Friday, December 24, 2010

Continued Prayers, Wishes, & Hopes

I pulled up my last-year wishes for you and found myself nodding my agreement as I read, finding that the sentiment and spirit are as strong today as when I wrote them one year ago.

My continued prayers, wishes, and hopes for you and yours...have a Blessed and Happy Holidays.

Another holiday season is upon us. For all the unbridled joy and excitement that surrounds us, however, there is an uneasiness within my core that seems to seed itself every year. I don't think I am alone.

I have seen enough heartache through the year to know that joy and excitement can be very temporary. Can you even imagine wrapping presents only to return them after the holiday season because of an untimely death, never having the chance to give them? Over the holiday season, especially, heartache seems to magnify itself into a swirling tornado ready to touch down on so many lives. I've seen a lot of energy spent outrunning that tornado.

So, for all the happiness, I still can't help but be reminded of how hard these upcoming days will be for so many. My heart goes out to them. Especially the children.

How do I remember the important things in my life? And not just over the holidays, but every day? I know I have been blessed in my life. When I think of these blessings, none of them have to do with material things but rather things that spiritually feed my soul. Companionship, loyalty, kindness, and love. And more love. These make me a better person.

So, in the spirit of this holiday season, I share just a few of my prayers, my wishes, and my hopes with you.

I pray for my family, my friends, and those in the world that are in need. I pray that my son remains in remission for another five years, and another five years after that. I pray that my mother can look down on my family and smile. I pray she knows the power of her prayers, asking a forgiving God to show my son mercy and take her in His arms instead when they were both battling their malignancies. I pray that I can be gracious in adversity, always.

I wish for my family, my friends, and those in the world to know love, to embrace kindness, and to step outside the box and give more of themselves. I wish for endless hugs. I wish for good health. I wish for every child to know warmth in their heart and comfort in their soul. I wish for peace.

I hope that the ripples from compassion will disperse beyond our wildest imaginations. I hope that random acts of kindness multiply. I hope that thoughts of others will replace thoughts of ourselves. I hope that we all remember that we are in this together. I hope that your joy, your happiness, and your excitement is not temporary but rather infinite.

I pray you have a wonderful holiday season. I wish for all your expectations to be fulfilled. I hope the most important presents you will give this holiday season are gifts you can give each day through the year.

Happy Holidays...

As always, big thanks for reading... To my amazing readers...I truly hope this holiday season is blessed and happy for you and all the people in your lives.

Tuesday, December 21, 2010

Defining Emergency

Emergency, as per the all-knowing Webster, is defined as an unforeseen combination of circumstances or the resulting state that calls for immediate action. Furthermore, an emergency is also defined as an urgent need for assistance or relief.

These definitions sound pretty spot-on, right? When thinking about emergency room settings, even, one can easily correlate the words of Webster to what one would necessitate to be a situation requiring emergency medical treatment. A trauma. Broken bones. A heart attack. A stroke. A seizure. Respiratory distress. A cardiac arrest. The list goes on and on and on. When a critical illness or injury occurs, then, we should all be thankful that we live within a society where emergent, life-saving medical care is available.

Lately, though, it seems the system meant to provide this care is being bogged down by questionable decision-making. Instead of providing emergent care, it seems I spend at least half of my emergency room time now playing doctor to chronic illnesses. To pain control issues. To mildly elevated blood pressure readings. To months of nonspecific weaknesses and fatigue. To office appointments sent to the ER because "we are overbooked today." And our ER is not alone. I hear the frustration of my colleagues and see first-hand how overworked most of us who provide health care in the ER setting have become.

A month back, I was in the middle of a very busy shift. Several patients with chest pain (one requiring immediate catheterization), two patients with respiratory distress (one from skipping dialysis and one from a COPD exacerbation), and three patients from a motor vehicle collision presented almost simultaneously to our ER. Within minutes, all of these critical patients had been treated with efficient, appropriate life-saving care. The team on deserved kudos for doing their job well and making a difference in these patients' outcomes.

Walking back to the nursing station, then, I was surprised to find our secretary being berated by a gentleman in his thirties at the counter. His voice was loud and menacing. His face was pinched with anger. His fists were clenched by his side.

"Whoa," I said, walking up to him, standing between him and the secretary, "what seems to be the problem, sir?"

"We've been waiting two hours to be seen by a doctor!" he exclaimed. "What the hell is going on around here?"

Are you kidding? All he had to do was look for himself to find the organized commotion that was occurring in our ER setting. What followed was the briefest of conversations.

"Sir," I asked, "what brought you to our ER today?"
"My daughter's left ear is hurting her."
"For how long?" I asked.
"Two hours," he replied.

Two hours of ear pain? I get it--maybe he was worried about his daughter. I would be as well. But my daughter would also have gotten Tylenol and Advil and watched her daddy patiently wait for their turn to be treated once the dire situation had been explained. Better yet, we would have probably waited until the morning when a call could be placed to her personal physician.

I explained to him that we had multiple critical patients brought to us and we would be with his daughter as soon as possible. "We're all trying our best, sir," I added, "but you're going to need to be a little more patient."

The father stared me in the eye. I stared back. Finally, he blurted out what he had been thinking to say. "Well, then," he spoke, sarcasm dripping from his pathetic words, "try harder." It didn't end there, though. He continued. "This is bullshit waiting two hours to be seen."

Before I could respond, he turned his back and huffed himself back into Room 27 where, the nurse shared with me, his eleven year-old daughter comfortably sat watching TV. "And," the nurse added, "I had already explained to him why they were waiting to be seen."

After this, one of our regulars who had been to our ER over 200 times (since we started tracking in March of 2006) arrived via ambulance. Then a gentleman carrying a big bottle of Mountain Dew was escorted from his ambulance, by foot, into our ER because his main complaint was "I just want to take a nap and was too far from my apartment." Next, an asymptomatic patient with elevated blood pressure for three years, non-compliant with her medications for financial reasons (yes--I noticed the pack of cigarettes hanging from her purse), was sent to us from her family doctor to be cured on the spot. "Go right to the ER," she was told.

Can you appreciate the obviousness of the long waiting times in the emergency department? Although we all pride ourselves on providing expedient care, a four to six hour wait is sometimes the reality for some of our noncritical patients.

As if to hammer the point home, my last patient during my shift that night (I was working 5pm to 3am) was a sixteen year old female who had presented to our ER, via ambulance at 2am, with her mother.

I walked into her room to find this patient and her mother both lying in the cot, laughing while watching TV, the patient in no obvious distress. I introduced myself to them before I started asking questions. "What can I do to help you tonight? What brought you to our emergency room?"

The girl looked at her mother and started giggling, my first sign that she would survive whatever her ailment may be.

"Well," she said shyly, "I've had some burning when I pee for about a week. And," she added, not done "I have something gross leaking from down there (she swept her hand towards her pelvis as she spoke)." Upon further questioning, I learned that she had been diagnosed with a yeast infection from her family doctor one month ago but failed to get her prescription filled. I also learned that she was sexually active with not one, but two partners. Unprotected.

I was disheartened. "What made you come to the ER at 2am when these symptoms have been going on for over a week?" I asked, hoping there was some rhyme or reason to her seeking out emergent care at this time. There wasn't. Her answer to my question--"Why not?" I didn't even approach her on why she came in by ambulance. Some things are better not known, I guess, especially at 2am.

