Tuesday, September 28, 2010

The Saving Brother

I heard the patient's agonizing scream emanate from Room 31 just seconds before Nurse Carla ran up to me. "Dr. Jim," she said, grabbing me by my arm, "I need you in 31 right away." Her face was flushed, her voice edged with concern. Carla, usually calm and collected, had me worried with her nervousness.

As we hurried down the hallway toward the room, we were greeted by yet another gut-wrenching scream. Somebody was hurting. And hurting bad. We hear many types of screams in the ER--demented screams, angry screams, excited screams, drunken screams, etc.--but this primal scream from being in extreme pain was by far the worst.

"What's going on, Carla?" I asked her, intrigued as to what I was going to find when I walked through Room 31's doors.

"Bad burns," she said, "and trust me, your heart's going to drop over this one."

We walked into the room and I was surprised to find an eighteen year-old male patient sitting upright in his cot, completely naked. He was alone and crying. He was thinly-built with shoulder-length blond hair, his face painfully scrunched-up as a result of his despair. His hands were alternating between flailing and holding his genitals. The nauseating smell of burnt skin and hair permeated the room.

I rushed to his side while Carla assumed position on his other side, preparing to start an IV. On a quick, cursory exam, I saw that he had apparent burns to his lower abdomen, his inguinal areas, and his penis and scrotum. Poor kid.

I quickly introduced myself to him. Through abbreviated, gasping words, he told me his name was Matthew.

"Matthew," I said, "we are going to start an IV and give you some pain medication to make you more comfortable, okay?" He nodded his agreement while grimacing from his discomfort. I continued. "After we get you a little more comfortable, we'll talk about what happened. In the meantime, I need to perform a physical exam to see what the extent of your burns are."

Carla had an IV established before I was even done talking. "Morphine?" she asked. "Morphine," I answered, "and lots of it." After giving her some further orders for IV fluid hydration, she hurriedly left the room.

I looked closely at Matthew's head and face. He had no singed nasal hairs, no burnt eyebrows or lashes. I had him spit in a container. His sputum was clear. He had no stridor or difficulty breathing. All good findings to suggest his burns didn't affect his airway. His heart sounds were excellent. His lung sounds were clear. His abdomen, barring the lower skin burns, was soft and without pain. His extremities revealed him to have redness and blistering to the palms of both hands.

Next, as Carla administered the morphine, I focused on his burned privates. His entire penis was red and blistered but, thankfully, the burns were not circumferential. A band of burns that completely encircled the penis would have had potential to cut off the blood-supply to the distal part and that would have been very bad. Matthew's scrotum was also burned, red with significant blistering covering its entire surface. His groin area and proximal thighs on both sides were also a bright, angry red and blister-filled. His anus and rectal area had been spared.

Because of the location of his partial-thickness and potentially full-thickness burns, Matthew needed to be emergently transferred to a burn-unit with his injuries.

After making quick arrangements for his transfer, I returned to Room 31 to find a much more comfortable patient. Several nurses, including Carla, were bent over Matthew tending to his burns.

"Matthew," I said, "do you feel better." Groggy from the pain medications, he smiled a goofy grin at me. "I sure do, Doctor. Thank you."

He then went on to explain to me how he had received his burns. His younger ten year-old brother had been playing with fireworks when Matthew had happened upon him. His younger brother, Matthew continued, was holding an M-80 in his hands, lit, and was trying to slide it down a tube that wasn't wide enough. Matthew, watching with horror, saw the wick of the firework burn down to almost nothing and he decided to act.

"I ran up to my brother, Doctor, and grabbed the tube with the M-80 sticking out of it. I thought it was going to blow up in his face, so I snatched the tube and held it against my belly so it wouldn't hurt him."

As you can probably guess, the M-80 blew while Matthew was pressing it against himself. Although the force of the M-80 missed causing him significant injury, Matthew's clothes caught on fire, resulting in his burns. Matthew was a hero.

"Is your little brother okay?" I asked. "I think so," he answered, "he and my mom should be here soon."

I liked this young man. Here was a respectful, saving brother who risked his manhood, his life actually, to keep his younger brother out of harm's way. I had no doubt that if the exact scenario repeated itself, he would do the same thing.

Within minutes after our discussion, I greeted Matthew's mother and younger brother in the hallway outside of his room. They were both distraught and crying, their tear-stained faces looking expectantly at me for some good news. Especially the younger brother.

