyes searched for anyone close to having a 33w. Or a shuffle to their walk. Or brown-stained pants. No one...

Driving home, I ended up calling in the problem anonymously from my cell phone. Okay, not really. But I do wish I had thought of that at the time. It's just that, for being a level-headed guy, I was a bit flustered.

When we share this story with friends, family, and coworkers (and trust me, we got a lot of mileage out of this one), they seem to be split on what they would have done. Do you know what you would have done?

One of my coworkers, Bill, said it best. "That sure was a shitty predicament."

Yeah, you think?

My next post, an ER story, will be Monday, December 7. I assure you that my kids are very happy and well-adjusted and carry no ill-effects from this shopping trip. Thanks, as always, for reading and have a great weekend.

Wednesday, December 2, 2009

Big Stuff, Big Words

I have become quite good at reading people within the first few minutes of meeting them. It comes with the job, actually. Thirty patients (and their families) a shift and rest assured, after 16 years in the ER, I have been exposed to many different personalities. I am a poker player of sorts, keeping my personal feelings hidden behind my smile while I measure up the alpha male, the needy daughter, and the nosy neighbor, all begging for more attention than the actual patient.

With all the family dynamics swirling around a patient's room, it is important for me to swiftly figure out the who, what, when, where and how so that I can attend to the patient's illness. You would be amazed how just one person can affect the entire ER experience, either positively or negatively.

And in Room 12, that one person happened to be a father of two boy, ages 10 and 12.

I walked into the room to find the ten year-old boy lying on the treatment cot, his forearm bent in the shape of an "L", obviously broken. The nurse was starting an IV to give him some morphine. Sitting in the corner of the room was this patient's twelve year-old brother, his face tear-stained and agonized, looking as hurt if not more than his younger brother. Pacing nervously alongside the patient's cot was their father.

Nothing really too much out of the ordinary.

Except the tension in the room was explosive. Something wasn't adding up.

And then Dad opened his mouth to speak to the son in the corner and it all made sense.

"I hope you're happy, damn it. Just look at your brother's arm. What the hell is wrong with you?"

Whoa, back up here. As the nurse was starting the IV, she looked up in the middle of Dad's rant to give me "the look," a warning that all was not good in this room. I interrupted Dad to introduce myself.

Dad bit his tongue during the introduction, but as soon as I asked what happened, Dad jumped right back in where he left off.

"He's always causing problems...pain in my ass...doesn't care about anyone but himself..."

His rant against his older son continued and the more he spoke, the more his son's shoulders shook from silent sobbing. The younger son with the broken arm sat silent, his pained expression speaking volumes.

The story played out that the two brothers were in the front yard playing soccer. Soon after, bored from kicking the ball, they started tackling one another. It was then that the older brother tackled his younger brother and, in the midst of the tackle, broke his younger brother's arm.

An accident, pure and simple. I could see it, the nurse could see it, and I know as you read this you see it.

Dad didn't see it. And I was finding it difficult to give him some benefit of doubt during his family's stressful crisis.

After several more hurtful insults, I had had enough.

"Come outside into the hallway with me, Dad. We need to talk."

In the hallway, Dad tried to start all over again with how his older son was a "problem child" and always created conflict in their family, but I halted him. Rarely have I met a "problem child" that didn't have a "problem adult" in his life.

I took a deep breath, not wanting to be anything but professional during this conversation. Deep down, though, my insides were screaming. I wanted to grab this guy and shake him, make him take an outside look at what he was doing to his older son.

"Listen, sir, I understand you're upset. But you have the power to make this a better experience for both of your sons right now. As things stand, your words are only making the situation worse."

"But damn it, he's got..."

I stopped him. "I've heard you already. And so has the nurse. And so have both of your sons. What I am asking of you is to go back in the room, find something nice to say to your older son, and then sit on the cot with your younger son and help him get through this visit. I don't want any more negative talk from you while we help your family, okay?"

I stared at him and he was silent. "Okay?" I asked again, more loudly.

He shook his head yes.

We walked back into the room. I looked at Dad. He was ready to talk to the son in the corner.

"See," the father said, "now you got me in trouble. I hope you're happy with yourself."

I was shocked. And angry. And frustrated with this man who, I felt, was clearly not appreciating the blessings of having children.

He looked at my face and, for once, I failed to hide my emotions. He did not say another word while we fixed his son's fracture.

After successfully reducing the broken arm, we sent the younger son to X-Ray for post-reduction films. We had Dad accompany him. I hung back with the older son.

Over popsicles, we got better acquainted. He shared that his dad said "a lot of mean things" to him. Words "that hurt sometimes." He assured me, though, that this was the extent of his father's unkindness. "He treats me okay most of the time," he added.

"You know this isn't your fault, right?"

He thought I meant his brother's broken arm. "But it is. I shouldn't have tackled him so hard."

"No, but that's not your fault, either. Things like this happen between brothers. I'm talking about the angry words you hear from your dad. Some parents love their kids very much but just don't know how to pick the right words to tell them."

He nodded while he looked down at his sneakers. I continued. "I have no doubt that you are a good son and brother." We talked a few more minutes that culminated with a smile from him.

Dad had calmed down before his son was discharged. Prior to leaving, I had an instinct that he wanted to say something to me--something apologetic, by his expression. But he didn't. A part of me, though, could only hope that he had looked in the mirror and didn't like what he had seen.

The nurse planned to arrange follow-up with this family.

Sometimes, despite our best efforts and resources in the ER, life and fate will continue to play out the way they were destined to.

Darn it all.

Next post will be Friday, December 4. See you then...and hats off to the caring nurse who provided more than just good medical care for this family.