I'm not sure this is the system that was imagined when emergency departments started gaining favor in our society. Don't get me wrong, though. I, like all of my colleagues, are 100% committed to providing respectful and appropriate care to anyone who shows up in our department, whether it be a critical, life-threatening illness or a chronic "nuisance," so to speak.

I can only hope that people will be patient and understanding as we all cope with the evolving changes that seem to be occurring with our health care system. And my hat is off to all the medical folks who work hard, day after day, treating our fellow mankind as best we can within this currently accepted system. Because, even as bogged down as we can sometimes become, what an awesome privilege we have in meeting and greeting and treating our fellow kind. Of helping them out in their time of need.


As always, big thanks for reading. I wish a blessed holiday season to each and every one of you...

Friday, December 10, 2010

Keep Your Cranky

Although the majority of my emergency department time is spent in a local 36-bed trauma center, I continue to work a few shifts each month in the small rural hospital near my childhood hometown, several hours away. It is a great change of pace, treating the local folks, while affording me a chance to spend a few evenings with my father and siblings' families.

Last week, I had to drive through white-out blizzard conditions during my most recent two-hour trip, taking approximately four hours each way because of the weather. White knuckles, breath-holding, tense and contracted muscles, stress headaches, and bouts of complaining to myself in the car--these were all part of the package deal. I imagined the cozy, 12-bed emergency department awaiting my arrival, however, and kept plugging along the icy roads, refusing to abandon my place in the thirty-car line of traffic. Going 20 mph. And braking every five seconds. Yep, good times, as any of you ever caught traveling in a snow storm are familiar with.

Arriving at the small ER, then, I was pleasantly surprised to see the festive decorations that adorned the department. Gold, shimmery garland draped the nursing station. Felt stockings and striped candy canes hung in random fashion along the glass enclosure walls. A Christmas tree was standing tall, twinkling and proud, in a nook of inactive space in the corner. It felt Norman Rockwelly and old-fashioned, and I felt welcomed. 'Tis the season.

The first of my scheduled shifts was quite hectic. From my prime seating in front of the ambulance bay doors, I was able to appreciate the outdoor weather. Blustery gusts of snow and heavy thick blankets of engorged snowflakes descended and tormented, without pause, the small town through the day. Although I felt worry and concern for anyone out in this weather, a blazing fireplace, a good book, and a glass of wine were the only things that would have added to the enjoyment and appreciation I felt for this crazy weather.

Three hours into my shift, though, I remembered what the first snowstorm of the season means to an ER staff. Multiple MVCs (multiple vehicle collisions). First-time-of-the-season shovelers developing chest pain as they try to clear their sidewalks. Frequent falls resulting in contusions and broken bones and lacerations. Cough and cold symptoms magnified tenfold with every ten degree drop. Frostbite. And on...and on...and on...

By mid morning, we were swamped. And I loved it. All twelve beds were filled and the waiting room was starting to spill over. The multiple ambulance runs to pick up and drop off ill patients created a steady, rhythmic sense of humming chaos. Despite the craziness, the staff I was working with (many of them friends from my childhood) continued to smile while pushing onward. I was proud to be part of such a team, their hardwork quite evident. We were providing excellent care in a very efficient manner, discharging and admitting and transferring patients left and right.

So, was it really a surprise to me to find that, eventually, all good things come to an end and this run of busy but gratifying work would be interrupted by something unpleasant? I guess not, although I could still hope, right?

The unpleasantness came early afternoon, in the form of a man's booming, angry voice resonating from the hallway. I had been in Room 2 at the time, examining a new patient, an elderly female with dizziness.

"If you'll excuse me, maam," I said, "I need to go see what's going on in the hallway."

I left her room and shut the sliding glass door. Several nurses were in the hallway already, standing in front of a 60ish man, his mouth moving while he leaned forward into his walker. The obvious source of the angry yelling.

"Excuse me, sir," I said, walking between the nurses and right up to him, "what seems to be the problem?"

If any of you have seen the movies Grumpy Old Men and Grumpier Old Men, picture a shorter version of Walter Matthau with slightly more gray hair peeking out from his baseball cap. A pinched-up face. Angry, flaring eyes and a reddened, ruddy complexion. His flannel shirt was untucked from his blue denim pants. And his hands were balled into fists while maintaining his grip on his walker.

Those angry, flaring eyes didn't take long to focus on me. "Who the hell are you?" he asked, practically spitting on me with his disgust.

"I'm Dr. Jim, the emergency room doctor on shift for the day," I said, keeping my cool. "And you are...?" I deliberately left the question open.

"I'm the God-damned boyfriend of Room 6, if any of you lazy sons-of-bitches care," he screamed out, "and I need somebody from this God-damned first-aid station to tell me what the hell is going on with her."

I was surprised at this man's behavior, wondering to myself if he had tipped a few back during lunch. The level of rudeness and obnoxious behavior I encounter through my shifts continues to amaze me. Trying to placate this man would turn out to be an obvious failure.

Room 6, this patient's girlfriend, contained a woman in her 60s who had lingering burping and belching for six months. Today, this day of stormy weather, was the day she decided to pursue her symptoms, for no other reason than just "because I figured it was time to get checked out." She was right to come in, since her EKG revealed signs of heart ischemia that were confirmed by her elevated cardiac enzymes via blood work. I had seen and treated her immediately upon her arrival to our ER, as well as checked-in with her multiple times, making sure her symptoms had resolved and explaining the results of her tests. Currently, the cardiologist was on his way to the ER to make further recommendations.

At no time during this woman's hour stay did a boyfriend present himself. She had been in the room alone.

"Sir, keep your voice down," I told him, "we have a lot of sick patients in this ER today. And when did you get here," I continued, "since I've been in your girlfriend's room multiple times in the past hour."

"Me, too," piped in Marsha, the patient's nurse.

"I just got here," he said, shaking his head in disgust, "and nobody made it a point to explain things to me." He continued to rant and rave, insulting anyone associated with the small rural hospital.

"That's not true," Marsha disputed, "I explained everything I knew to you, just a few minutes ago, after you walked into your girlfriend's room. I even offered you a chair, coffee, a blanket."

"Regardless, sir," I said, proud of Marsha, "you could have asked in a much better way than walking into the hallway and screaming like this for everyone to hear." He eyed me up, surprised at my confronting him on his behavior. "Now," I said, "these are your two choices. Either leave the department and wait in the waiting room, or go back into your girlfriend's room and act like a gentleman. After she answers your questions, I'll be in to answer anything further. With her permission, of course."

There was a standoff. He eyed me. I eyed him. The nurses all held their breath. Finally, he spoke. Or yelled. "Screw you. I'm going to go, God-damn it, and feed her God-damn mutt of a dog. But I'll be back," he said.

Before leaving, he tried one last parting shot. "I envy your God-damn generation," he muttered, "none of you know what hard work is. Not a single one."

Well, I thought back to my 14 hour days working with my father's crews in the woods when I was a teenager. I thought about waking up in my childhood on Saturdays and Sundays to cut and stack firewood and cut grass. I thought about the numerous chores our parents expected of us. I thought about the endless sleepless nights I spent, first studying through college, then medical school, and finally through residency, before some semblance of normalcy finally arrived to my life.