I put my arm around his trembling shoulders while I addressed them both. "Matthew is much more comfortable now," I reassured them, "but I have some concerns about how bad his burns may be. We're going to transfer him to the regional burn center so he will get the best available care possible for his burns."

The mother nodded. "Please do whatever you have to do to get Matthew better, Doctor."

I escorted them into Matthew's room, where the younger brother immediately bolted to Matthew's side, hugging him. "It's all my fault," he muttered between his free-flowing tears. "I'm sorry, Matt." The guilty weight of the younger brother was heartbreakingly evident. Matthew, as I knew he would, put his protective arm around his younger brother. "It's alright, bro. I'm just glad that you are okay." Mom came up then, wrapping her arms around both of her sons. Carla and I stepped out to give them some privacy.

We transferred Matthew to the burn unit without incident. Prior to his leaving, we wished him well and told his mother to please keep us posted as to his recovery. We all wanted Matthew to have the best of outcomes.

A few weeks later, waiting in my work mailbox, was an update letter from the receiving burn unit regarding Matthew's condition. I eagerly ripped it open, nervous about the news it contained. Thankfully, it held the best news possible. Matthew hadn't required any skin grafting and, although his burns were significant, they expected a full recovery without any permanent injury or damage.

Sometimes, things turn out just the way you hope they will. Cheers to Matthew.

As always, big thanks for reading. See you Friday...

Friday, September 24, 2010

A Third Look

I sometimes wonder what the commotion of our emergency department must look like through the eyes of a patient or their family. Imagine walking down the hallway to visit Aunt Lucy only to have a half-naked patient, his gown loosely-tied and his junk hanging out, walking at you from the other direction. Or seeing an unresponsive patient on a cot being rushed into a room with a paramedic sitting on top of him, performing CPR. Or hearing the drunk patient in the next room violently vomiting and gagging while filling-in the space between with obscenities.

The imagery and sounds that come from our busy shifts must haunt some of these visitors not familiar with the day-to-day workings of an ER.

Better yet, I wonder what these same patients and their families think when they see our staff's occasional blase' attitude. It has to be something pretty remarkable and out of the ordinary to get us to cringe or flinch or react, it seems. Which, I'm sure, comes across as uncaring to some. Trust me, though, it's not that the staff doesn't care, it's just that with the constant bombardment of these scenes, we have become somewhat immune to being caught off-guard.

When was the last time I did a double-take, you ask? Easy. It was two weeks ago. I had been standing at a counter in the nurses' station, finishing a chart, when I looked up to find one of our male techs helping a female patient stand from her cot. She had needed to go the bathroom and had insisted on using the hallway bathroom. She was a short but heavy woman, mid-forties, frosted blond hair, wearing a gown and nothing else. I presumed it had been tied up in the back.


As the tech helped this woman out of her room and down the hallway, away from me, I glanced to make sure she was steady on her feet. She was. But after what I saw, I wasn't. This woman's very robust ass was hanging out of her gown. Evidently, her gown hadn't been tied correctly. Now, I can handle the robust ass part. That's not a problem. If I've seen one robust ass in my career, I've seen a hundred. But what made me look twice at this one was the very tiny triangular patch of bright orange at the small of this patient's back.

"Noooooo," I thought to myself, "that can't be a thong. Can it?" A small part of me, although not a fan of them, hoped it was a "tramp stamp," a tattoo. For some reason, I would have accepted this a little better. As much as I hate tramp stamps, I hate thongs even that much more.

So, what did I do next? Heck yeah--I looked a third time. And disappointingly, I realized that the itsy-bitsy patch of orange was fabric. No tramp stamp for this classy patient. Straining my eyes, I couldn't see the rest of the thong, though, as it seemed to disappear among the fleshy cheeks.

With my mouth gaping, I watched the tech and the patient arrive at the bathroom, where he helped the patient in before stepping out and giving her some privacy. Afterwards, I looked behind where I was standing, only to find one nurse, one radiology tech, and two family members from another room (they had been asked to step into the hallway while a portable chest x-ray was being taken) standing in the hallway, watching the same scene I had just witnessed.

Their mouths were gaping, too.

I walked to the tech waiting outside the bathroom for this patient. "Hey, Mike," I said, "you have to cover up this patient when she comes out. Her backside and thong are hanging out for everybody to see."

"A thong?" he asked, "No way." I understood his amazement--this patient wasn't our typical, narcissistic thong wearer. "Trust me," I answered, pointing down to the family members looking our way, "they got a free show."