"Sir, you don't know me or any of the nurses, do you?" I asked, sweeping my hand towards them. He nodded "no." "Then how," I continued, "can you say such a rude thing? I would never consider insulting you the way you've insulted our staff. It's not necessary and your bad attitude isn't helping anyone. It's time for you to go."

"Well," he stammered, "even if you aren't lazy, most of your God-damn generation is."

And with that, he continued on his way out of our "first-aid station," decorated to celebrate the joy of the wondrous holiday, shaking his head in disgust until he walked through the waiting room doors.

After he left, our staff regrouped in the nursing station. Amazingly, not one person was affected negatively by this gentleman. Everyone had the good sense to dispel his insults and demeaning behavior without a second thought. "I can only hope," I warned them all, "that I'm not that grouchy when I get older."

I visited Room 6, the girlfriend. She was still clear of all her symptoms, but looked teary-eyed. "I'm so sorry for his behavior," she said, obviously hearing the conversation that had just occurred in the hallway, "he's like that all the time. But Doctor, just so you know, your staff treated me wonderfully today." She assured me, upon my questioning, that she was safe and not being abused physically. She declined any counseling offers. "He's a dog with a big bark and no bite," was how she put it. I wanted to ask her "Why?" Why in the world would she stay with a man so unpleasant, so abrupt and obnoxious? But I didn't. We all have our reasons for living our lives the way we do, and she was no exception. Besides, the world was continuing to revolve and I was needed in several other rooms.

An hour later, Mr. Crank was back. Before even entering his girlfriend's room, he walked himself right through the nursing station, stopping on its edge. "Now what the hell is going on?" he yelled, lifting his walker from the floor before banging it back down, startling me from the chart I was working on.

And the conversation continued as before--him insulting our staff and hospital with vulgar language, me giving him the option of either going to his girlfriend's room or the waiting room. In my book, this was his last chance, and I conveyed it respectfully to him.

He walked to his girlfriend's room, entered it, and shut the glass door behind him. Surprisingly, he was only in there for a minute or two before opening the door, walking into the hallway and out the ER while muttering to himself. Whereas before he had conveyed, with his body language, some misplaced pride, this time while walking past our nursing station he looked like a man who had just been brow-beatened. No doubt, the girlfriend had the last say in this matter.

Throughout this holiday season, we will have many opportunities to spread good cheer and love. Compassion and kindness. And endless smiles. Or, we will have opportunities to spread poison and malignant anger. Hurtful words and deliberate insults. And pinched-up frowns.

The choice is yours. The choice is mine. Just remember to pause and look at the infinite garland, the Christmas trees, the stockings, and the candy canes--all of the beauty of the season that surrounds us. Notice and acknowledge the smiles on the faces you pass. Remember your inner child's spirit and reflect on the deeper meaning of this holiday.

I can only hope your choice fills your heart with warmth.

And I wish for nothing less for Mr. Crank.

As always, big thanks for reading. Despite our respectful attempts to break through Mr. Crank's grumpy exterior, we were unsuccessful. Darn it! I hope this finds you well and ready for the holiday season and all it brings your way...see you early next week.

Thursday, December 2, 2010

I Got Me Some Flu

I am one of those people who has avoided the flu shot, at least for the past six years. Outside of diligently receiving it during the few years that my son, Cole, and my mother were on chemotherapy, I find that the constant bombardment of exposures to various infections during a typical shift in my emergency department has given me the small doses of immunity needed to remain healthy and infection-free.

Although I'm not one to ascribe to the notion that the flu vaccination is the cause of a multiple sequalae of ailments after receiving it, several years ago I myself had developed an odd peripheral neuropathy after my third yearly shot. After multiple MRIs and blood work, including a spinal tap, failed to reveal the reason, I have since avoided the flu shot on this basis. And my peripheral neuropathy, thankfully, is a thing of the past.

Do I think the peripheral neuropathy was due to the flu shot? It depends on the day you ask me. After witnessing the flu shot being blamed for everything from causing heart attacks to promoting cancer, though, I was hesitant to put the blame on it for my own symptoms. I was young (in my thirties), healthy, and in great physical shape. I was admittedly stressed out, however, between Cole's relapse from remission and my mother's battle with leukemia, all the while desperately struggling to show the world nothing but a smile on my face. We all know how important a healthy mental state translates into physical well-being (known as "psychosomatic" in the medical community), so I had obvious other reasons, besides receiving a recent flu shot, to suspect my body's failings.

That said, I think the flu shot is a wonderful option for people who pursue it after an informed decision, and I have no doubt that it is responsible for saving a significant number of lives, especially those from the populations of being elderly, young, or immunocompromised.

It's just not for me.

Recently, after having several days off during this past Thanksgiving holiday, I returned to work, on Sunday, only to learn that the nasty GI bug had exploded in our community. Diffuse abdominal cramping, nausea with uncontrolled vomiting, diarrhea, fevers, aching muscles, headache--it seems this little bug was responsible for a multitude of holiday gifts to a multitude of people from every background. Gifts, unfortunately, that kept on giving. According to one of our senior resident physicians, during his prior day's shift, he treated twenty patients, seventeen of which had this flu syndrome. And, it seemed, the virus was working its way through our staff.

Uggggggghhhh. Welcome back to me.

I took every precaution I typically take before starting my shift. I got the industrial, kill-everything wipes (in the container warning to wear gloves before touching them) and wiped down my phone, my computer and its keyboard, my workspace counter, my pen, my stethoscope, my chair handles, etc. If there was a chance I was going to touch it during my shift, it got wiped. I may have even gone overboard, obtaining a clean bed sheet, folding it several times, and putting it on the cloth chair I was using. In my mind, I ridiculously believed I had effectively halted any bug from climbing from the navy blue seat, through my khakis, through my underwear, to my skin, where it would multiply and overtake me, unselfishly sharing all of its pleasant symptoms with me. I'm surprised at myself, on hindsight, that I didn't soak the bed sheet in ammonia first.

I'd be damned if I was going to get that nasty flu.

As usual, I made sure to put on latex gloves, from the hallway station, before entering any patient's room. Every time. Without exception. I wasn't going to be shaking any hands or touching any bed railings if I could help it. When necessary, I also donned a mask and disposable body gown, rendering me as a wrapped mummy. You can only imagine the screams from the pediatric patient who, on a normal basis, suffers from white-coat syndrome now being approached by a tall blob of a person bulkily wrapped in pastel-yellow paper, purple latex gloves, and a light-blue mask, two eyes peeking out of its top border. I think I would probably scare myself, even.

For added precaution, to make sure I didn't pass anything on to my family, I stripped myself immediately after walking into our mudroom from a shift, depositing my clothes in the washer and running quite briskly through the house to our bedroom shower, where I proceeded to scrub myself down. I'm hopeful I won't hear from any of our neighbors claiming to see, through our house windows, a naked man running around. Make that a sexy naked man, thank you very much.

So, after all of my precautions and not getting the flu for the past six years, I was pretty confident that I wouldn't be one of the unfortunate many getting ill during this recent outbreak. Nope, not me. Get out of here, you nasty bug, and find someone else to populate a new colony in.

Fast forward to my third and final shift. Tuesday evening. Eight hours into my ten-hour shift. Me, sitting at my computer in my tan cords and long-sleeved rugby shirt, happily typing in orders on yet another patient, thinking about having off the next four days.

And suddenly, just like that, I heard it. And then felt it. A loud gurgle, followed by a wave of cramping. "On no," I thought to myself, "it must be the fish sandwich and steak fries I ate for dinner." How easy our minds can hide the truth from us, sometimes. Despite my denial, the gurgling continued and the cramping waxed and waned. Finally, the shift over, I drove home, mumbling useless prayers, barely making it into my house before visiting the bathroom.

What a great way to spend a few days off! After missing basketball practices with my son and youngest daughter, skipping family meals, taking numerous small sips of water with repeated doses of ibuprofen, and imbibing in several warm baths followed by extended naps (yesterday from 1 p.m. to 5 p.m.), I am actually able to stand up from bed this morning without getting dizzy. I am hopeful that the cause of these past two days of misery is now on its way out.

I even missed writing group last night, which speaks volumes of just how miserable I was.

Are there any benefits to having the flu? Heck yeah. Like I just mentioned, the warm baths and extended naps. Trust me, those two things alone almost made being sick worth it. And being pampered by the family; for example, having a cup of tea made lovingly (after threatening to lick her face) by my youngest, Grace. However, if I am being honest, I don't think I was pampered nearly enough by my kids or wife. Whether it was simply avoiding me to prevent getting the flu themselves, or possibly avoiding my incessant manly whining, I'm really not sure. A moan from me, though, was more often met with laughter rather than concern. Maybe I was imagining it, in my febrile delirium, but I don't think so.

When I'm done finishing this post, I may go lick the clean rim of my wife's coffee mug before replacing it back on the shelf. That would teach her to give me more lovin' when I'm near-death.

Not really, of course. After all, at some point during my recovery, she and the kids carried up all of the numerous boxes of Christmas decorations from the basement and began to transform our house into a welcoming winter wonderland. What an appreciated, beautiful sight for me to behold after being bed-ridden for a few days.

If anything, though, now I may just have to reconsider the flu shot.

Oops, I have to run--the bathroom is calling for me. I hope this finds you all flu-free and healthy during this post-Thanksgiving season.

Flu shot or no flu shot? That is the question...

I'm back. As always, big thanks for reading. I hope you all had full bellies during this past Thanksgiving holiday. See you soon.

Monday, November 22, 2010

Extra Cream And Crescent Moons

I just realized that I have passed my one-year anniversary for my blog, StorytellerDoc. It has been an amazing ride, thus far, and I am grateful for all the amazing positives and new friends that have come my way with this endeavor. Thank you... Now, for a post that drifts way off my beaten path.

I pride myself on working hard to stay in good physical shape and maintaining a healthy lifestyle. This, despite my love of scoop Fritos and Nibble With Gibbles potato chips. I come from good genetic stock, however, which makes "fighting the fight' a bit easier. Regardless, though, my frequent trips to my fitness club are a mental necessity with physical benefits that I've grown to rely on in keeping some sanity with my often stressful job.

I've been at the same club for thirteen years. And in those thirteen years, I have seen many new faces and also continue to see many familiar faces. On days when I don't really want to be there, it is nice to see that familiar face pushing themselves at one of the weight stations. Especially when that face is worn by an 80 year-old woman who is kicking ass at the leg abductor machine. Or the middle-aged guy who just finished doing twenty pull-ups.

Some of those faces, both new and old, I have also seen in the ER as patients. For that reason, I often wear a baseball cap pulled down quite low, just edging my eyebrows. Believe it or not, I was more embarrassed to run into the college girl who I recently treated for PID than she was. At least I know not to follow her on the machines she just sat at. Even more necessary, I plug my Koss earplugs into my mp3 player and crank some great, energetic music. That way, if a former patient wants to talk to me about their thrombosed hemorrhoids or that nasty fungal infection that just won't go away, I can feign not hearing them. "What's that, sir?" or "Did you say something, maam?" I may have been guilty in saying that once or twice during a workout.

A few years back, my gym started a program, I think it's called "Silver Sneakers," which gives elderly people a membership discount, encouraging them to work out. This is all good and fine. In fact, I look at some of these remarkable people and am truly inspired by their effort and commitment. However, I like to work out at the same time (mid morning to early afternoon) as the Silver Sneakers folks do, which at times has begun to frustrate me.

Let me reiterate here that I truly am impressed by most of these folks. I can only hope to be in my 70s and 80s and push myself the way some of these people do in the club. But, darn it anyway, some of them are causing me to think about joining another gym. And I'm a creature of habit. After thirteen years, I don't want to join another facility. But here's why--and if any of my following supportive arguments upset you, I apologize for it beforehand.

Several months back, I began to notice that sometimes walking into the men's locker room, before starting my workout, held a dangerous risk. The entrance to it has a C-curve, which prevents those out in the gym area from getting a direct view. Unfortunately, upon walking in, I have been greeted one too many times now by the naked old guy, just finishing from his shower, standing in front of his locker, bent over, drying his toes. And more drying. And still, more drying. I didn't know that drying your toes (did I mention naked?) can be a ten-minute ordeal. But for some, I guess it can be a meticulous process.

So, just go along with me here. Are you picturing the guy? Because, while he is drying his toes, his weighty scrotum with its ten-pound hernia is swinging back and forth, welcoming all who enter the locker room to have a great workout. Trust me, it's hard to be inspired to work out after that. Really, if that is what I have to look forward to in another thirty years, I may just pack it in now.

I have also witnessed many men clipping their toenails (some while sitting naked on a stool). So sometimes, either standing in front of my locker or trying to walk through to get to my locker, I haphazardly step on little slivers and shreds of discarded nails and cuticles. What the hell is this? I actually have a buddy who left the gym because of this. Me? I am made of stronger stock, I guess, than my buddy. I still feel the need to complain about it, though.

Anyone need any talcum powder? Cologne? There is plenty of that after a shower, too. Unfortunately, though, it's not mine. Nothing, and I mean nothing, freshens me up better before a workout than to walk through the obnoxious cloud of baby powder and cheap cologne. I have actually worked out before and thought to myself, "What is that stink?," only to realize that the stink was me. And I don't even wear Stetson cologne!

Just a few months back, I walked into the locker room to be welcomed by another naked man, bent over, drying his toes, with his pendulous scrotum wishing me a "good morning." All well and good now, since I am becoming immune to such greetings. But this guy, at least 80, had something I haven't seen before on the Silver Sneakers folks. Because of the club's free tanning promotion, this guy had an all-over tan--all over except for two very pale half-moons at the inferior creases of his buttocks. In laymen terms, he had two curvy spots of non-tanned skin from where his ample ass doubled-over while he was laying in the tanning bed. If I only knew his name, I would probably tell his family on him.

We interrupt this post to bring you a joke. Someone, please turn on my microphone (tap, tap--okay, it's working). Imagine me talking to this guy's grandkids. "Hey kids," I could say, "what is one-half moon plus one-half moon?" The kids would yell out their answer, "One!" "Nope," I would answer, pausing to build their anticipation before answering, "one-half moon plus one-half moon doesn't equal one, sillies, it equals your grampa's ass!" Well, maybe they would be right--grampa was showing me his full moon.