Mike ran and got one of our scratchy hospital-issued blankets and tried to cover up this patient's backside as she exited the bathroom, but she refused. "Get that thing off me," she yelled, "I don't care who sees me!" Good for her for being proud of her robust ass. If only we could all be that confident.

Mike earned his paycheck that day. As the patient walked back to her room, Mike grasped her elbow for support while using his other hand to hold the back edges of her gown together. No easy feat on his part, but he handled it like a champ. Single-handedly, he got this movie's rating reduced from an "R" to "PG.

Sometimes, the noise can be just as disturbing. Just a few days ago, we had a pleasantly demented elderly woman sent to us from a local nursing home for a variety of medical complaints. Usually, if we can, we place this type of patient near the nursing station to keep a closer watch on them (in the event they try to climb out of their beds). Unfortunately, though, this patient was prone to frequently screaming out "Help me!" Every few minutes. In a loud, high-pitched, shrilly voice. For three full hours. Behind her partially-closed glass doors.

Imagine being one of the patients or families who bore witness to these screams. After a few minutes, the staff easily got used to them (although I'm sure most of them would have preferred a little more quiet). I'll bet, though, that it was probably somewhat disconcerting for several families to think a patient was screaming out for help and not finding the staff reacting.

Unbelievably, about forty-five minutes before Ms. "Help me!" was discharged back to her nursing home, an elderly demented man was brought to our ER and placed in a parallel hallway near the same nursing station. And can you guess what he was prone to yelling out? "Owww!" Yes, "owww!" Drawn out in a raspy, deep, masculine voice.

Suddenly, we had these two patients prompting each other. "Help me!" was followed by "Owww!" "Owww!" was followed by "Help me!" This duo had impeccable, precise timing in their forty-five minutes of togetherness.

We all shook our heads. The hilarity of the moment, unfortunately, was tinged with some sadness to the reality of their situations. In another thirty years, I thought, that could be me uncontrollably yelling out something. Something suave, I can only hope.

After the woman was discharged, the elderly man continued with his "Owww"s for a few more minutes before tapering off completely. Maybe he realized, through his dementia, that he was Simon without his Garfunkel. Or Hall without his Oates. Better yet, Ike without his Tina.

As for the patients and families that heard this duo's chorus, we offered several reassurances that these patients were okay and not in any pain. Hopefully, the families we didn't get a chance to offer an explanation to won't be scared off from returning the next time they need emergency care.

The families that saw the orange thong, though? I don't expect we'll ever see them again...

As always, big thanks for reading. Any of you have a funny story to share? I hope you have a great weekend...

Friday, September 17, 2010

Going Down or Going Up

Anyone who is familiar with the medical field is well aware of the hierarchy that exists for the typical doctor in training. It starts in medical school, when you are a lowly first-year, and culminates after you finish residency, when you are a polished doctor, an attending, defining your own terms.

During the first year of my emergency medicine residency, we were assigned a rotation of five to seven weeks in a very demanding surgical sub-specialty service. Lucky me. Not only was I assigned this rotation during December and January, the holiday months, but my specific time was seven weeks with this service.

Heart transplants, bypass surgeries, lung resections, and much more--all at my lucky finger tips. The main reason for our involvement in this rotation, as ER residents in-training, was to learn how to perform a chest-tube insertion. Simply, it involves cutting through the skin of your mid-lateral ribcage, through the muscle and cartilage layers between two ribs, and accessing the lung space. You then insert a hollow tube into this lung space, which when hooked to a low-pressure vacuum, evacuates blood or air, or both. Either of these (usually from a trauma) can collapse the lungs and cause respiratory distress, which can lead to cardiac distress, so quickly inserting this tube can be life-saving. This procedure, known medically as a tube thoracostomy, is one of the "musts" that anyone entering the emergency medicine field must learn.

Simply put, though, this rotation sucked. I can't put it in any nicer terms. I was tired and worn-out, depressed and miserable, from all the hours and extreme demands of this rotation. A typical day started between 4 and 5 a.m. and finished, if you weren't on call, around 6 or 7 p.m. I was on call every third day, which meant I worked a 36 hour shift that day. Over Christmas, it got even worse--I was on call every other day. This was genuine, hellish, character-building training back in the days when strict rules and regulations were just evolving.