If that wasn't bad enough, last week when I walked into the locker room, there was actually a naked gentleman with his left leg drawn up onto his stool, actively squeezing hemorrhoid cream in his buttock's crack. I kid you not! At least I think it was hemorrhoid cream. I was horrified, hurrying past him before he could ask me to help him out or, better yet, accidentally spray some cream in my eye as I walked by. What's next, the public insertion of a suppository?

Although I view being observant and cognizant of my surroundings one of my best strengths, especially in the ER, I am learning that I may just need to put on some blinders the next time I pull into my gym parking lot. That way, I won't notice any more of the following:

The woman in spandex walking around the track with a saggy, incontinent bottom.
The crescent sweat stain on the seat of the weight machine from the person before me.
The gentleman who's comb-over is not combed-over while he does the bench press.
The fashion trend of wearing two different socks with your walking Reeboks.
The extremely curly hair that is on the water fountain push button.
The inadvertent forgetfulness of putting on a bra before working out.

Should I go on? Trust me, there is a lot more. Or do you get the idea?

Regardless, I am extremely proud of all of my fellow gym-mates. After all, despite any of my misgivings, they are there, at the gym, giving it their best in maintaining good health. Good for them, I say. And because of this, I have never once gone to the front desk and complained. Nor would I. If I did, I wouldn't have anymore of those special "Good morning!" greetings upon walking into the locker room. I just need to get over a few small issues, I suppose.

On second thought, if you'll excuse me, I'm going to go fill out my membership form for Curves.

See what so many years in the ER has done to my sense of humor? As always, big thanks for reading! Please come back... I hope this finds you well and wishing you a good week. Jim

Monday, November 15, 2010

The Pit Stop

I walked up to the closed door and paused , exhaling a deep breath weighted with disappointment, trying to clear my thoughts for the conversation about to come. My clenched fist was briefly suspended, mid-air, ready to knock. Beyond the door, I could hear muffled conversation and movement.

A calm, pretty woman stood beside me. An emergency department case manager. She held a notebook and pen, ready to jot down any useful information that might be shared with us by the room's occupants.

I turned to the case manager. "Are you ready, Cindy?" I asked, making sure she was prepared for the gravity of this unfortunate situation. She nodded "yes," confident in her skills during such adversity.

I turned back to face the beige, chipped door of the family room and knocked lightly. The noises of conversation and movement suddenly ceased, and I could easily imagine the stillness and anticipation that pervaded the room.

I rotated the door handle, gently pushing the door forward before stepping into the room. The air and energy of the room were stale and suffocating, especially after leaving the hallway atmosphere of chaos. My eyes darted quickly, taking in the whole of the room. On the couch, two elderly people, a man and a woman, sat on either side of a middle-aged woman, their hands linked in unity. The two corner chairs were filled with a middle-aged man in one, a college-aged boy in the other. All five people focused intensely on our arrival, their dilated eyes wary for the news I was about to bring them.

Before sharing my news, I briefly introduced both myself and Cindy and learned that this room contained the patient's wife, his in-laws, his brother, and his son. After shaking hands, I deliberately continued to hold on to the wife's hand while her father rubbed her back.

"It's not good, is it?" the wife asked me. I shook my head "no" to her question before saying the word out loud. "No," I reiterated, "it's not good. Despite all of our attempts, we can't seem to get your husband's heart beating again."

I had left Room 17 for the family room with a dismal feeling. The woman's husband, in his late 50's, had collapsed at work and, despite being intubated, having immediate CPR and being given all the appropriate life-saving medications by our prehospital team, still had not responded to any medical interventions. He had arrived at our facility ten minutes earlier, thirty minutes after his collapse. After several attempts of high-Joule defibrillations and multiple escalating doses of medications, our team remained unsuccessful in our resuscitation attempts. I had left his room with the patient in asystole, a malignant situation where the heart was not making any electrical signals to stimulate itself to beat. It was not looking good.

For the next several minutes, I explained to the family, with earnest, what our medical team was doing in attempts to resuscitate their loved one. After I finished, the wife stood from the couch and dropped to her knees, half in prayer and half in disbelief. "Please, Gary," she wailed in a desperate voice, "don't leave me yet. I want to talk to you one last time."

After helping her back to her feet, I offered her to come to Gary's room with me to be with him during our resuscitation efforts. She accepted.

The patient's wife, Cindy and I walked back to Room 17. As we neared it, I explained the focused commotion she would witness when we walked into the room--three nurses, several techs, a senior resident physician, a pharmacist, a respiratory therapist, and several others all scurrying in their efforts to help her husband, who would be lying on his cot in the middle of all of this activity.

I pulled back the curtain to the room and walked in, surprised to see that CPR was not currently in progress. I introduced Gary's wife to the team and guided her to Gary's side before seeking out my chief resident as to what transpired in the last few minutes. It seemed that right before we had entered the room, Gary 's heart rhythm had switched from asystole to ventricular tachycardia, another life-threatening rhythm. However, this rhythm responded to our team's electrical shock and Gary, still unresponsive, now had a faint pulse accompanied by a normal sinus rhythm. After being down for forty plus minutes, this was nothing short of a miracle. A well-timed miracle corresponding to his wife, on her knees in the family room, pleading with him to hold on.

We encouraged her to talk as much as she wanted to her husband.

And so she did. With tears brimming her reddened eyes, she remained near her husband's left ear, continuously whispering her hushed encouragements and pleas while stroking his hair. Soon after, her son and the patient's brother also were escorted in to be with the patient. Their expressions of disbelief as they walked into the room were heart-breaking.

We called the cardiology team who, after arriving at this patient's bedside in minutes, prepared to take him to the cath lab. Unfortunately, his outlook was tenuous. I was skeptical, after 45 minutes of resuscitation, if Gary would have a positive outcome. Even if he survived, there was no predicting how mentally capable he would be after such a long time in cardiac arrest. If not to survive, why else would he be hanging on?

Suddenly, I thought back to Gary's wife dropping to her knees, begging for a last chance to talk with her husband. I thought of Gary and how, out-of-the-blue, he suddenly regained a faint pulse after multiple failed previous aggressive attempts to jump-start his heart. I looked at his wife, his brother and his son currently holding Gary's hands and whispering their loving words into his ear.

Was this the reason?

I was searching for some sense in this nonsensical situation. Possibly, I realized, I might have been over-analyzing the whole situation, trying to understand how Gary could possibly still be alive. Quite frankly, though, after 45 minutes without a pulse, Gary should not have been successfully resuscitated. Was the whole reason of Gary's lingering due to something beyond our control--the fates cooperating to let his wife and family have several more minutes with him? For proper goodbyes? Or was it because his body really was responding to all of our heroic measures and would heal itself with our modern interventions?

I was eager to know how our efforts would be interpreted by fate. Watching Gary being wheeled down the hallway, from Room 17 to the cardiac cath lab, with his family by his side, I was hopeful that there might be just a sliver of a chance at his full recovery. If not, though, just seeing his family have the opportunity to be with him, to speak to him, to accompany him so he wouldn't be alone during his passage, was enough of an explanation for me.

I got my answer when I returned for my scheduled shift the next day.

Although Gary had still been alive at the end of my previous shift, he never regained consciousness. Per Cindy, he peacefully passed soon after, in the evening, surrounded by his loving family.

He had hung on for all the right reasons...

As always, big thanks for reading. I wish much peace for Gary's family. I also hope this finds you all well. See you again later this week...

Wednesday, November 3, 2010

The Willing Caregiver

I imagine the world as a vast, boundless frontier weathered by our swirling human emotions and complicated energies--hurricanes of intense heartbreak and tornadoes of joyous, unbridled celebrations, with every weather pattern in between. Sunshine and rain included.

If I could gather this world, foolishly believing that I could sweep my arms and hands through the unsuspecting air to collect a smaller, more-contained version of reality, I know with absolute sureness that what I would be left with is a typical day's worth of experiences in the emergency department. It is a microcosm of something similar to big life.

So many patients, so many illnesses, so many human interactions. So many words of comfort. So many experiences bombarding us daily. And try as we might to protect ourselves, building brick-by-brick our fortress of emotional barriers, ultimately, we cannot help but let some of our patients weave their very own threads into our personal life blankets.

I walked into Room 20 to treat my next patient, a woman in her mid-seventies. Because of a life-long battle with diabetes and its resulting circulatory problems, she was now permanently wheelchair-bound. She sat upright in her cot, in a hospital gown, without any blankets covering her. At the base of her right thigh, poking out from her gown, was a puckered-up cork of skin, where her leg had healed from an above-knee amputation. On her left-side, her leg extended just slightly lower, below knee-level, where, again, the rest of her leg had been amputated secondary to gangrene several years prior.

She was petite and frail. Despite a high fever and feeling ill, she sported a recently washed-and-set hairdo. She also wore some light makeup and dark lipstick, appearing well-cared for. The smell of her room, however, suggested otherwise--it permeated with the familiar stench of a Depend diaper that was overdue to be changed, most likely saturated with stale urine.

In her room's corner, sitting quietly and patiently, was her only child. A son, probably in his late-forties to early-fifties. He appeared fidgety at times, but was very attentive to both myself and his mother. He was, as it turned out, his mother's only living relative.

And her primary caregiver.

"Hello," I said to both of them, extending my hand to shake first the patient's and then her son's. "I understand you're here because you don't feel well, Mrs. Smith. Is that right?"

"Yes," she answered, slightly nodding her head as she spoke in a high-pitched, whispery voice, "I think I probably have a urine infection." She was probably spot-on, since that can be one of the most common causes of illness and fever in an elderly woman. She went on to explain the burning she experienced with recent urinations and her need for wearing Depend diapers because of the resulting incontinence.

"Have you had a urine infection before?" I asked her.

"A few months ago, yes, but otherwise I've been lucky, knock on wood," she answered, lightly knocking her closed fist against her imagined wooden temple. She then went on to explain to me that her right stump had healed beautifully from her recent surgery and had little reason to suspect that this might be the problem.

After reviewing the rest of her history and performing a stable physical exam, I ordered the patient's tests. And sure enough, she had a UTI, just like she suspected. With the help of some Tylenol, we were able to break her fever and by the time her blood results returned stable, she had been cleaned up and was feeling much better, with an IV dose of antibiotic finishing its run into her left arm's receptive vein.

I explained the results to her and her son, who, despite his mother's good response, had remained quietly sitting in the corner. He was edged forward on his seat, however, as if eager to say something.

"Sir," I said, "you look like you have something to say."

"Well," he said, glancing between his mother and myself, "do you think it's my fault that Mom got the urinary infection? I'm still learning how to help care for her."

"Michael," the patient answered quickly, "of course not. These things happen."

I liked her answer, but his question opened a floodgate of mine. "Why would you ask that, Michael?" I asked him, intrigued.

As it turns out, Michael, this patient's successful, independent son, had sold his out-of-town condo, sacrificed a current relationship, and moved back to our region and into his mother's home, all to take care of his mother after her second amputation.

"Do you have a medical background, Michael?" I asked him, amazed at his devotion. He nodded "no" to my question. "Have you ever been a caregiver before?" I continued, fully understanding just how much weight now sat on his shoulders.

The patient chimed in. "I told him to stay put, but he wouldn't hear of it. I feel bad he's halted his life to help me with mine."

"Mom, I wouldn't have it any other way. You talked me out of returning after your first surgery," he spoke shyly, pausing to nod at her left leg, "but there was no way I was going to stay away after this recent amputation. Unfortunately, I think your urine infection is from me not cleaning you well enough."

Now, imagine being a grown child, with no previous caregiver experience or medical background, halting the life that you've created only to move in with your sick parent. Your parent of the opposite sex, no less. Assuming care that included bathing responsibilities, bathroom runs, feedings, cleanings, appointment dates, and on and on and on.

And on. This was role reversal at its most intimate level.

Michael became an official caregiver. A frightening word for some, a privileged word for others. Regardless, it is a word that many people rightfully now use to describe themselves. Whether it be a sick child, a parent, a spouse, a partner, a grandparent, a relative, a neighbor, or a friend, there are currently 49 million people in our country who provide care in either a professional or personal sense.

Suddenly, I looked at this son in a new light. With no obvious agenda, he was doing what he felt was the right thing for his needing parent. And with his new responsibilities, he was going to be facing a whole new world of emotional weather.

Without any warning, my memories transported me back to when my father, my six siblings, and myself committed ourselves to providing 100% of Mom's home care during her last few months of battling leukemia. Although filled with much learning and many surprises, I think I can say that we all became extremely appreciative of the effort involved in taking total and complete care of a loved one. We were grateful for the experience, though none moreso than Mom, whose beauty and bravery during her last few days only magnified under our personal and steady care.

The patient spoke again, bringing me back to the present. "Michael," she said half-heartedly, "I wish you would have just agreed to put me in a nursing home like I wanted you to do."

"Mom," he responded emphatically, "I won't hear of it. At least not now. If things get too complicated, then we'll talk about it again. But wouldn't you rather be home, still? Seriously?" The patient took her time answering. "Yes," she finally admitted, "yes, I would rather remain home. But not if it means you are going to stop living your own life."

"I'm fine with it, Mom. I would never have moved back if I wasn't. And quite honestly, there is no where I would rather be right now than here, helping you the best I can."

Their smiles reflected off one another while another brick crumbled and fell from my fortified emotional barrier.

I finished the patient's treatment with a case management consult to ensure that Michael and his mother would benefit from several available resources, including home nursing visits. Walking out the door, I wished them both luck. But before leaving, I had to ask. "Michael, did you help your mother with her makeup, hair and clothes today?"

They both laughed. "Yes, he did," the patient answered. "How do you think he did?" Now it was my turn to laugh with the patient and good son. "I think he did a darn good job," I answered, "you look very nice, maam." I turned to Michael. "Well done, buddy." And I'm sure he knew I wasn't talking about how his mother looked that day.

Now, if only he would learn how to change a Depend diaper...

As always, big thanks for reading. And especially for bearing with me through a few weeks of barren writing. Much happening, but all good. I dedicate this post to all of you who have intimate knowledge of the sacrifices and hardwork necessary to be a great caregiver. See you back in a few days...

Friday, October 22, 2010

Kung Fu Fighting

I love a distraction. Especially in the ER. Sometimes the distraction can be subtle and minor, one that I have to search out to find. Other times, though, a distraction can be glaringly obvious, practically smacking me in the face. Whatever the diversion, these moments can make a hectic, chaotic day in the ER much more tolerable. Not to mention fun.