The hierarchy was never more evident to me than during this rotation. I was a lowly emergency medicine intern on service with several medical students below me and a fellow surgical intern beside me. Ahead, a second-year internal medicine resident, a fourth-year surgical resident, and a "fellow," a graduated surgical resident pursuing several additional training years in a surgical sub-specialty. And, of course, our attending, who varied day-to-day. Eight of us made up the team.

Did I mention that this was a hard rotation?

The funny thing about medicine, though, is that, as a resident, an intern, or medical student, there is much more to be learned from a rotation than just the medical knowledge and patient care. I constantly stress this to our emergency medicine residents. Be alert. Absorb everything about a patient and their case. Be compassionate. And watch those teaching you, extracting the best and worst of those experiences to add or avoid in their own practicing. I credit myself for being the doctor I am from emulating my favorites attendings just as much as from learning how not to behave or practice from certain individuals in the medical field.

From all my experiences during these seven weeks, one negative experience prominently stands out. Unfortunately, it doesn't involve a patient but rather the attending of our team. It was Christmas Day, around 11 a.m., and I was on-call. After finishing morning rounds, the departing on-call team, the attending, and our oncoming on-call team were collectively going down an elevator to the main-entrance lobby. Our attending that day was a fiftyish, hard-working, intelligent physician who, quite honestly, was always quite impressed with himself. His people skills, though, were extremely lacking.

Despite everyone being either depressed or exhausted, a lot of effort by others was going into kissing our attending's ass--laughing at his jokes, hanging on his every word, schmoozing left and right. Someone eventually asked him what the rest of his Christmas Day plans were.

"Well," he answered, "unfortunately, all my kids came home for the holidays."

"That's a bad thing?" I blurted out, surprised by his answer. I would have done anything, anything at all, to have spent the day with my wife and my family.

"Yes," the attending replied, surprised by my question, "very bad, actually."

"May I ask exactly why it's bad, sir?" I asked, ignoring the glare of my senior resident. I knew she wanted me to shut up, but that wasn't happening. "Is it too many people in the house? Too much commotion? Something like that?"

"Hardly," he replied, laughing to himself and shaking his head. "My family aggravates me and, quite frankly, I don't enjoy their company." He could have stopped there but didn't. "My wife and I have four kids, two married, no grandchildren. I would love some grandkids, but my kids are too damn selfish for that."

He got momentarily lost in his thoughts before speaking again. "Let me give you all a little piece of advice. This job we do--make it the priority in your life. Don't get distracted with a spouse and kids if you can help it. Trust me, they only get in the way." I waited for him to laugh, to finish out his joke of a statement. No laugh ever came, though.

His words had silenced the elevator and still, he continued. "Now I have to go home and play nice with my wife and kids. Trust me, that's a much harder job than this, any day. If I had my choice, I'd avoid all of them and stay here for the day." The elevator bell rang as he finished speaking, the doors quickly opening to let the departing on-call team and the attending out. No last holiday wishes from any of them.

If only the attending had remained silent and lost in his thoughts, I wouldn't have had to pity this man and his ridiculous words. "Have a nice fricking Christmas," I mumbled to no-one in particular.

Here I was, an intern-- a low-life medical scum barely clinging to the bottom of the totem pole--wishing for nothing other than to be surrounded by the ones I cherished on that Christmas Day. And here was the attending-- a worshipped doctor high on his pedestal--wishing for anything but to be surrounded by his family on Christmas Day. Clearly, he was letting his life be defined only by his successful professional accomplishments. And he seemed to be okay with that. He didn't seem to be affected by his failures as a husband. As a father. As a friend. As a man. He probably didn't see it, even.

How sad. How very, very sad.

Although I learned a lot during this rotation, none of my gained medical knowledge came close to the perspective I gained going down that hospital elevator on that Christmas day. I was shown a clear example of what I did not, nor would ever, become. No textbook could have taught me that.

Writing this post, I realize that I never found out how that Christmas day turned out for this attending. I wonder if there were any family arguments? Did anyone drink too much? And what emotion saturated the dining room while this family ate their holiday meal? Anger? Silence? Am I too hopeful and naive to think that maybe there was a little happiness? I picture extreme silence, barring the silverware clinking the plates, with everyone maintaining their robotic and detached manners. I hope I am wrong.

This attending gets full credit for teaching me something valuable during that rotation. Climbing up the hierarchy of medicine did not mean that I would have to sink down the hierarchy of family and friends. I would never sacrifice one for the other.

Best Christmas present I got that year, for sure.