Although it's usually the patients who provide the main attraction, occasionally it can be the waiting family or friends of the patient. For example, Aunt Alice's nose mole and smeared lipstick might make me do a double-take, detracting from the attention I would otherwise have given her nephew, the patient. Grandpa Ben isn't fooling anyone about his gas problem either, sitting over in the room's corner wearing a smug smile, shifting around on his chair before releasing another foul air biscuit.

The possibilities of distractions are endless and, quite frankly, most welcomed by my receptive self.

A few weeks back, I had a two-for-one zinger--both an intriguing patient and her entertaining boyfriend. The patient herself had a significant history of anxiety, bipolar depression, and schizophrenia and, while at an appointment at her mental health clinic, she had become extremely anxious and began to hyperventilate, ultimately passing out. This lead to her trip to our ER via the ambulance service. Her boyfriend, I was told, met her after she arrived.

Walking into Room 22, I found an anxious-appearing, thirty-ish, blond woman with extremely poor dentition. In fact, one of her front teeth was angled outward, barely hinged to her gums, and her tongue seemed to constantly caress this wayward tooth. Her blue eyes seemed out of focus, glazed-over even, probably a result of the valium given to her by the prehospital team. She fidgeted with her hands while her right foot rhythmically rubbed up and down her left shin. Her room smelled quite strongly of stale cigarette smoke.

Standing in the obscure corner of the treatment room was this patient's boyfriend. He was a small man, maybe 5'5", balding with a gathered ponytail. As I took his appearance in, he looked shyly down at his feet while pressing his hands together in front of him, prayer-like. Interestingly, he had no shirt on, just sandals and some worn jeans. His chest was sunken-in and fuzzy. His abandoned white t-shirt rested on the room's only counter top.

Between the two of them, I would have been quite content to spend the rest of my shift hanging out in their room, people-watching. I had a feeling that this interaction would be a memorable one.

The patient eyed me suspiciously as I approached her with my hand extended, ready to introduce myself. While in the middle of saying my name and explaining that I would be her doctor during this ER visit, I heard a loud exhalation followed by a hum originate from behind me, from the corner where the boyfriend stood. Quite frankly, it startled me.

I turned my head to look at the boyfriend, only to find him performing exaggerated motions of what I assumed to be some form of martial arts. After several moments of unorganized, flailing movements, he quit humming and folded his hands back together, bowing his head to me. Although I'm sure he didn't mean it to be, his actions and behavior were quite comical, and I fought myself from laughing out loud.

"Eddie," the patient shrieked, bringing my attention back to her, "cut that shit out. I ain't gonna watch your bogus karate while I'm lying here sick."

At this, Eddie began to hum loudly (again), keeping his head bowed, his hands folded, and his eyes closed. Suddenly, though, as if an "on" button had been pushed, he launched into another routine of air karate, randomly slicing and jabbing his hands while awkwardly kicking his feet outward. For his grand finale, he did a spin kick, almost tripping and falling to the ground on his landing. After collecting himself, he again folded his hands, bowed his head, and nodded to me before closing his eyes.

Funny, but I didn't feel threatened or in danger. I was, however, completely and totally mesmerized.

"Eddie," screamed the patient again, "if you do that one more time, I'm going to climb out of my bed and come over there to kick your ass. Got it?" Eddie apparently didn't, or else simply chose to ignore the patient's threats, remaining in his deep meditative state.

I tried to diffuse the situation. "Eddie," I said, smiling, "that's some really good stuff. Are you a professional?"

I had barely finished my question when the patient chimed in, laughing hysterically at my question. "Professional? You've got to be kidding!" she exclaimed, now choking on her words. "Hell, he's just making all of this shit up as he goes along."

"Well," I said, "his routine sure impressed the heck out of me." I was telling the truth, too. His routine was unlike any I had ever seen before.

With this, Eddie bowed forward again, I assume in thanks of my words.

"Bullshit," the patient said, emphatically, "he doesn't know shit about karate or anything else. Tell him, Eddie." I looked from the patient to Eddie and, after he remained silent in his own world, back to the patient again. "Oh, that's right, I forgot," she added, now sarcasm dripping from her words, "you don't talk during your karate sessions. How could I have forgotten?" She rolled her glazed eyes as she spoke.

Ouch. For her sake, I could only hope that Eddie would never try out his routine on her.

They became the couple of the moment in our ER. When they were alone in their room, there seemed to be a quietness, a calm, to the area. But the moment someone, anyone, walked into the room, the show began. A loud exhalation by Eddie. Humming. Eddie's routine of his remarkable abilities, capped off by his spin kick and landing. The bowing of his head and folding of his hands in conclusion. The girlfriend's free earful of screaming at Eddie for his ridiculousness. The exit of the person who entered.

The nurse walked out of Room 22, shaking her head and laughing after witnessing this same show that I did. So did the x-ray tech. And EKG tech. "Is this for real?" I heard several of our staff ask, after checking out the scene on their own.

"It is," I assured them.

After clearing the patient with a good physical exam and several tests, we quickly discharged her, if only to get Eddie out before he hurt someone or himself.

You can't buy a ticket for this stuff. And you surely can't make it up. The only thing you can do, really, is appreciate these distractions that come with a job in the ER. Well, that and closely inspect the room's corners to make sure there isn't a hidden camera trying to record your response for some reality TV show. That you've been set-up, somehow.

I look forward to the next distraction to arrive. Somehow, as sure as time keeps ticking, I know I won't be disappointed.


As always, big thanks for reading. I hope you have a great, distracting weekend...

Thursday, October 14, 2010

The Emaciated Shoulder

She paced protectively beside the hospital bed and its current patient, her grown son, the mother lioness protecting her vulnerable cub. In her hand, she gripped a small notepad, a pen snugly tucked into the coiled-wire binding. Her worried eyes peered through her small rectangular frames, suspiciously watching my arrival. Without blinking, she tucked her short gray bob behind her ears, readying their acuity to my words.

She was the mother of a son infected with HIV.

I focused on the patient. He was my age, in his early forties, with mussed up reddish-blond hair. His face wore the fatigue and ravages of his illness. His temples were sunken-in, his bluish eyes dull, his teeth fragile. Although he gave an effort to smile, his sagging skin weighed down the corners of his mouth. His body was tucked and bundled to his chin with several hospital blankets. To say that he was tired-appearing would have been an understatement.

While introducing myself, I approached him with my outstretched hand. After we shook, I turned to his mother and repeated myself. She took my hand warmly. After introductions, she opened up her notepad and asked me to spell my name, writing it on a fresh clean sheet near the pad's end. I could see most of the previous pages, worn and tattered, were filled with her busywork.

"Well, John," I said, leaning back into the room's counter, "what brought you here today that I can help you with?"

Without hesitating, John's mother began to talk. "Mother," John interrupted her, "I can tell the doctor my problems on my own." I hoped that she wouldn't take his abruptness personally, instead recognizing his attempts to cling to his independence. She quickly silenced herself, slightly embarrassed, as John began to share his story with me.

In the mid-90s, John discovered he was infected with HIV. Through his diligent compliance of lifestyle and medication, he maintained an almost non-existent viral load. He worked-out, he ate well, he enjoyed life to the fullest. Unfortunately, in the past few years, his body and illness became resistant to his previous successful approach and, suddenly, he was dealing with the ravages of advancing HIV. Weight-loss, skin issues, opportunistic infections--each and every new problem was another lost battle in his war. After his most recent diagnosis of HIV-associated lymphoma, he moved back in with his mother and began chemotherapy. He was struggling immensely from both the effects of chemotherapy and his disease.