As always, big thanks for reading. I hope you all have a great weekend. See you next week...

Wednesday, September 15, 2010

Pipe Cleaning

I usually work two or three shifts a month at a small, rural hospital about two hours from where I live. Why? Mainly, the small hospital is less than ten miles from my childhood home, where my widowed father still resides, and thus provides me an opportunity to catch up with Dad as well as four of my siblings and their families, all who live within five miles of Dad.

I also thoroughly enjoy the different ER setting that working in a small hospital provides when compared to the trauma center I have been a part of for fourteen years. People are more appreciative, it seems, and less demanding. People are respectful. There seems to be a more heartfelt connection between the small town folks and the ER staff versus the big city dwellers who demand everything on their terms with our trauma center staff. I have yet to be asked for a turkey sandwich, a warm blanket, an extra pillow, or internet access at the smaller facility.

It is, simply put, refreshing.

Still, I have a hard time drawing the line between how emergency medicine should be practiced in a small town versus a big city. Should there be a difference, even? I'm not sure if there should be. I like to think I extend myself and my staff quite well to each and every patient, whether I'm in Smalltown, USA, or the big city.

During my last round of ER shifts near Dad's, an energetic, spritely 80 y.o. woman came in complaining of constipation. By her tightly wound perm, I should have seen that she would be a hard patient to please. She typically had a bowel movement everyday. Unfortunately, the day before she came to see me, she had not had her typical movement. The next day, upset about skipping a day of evacuation, she came to our ER demanding to get an enema.

"Maam," I asked, after introductions, "do you have any abdominal pain?" "No," she answered. I continued. "Do you have any fever? Do you have any urinary complaints? Do you have any vaginal complaints? Do you have any nausea or vomiting?" To each question, she answered a resounding "no."

"Maam," I said, quite honestly, when I had finished a perfectly normal physical exam, "I am trying to figure out why you came to the ER if you otherwise feel alright. Did you call your family doctor about your constipation?"

"Why would I do that?" she asked, "they don't do enemas in the office. And I need an enema."

"Well, maam," I confessed, "I don't require our nurses to give enemas to people unless they medically need one. Without a fever, abdominal pain, or any other changes to your health, I don't even feel you need an enema for just skipping one day of your regular movements."

"You mean you aren't going to order me an enema?" she asked, incredulous. "Have you had an enema here before, maam?" I asked, curious as to why she was so focused on getting an enema. "No, I haven't," she said, "but I know lots of people who come here to get one when they need one."

While the patient went to the bathroom to "try to go again," I left her room to question the nursing staff about their enema practices. "Oh no, we don't do enemas unless we really have to," the nurses said, almost in unison. What other answer was I expecting? Of course, nobody in their right mind was going to volunteer to give an enema to a healthy, non-distressed patient.

The woman returned from the bathroom. "No luck," she said, smiling as if to say "so there," as she comfortably walked back to her room and easily jumped up into her cot. "Well," I said, "I think we have a plan for you, maam." I then explained how I approach constipation in the otherwise healthy patient. I explained that she needed to make sure she ate enough fiber in her diet and drank enough liquids. She needed to be physically active which, judging from her energy, wouldn't be a problem. We talked about her taking something to "keep her regular," from FiberCon to Metamucil to MiraLAX, as she needed.

Finally, I talked to her about the meat of her problem. "Maam," I said, "although I don't suggest it right now, if you feel you are constipated and want to aggressively treat it, then use a Fleet's enema. If you don't have relief in one hour, repeat it. And if that doesn't flush you out within four hours, drink a half bottle of magnesium citrate." I went over this twice, actually, as she nodded her head.

When I was done, she got quite snippy with me. "You mean I won't be getting an enema here in the ER today?" "No, maam," I said, "I'm sorry if you are disappointed with that, but I wouldn't make my staff give you an enema I'm not sure you even need."

"I'm not giving myself an enema," she yelled now, "I never did and I never will!"

I assured her that the instructions that come with Fleet's enemas are very good, including pictures of how to go about things. As a side note, if you want a good laugh sometime, spend the dollar on an enema to see the cartoon drawings in the instructional pamphlet.

Well, she wasn't buying what I was selling. "You mean my husband and nephew have been waiting in the waiting room for nothing? I came here for an enema and I am not happy I'm not getting one."

She then requested if home-nursing would come by her house to give her an enema. Having an important connection with the home-nursing team (my sister Chrissie is a nurse who heads that department), I called Chrissie to get her input. After reviewing the patient's complaints and exam, she mirrored my thoughts. "Does she even need an enema, Jim?" No, I assured her, she doesn't. "Then just have her follow up with her family doctor in a day or two and if she is not successful by that time, we can send someone out to help her. It would be hard to justify sending home nursing in at this time." I love my sister Chrissie, no bones or bullshit with her approach. Just like mine.

I went back in to the patient and explained my conversation with Chrissie to her. The patient was not happy. But she was healthy. Healthy and a little constipated.

After she left, threatening to go to a neighboring rural hospital an hour away where "I'll bet they'll give me an enema," the nurses gave me a round of applause. I felt kind of bad, actually, for having this patient leave disgruntled, without her enema.

"Thank you for separating an emergency enema from a non-emergency enema," said the charge nurse. I nodded my head to her as she continued. "You are the first doctor who ever said 'no' to that demand."

This whole incident got me to thinking. At the big trauma center, I would never have considered giving this patient an enema, no matter how much she thought she needed one. We are just too busy to not utilize our time more efficiently. In the small town, however, people seem to expect that extra "oomph" of kindness. But a line has to be drawn at some point. Incidental constipation without symptoms does not, in my book, demand an enema "just because" the patient is obsessing over her bowel movement patterns. Or because they happened to sign into an ER to be seen.

Something tells me this kind lady will not be baking me an apple pie as a thank-you. Which sucks, since I love apple pie. But at least, whether it's in a big city or a small town, I feel I treated the patient correctly.

As always, big thanks for reading. See you Friday...

Friday, September 10, 2010

The Reverse Peeper

It is 7:30 a.m. A weekday. Imagine that you walk up the two-lane driveway that leads to the brown-sided, two-story home, accented by shaker shingles and maroon shutters. You gingerly approach the burgundy front door, the morning sun warmly glowing against the house's reflective, cross-hatched windows as it bathes comfort to your posterior neck. You deeply inhale the passing autumn breeze, saturated with the smells of change. Slowly, you open the front door, turning the gold-plated handle down while pushing inward. You step forward, off the brick-lined stairs, into a foyer entrance.

You step onto warm, beige tiles as you gently close the door behind you. Facing you, a winding staircase embraces a wall completely covered in a variety of frames, their contained pictures telling a story of past and present family, from grinning babies with sprouting hair to formally-dressed young couples in love during the depression era. You glance to your left, noticing the wide, oak-framed doorway that leads into the formal room. A mahogany piano with glittering white keys sits in the corner, sheet music scattered across its front.

To your right, you see a glass-paned door invitingly open, leading into a home office. You casually peer in, noticing the filled mahogany bookcase, the L-shaped desk with a pile of paperwork off to one side, and the cozy, hunter green leather chair, draped by a matching green afghan and ottoman, in the far corner. You notice shelves of collectibles, more frames of family, and hung diplomas and artwork on the coffee-colored walls. The room looks comfortable and lived-in, a room you can accomplish paper-work in.

Finally, you notice the two oversized, side-by-side windows that dominate one entire wall. They face the front yard, watchful of the path from you which you just arrived.

And watchful of the path that leads away.

In front of those windows, on most mornings, stands a father watching his children walk away from their protective, comfortable home to their bus stop. He stands there in his pajama bottoms and a white cotton t-shirt, holding a steaming cup of coffee. His forehead and nose press against the pane, hoping his children will turn around to give him one last wave, one last acknowledgement, before they will soon round the bend of their cul-de-sac and no longer be in view.

He watches his oldest child, as tall as her mother, walk beside his middle child, his only son. They walk alongside one another, occasionally stopping to shift the heavy backpacks they carry. They nudge each other frequently, bumping into one another with the familiarity that only family knows. Their faces turn frequently to one another, and the father can see clearly the smiles and laughter privately shared between his two children. It makes him proud. Soon after, though, they separate, she going with a friend who met up with her and he chasing after two friends waiting for him further down the road.

They round the bend and disappear from sight. They are growing up too fast, the father thinks, wishing to himself that he could rewind time and slow down the hectic pace of life. He exhales, turning to face his quiet office, wondering if today will be the day he finally attacks the pile of paperwork waiting for him. He sits in his office chair and pulls up to the desktop computer. He is reflective, sitting there thinking about the stillness of the house. It seems too quiet. Perhaps, he thinks, he will write about this moment.

Within five minutes, thankfully, the stillness of the house is interrupted. A young, sweet, girlish voice, the voice of his youngest child, greets him. "Good morning, Daddy." She walks down the winding stairs with her bed's comforter wrapped tightly around her. He pauses at his computer, returns her greeting with a hug, and lets her begin her day. Her mother waits for her in the kitchen.

By 8:30, she too is ready for the school day. She stands at the front door yelling her last goodbyes, hooking the straps of her backpack around her strong shoulders. As she pulls the door shut, the house's canyon of stillness that just an hour earlier had haunted the father reemerges.

He resumes his position at the office windows. He watches his little girl traipse across the front lawn, her foot steps temporarily etched in the morning dew. She marches directly across the street, her blond ponytail swaying with her enthusiastic steps, where her bus stop awaits the queen's arrival. There are nine kids, ranging in age from kindergarten to fourth grade, and four hovering parents each morning. The father sadly shakes his head, thinking back to the days when he stood in line waiting with this daughter, a proud hoverer himself. Since those days, however, he and his wife had been dismissed from the job. "I'm too old to have you walk me out anymore," their independent daughter had explained.

The parents greet his daughter and look to the window, waving to the father, knowing he stands there on his days off. He returns their wave. The youngest of the children rush his daughter, their small arms quickly jumbled around her waist. She drops her book bag and kneels down onto one knee to return the hugs. Smiles and giggles and endless circles of running fill the next five minutes, until the screeching bus rounds the corner and stops to pick them up.

Through the bus windows, the father sees shades of his daughter's body as she walks the bus's main aisle until the last seat. She plops down her book bag before sitting herself down. On some days, she remembers to wave to her parents from her window as the bus pulls away, but this was not to be one of those days. The father waves eagerly anyway.

As the bus rounds the bend and leaves his sight, the father, once again, turns to face his quiet office and the stillness of the house. He had grown accustomed to a summer of chatter, of laughter, of arguing, and of simple daily moments--moments now stolen back from the eight-hour school day.

The father sits at his computer and stares at the blank screen. He misses his kids already. He is, however, not that naive to think that his pain is isolated. Parents everyday walk this path he is on. How they cope, however, may not be the same way he does.

He writes.

And so he pulls himself up to his desktop and begins. It is 7:30 a.m. A weekday...

Big thanks, as always, for reading. I hope you have a great weekend. This piece was an interesting one to write. I hope you enjoyed the peek in and "the father's" unique perspective.
See you next week!

Wednesday, September 8, 2010

A Nice Person

Big thanks to all of you who reached out to make sure I am okay. I am. In fact, I have just finished a long string of overnights, the kids have successfully adjusted to the new school year, and I have a week off! I'm better than okay... Now, after a hectic but fun summer, I hope to get back to my regularly scheduled postings. Thanks for your concern and patience, friends.

The nursing staff gave me ample warning about the mother of my next patient, a nineteen year-old female with right upper quadrant abdominal pain. Supposedly, the mother had squealed her car into the front parking circle of our ER entrance, jumped out while leaving the car run, and hurried into the waiting room, abruptly cutting to the front of a line of eight patients waiting to be registered.

"Help! My daughter broke her leg and she's in my car bleeding!" the mother yelled, prompting our triage nurse and techs to grab an available cot and rush out to the car.

Disappointingly, our team did not find this woman's daughter, as she had screamed, lying in the back seat with a bleeding broken leg. Instead, what our team found was a young lady, mildly uncomfortable, sitting upright in the front passenger seat of the car. The daughter had gall bladder disease and had just eaten a fatty meal that she shouldn't have.

Sue, our triage nurse, confronted the mother alongside her car while the techs took the cot back into the building and returned with a wheelchair for the patient. "Why would you possibly come in screaming lies like that? Your daughter doesn't have a broken leg? She has abdominal pain!"

The mother, unapologetic, said, "I knew you guys would come running a lot quicker if it was a broken leg." Sue, who has been a nurse for nearly thirty years, simply shook her head. "I've never seen such a thing before," she had said to me, "and I hope never to again."

Sadly, though, the mother's startling behavior didn't end there. After finding out that her daughter would be third in line to be evaluated by the triage nurse, behind two other patients who were deemed more ill and waiting longer, she showered a tirade of obscenities not heard from the mouth of a sober person in quite a while. When that didn't get her daughter moved to the front of the line, she began to threaten "to sue."

It tells you about the state of affairs in medicine when an angry patient or family member threatens to sue and nobody really flinches at the threat. Most in medicine have become immune to the fear that threat once elicited.

When her threats to sue were disregarded, the mother finally threatened to call an ambulance service to pick up her daughter from our waiting room and transport her around the corner of the building to the ambulance entrance bay where, according to her, her daughter would "be guaranteed a room right away."

"Listen to me," Nurse Sue said, addressing this mother again, "you have the right to do whatever you want. But calling the ambulance does not guarantee your daughter an immediate room. In fact, the triage nurse back in the main ER may decide that your daughter doesn't need to be seen immediately and send her back out here, and then she will need to start the whole process of registering again."

The mother decided to not call the ambulance service. Ultimately, after several hours of waiting, in which time she continued to be quite rude and disruptive as well as consulted by a patient advocate, the nursing supervisor, social services, and security, her daughter was finally placed in Room 27, where I stepped in to see them.

I walked into a tension-filled room where mother and daughter did not appear to be enjoying each other's company. I approached the patient, an embarrassed-appearing young woman with straight shoulder-length hair. She seemed quite comfortable sitting upright in her cot. "Hello, Lindsey," I said, extending my hand, "I'm Dr. Jim and I'll be taking care of you today." Lindsey took my hand lightly into hers, barely gripping back my welcome. I then turned to the mother, hand extended, to introduce myself to her but, before I could speak, she started explaining herself.

"I'm sorry for my behavior today," the mother said, "but I didn't want my daughter to wait a long time to be seen. I really am a nice person, you know." From so many years in the ER, I have learned that if you have to explain you are a nice person, you might not be so nice.

"I understand from several people that you have been quite unhappy since you arrived to our ER, maam," I said, addressing her head-on, "but if you want to apologize to anyone, apologize to our triage team who appropriately followed the guidelines of our system in approaching your daughter's care."

"I just don't understand why a sick patient would have to wait two hours to be seen," she continued, while her daughter hushed "Stop, mom," at her.

I'm not sure why I did, but I explained that there was currently a five-hour wait for several non-urgent patients. I also explained that we had been busy dealing with multiple unstable, critical patients who, as long as her daughter's vital signs and exam were stable for our triage team, needed to be treated on a more emergent, immediate basis than her daughter. "Our system is designed to treat the most critical patients quickly," I added, "but that doesn't mean we aren't on your daughter's side--we want to help her as well."

After clearing the air somewhat, I reviewed with Lindsey her history of gall bladder disease and the meal she had eaten prior to developing her pain. Pain which, incidentally, was now gone. After a stable exam, we repeated a round of stable vital signs. Finally, upon review of all of her labs, I went in to explain our plan with the patient and her mother.

"Lindsey," I said, focusing on her, "you are currently pain-free. You don't have a fever, you have stable vital signs, a pain-free physical exam, and normal lab work. In essence, I think you aggravated your gall bladder to spasm with your fatty meal and now it has calmed down." Lindsey shook her head in agreement. "So," I continued, "I talked to your family doctor and made you a surgical appointment in two days. Is that okay?"

"No," the mother blurted in, demandingly, "I want Lindsey to have her gall bladder taken out today and be done with this." I looked from the mother back to Lindsey. "Lindsey," I repeated, "are you okay with my plan?"

"Yes," Lindsey answered, clearly relieved, "I cheated on my diet today and paid the price. I don't want surgery, anyway. Unless I really, really need it."

"Then don't come complaining to me if you get another attack," the mother said snidely to her daughter.

"Listen, Lindsey" I said, "I will write you for some pain medication if you get another attack. And watch what you eat. Clear liquids for the next 12-24 hours and then slowly advance to a bland diet. Otherwise, the surgeon will help you through this, okay?"

The mother huffed. Lindsey smiled her approval. I quickly went back to my station to get her discharge instructions ready. It was futile to try to please this mother. Couldn't she see we invested more time placating her than treating her daughter?

As I typed out the discharge instructions, I heard the mother's voice at the nurses' station. She must have followed me out of the room. She was apologizing again, attempting to save face with our staff. "I really am a nice person," I heard her repeat to the nurses.

Just maybe, I thought, she was saying this out loud to convince herself. I had to fight myself, though, from sharing with her my favorite quote, by the genius Ralph Waldo Emerson: Who you are speaks so loudly I can't hear what you're saying.

Sadly, we all heard loud and clear what this woman was saying.

As always, big thanks for reading. I hope this finds you all well. Be back Friday...