"Look, Doc," he said, unwrapping his blankets and lifting up his gown to reveal a swollen abdomen and legs, multiple tiny, kinked, bluish-veins spotting his transparent skin, "I have so much edema now that I rely on pain medication to help with the discomfort." His predicament looked painful. In fact, this uncontrolled and worsening swelling had been the purpose of his ER visit.

We talked a little longer about his life, his illness, and his recent setbacks. And through this conversation, I noticed John's mother slowly sadden and withdraw to the chair in the corner of the room. My heart went out to her--I couldn't imagine her pain, having to watch one of her children slowly dwindle from this sometimes devastating and unforgiving illness. Her anguished face, just moments before alert, now wore a look of tattered defeat.

"John," I assured him, "let me finish my physical exam and then I will order up some medications to make you comfortable." His mother wrote in her notebook as I talked.

I continued with my examination, after closely inspecting his protuding abdomen and edematous legs. His exam was difficult. He seemed to have significant findings with every system of his body, despite his vital signs begin stable.

Finally, I asked John to sit up so that I could auscultate his lungs from a posterior approach. "Can you help me, doc?" he asked, holding out his right arm to me. "Sure, John," I answered, grabbing his hand with my right hand and placing my left on his shoulder.

And that's when it hit me. Hard. Just how terrible John's predicament was. Don't get me wrong, I fully understood just how much suffering he had been dealing with recently as his body seemed to succumb to his setbacks, but touching his right shoulder had made me catch my breath.

Under the grip of my left hand, while coaxing John's worn body to sit up, the bareness and emaciation of his right shoulder astounded me. He had absolutely no bulk to it--no muscle, no fat, no cushiony subcutaneous tissue that one typically has to their shoulder contour. Nothing. All I could feel was bone. His clavicle, his humeral head, and his shoulder blade all right there. It was remarkably sad. I shifted my fingers in a futile attempt to palpate any "meat" on his bones. There was none.

After successfully sitting John up, with his mother's help on his other side, I shifted his gown off his shoulder while listening to his lungs. My eyes fixated on his shoulder's thin, transparent skin barely accomodating the stretching from his protruding bones. I simply couldn't quit looking at the fragile shoulder, a dichotomy to John's enlarged, padded ascitic legs and abdomen. What a damn, awful disease.

I left John's room and ordered his work-up and medications. Soon after, he was much more comfortable.

A few minutes later, the secretary called me. "Dr. Jim," she said, "the mother of Room 28 is waiting at the nurses' station to talk to you." I finished with a chart and walked the hallway, finding the mother leaning into the station counter, flipping through her notepad. "Hello, maam," I said, approaching her, "I understand you wanted to talk to me?"

She looked up from her notepad, closing it, while her eyes settled on mine. "Yes, doctor, I do." She paused before continuing. "I just want to thank you for your kindness to John. I know you are just doing your job, per se, but there was something more from you, something I can't put a finger on, that made us both feel very good." She choked up as she spoke.

I grabbed her hands, one of which still held her precious notepad, and thanked her for her kind words. "My heart goes out to both of you," I continued, watching her tears progress to sobs, "what an awful disease for anybody to endure." She took her eyes from mine and looked at her feet. I thought of what to say next, the words coming quite easy. "John is so lucky and blessed to have a mother like you. You opened your home, you take notes, you accompany him to all of his appointments. We should all be so lucky." I paused before finishing. "And loved."

She looked at me again, her act of the protective mother lioness long-abandoned. "Thank you," she repeated before turning and walking back towards John's room.

We admitted John for further care.

Although I pride myself on my composure through all of the emergency department's chaos, I am only human and sometimes cannot shake a patient's affect on me. John was one such patient. It must have visibly shown, too, since several of my coworkers asked me if I was okay. "No," I answered honestly, "but I will be."

At the end of the day, we are all human. We are all in this world together. We are all united by the common threads of emotions. We are all prone to the extremes of happiness and sadness and everything between. We are all in need of compassion and kindness and love.

Especially, though, those who are suffering. And John was suffering. My greatest hope for John is that he may find much love, compassion, and kindness on his continued life journey.

There is no human being who deserves anything less.

As always, big thanks for reading.

Monday, October 4, 2010

The Power Of A Voice

This morning in church, I closed my eyes to fully absorb the priest's deep, husky, richly-layered voice which emanated from the alter and, suddenly, I was transported back ten years, to a time in my life when I was buoyed by this same powerful voice, the one speaking to me now as I sat in my maple pew on this cold, rainy Sunday morning.

Ten years earlier, I had been up all night, uncomfortably spooning with my wife in a lazy-boy recliner in my son's hospital room, waiting anxiously for morning to come. Neither of us wanted to leave Cole's side. Neither of us wanted morning to come, either. Morning would bring surgeons and specialists who would transport my son to the operating room, to debulk and biopsy a neck mass discovered the day prior. A day prior that was filled with haunting, harrowing memories of being told, after several emergency CT scans, that my son had something "seriously wrong." The news of the tumors in his neck and chest, accompanied by swollen lymph nodes, had collapsed our world.

Finally, five a.m. arrived. The early light of another day, confirmation that the world wouldn't stop with our sorrow, began slivering between the room's vertical blinds. I rolled off the lazy-boy, covering my wife with our shared blanket, before gingerly tiptoeing to the crib. I watched my son's chest rise and fall, his complacent, peaceful face giving no indication of the cellular war raging in his tiny body.

I was mesmerized, surrounded by my son's clouds of pure innocence, as I clung to the bars of his crib, trying to make reason with this path my son was suddenly placed upon. I listened to his steady breathing. I watched his little eyelids flutter. I wondered at the shadows of beautiful angles that his bent limbs created under his blanket. No different than the day before and, yet, the knowledge of his devastating illness now changed everything.

Suddenly, around 6 a.m., the room's phone screamed out, ringing to interrupt my trance.

"Hello," I answered, supposing it was someone from the hospital's staff.

"Hello, Jim," the familiar voice spoke, "it's Father Tom." Of course, I knew it was Father Tom. He needed no introduction to my ears, ever. Just hearing his calm voice, resonating with love and concern, wrapped a blanket of comfort around my aching heart. He continued. "I'm calling to see if you or Karen need anything." I should have expected our beloved priest to be checking in with us during our turmoil. Just not this early.

"Father Tom," I whispered into the phone, "we're okay. We have a tough day ahead of us, though. Please just keep Cole in your thoughts and prayers through the day and we'll let you know, as soon as surgery is over, what we are facing."

"Jim," he spoke again, his voice steady and strong, "I don't think you understand. I'm downstairs in your hospital lobby. I'm on my way up to your room but wondered if you or Karen needed some coffee or a bagel, even."

"What, Father Tom?" I asked, confused. "You mean you are here? Right now? In the Children's Hospital?" The hospital was at least two hours from our home, which meant that he would have had to have left by 4:00 a.m. to get to us at this time.

"You don't think I would stay away on a day like today, do you, Jim?" he asked. I couldn't answer, my wonder and thankfulness of his presence choking my words. A few moments of silence followed as he waited patiently for my answer. "No," I finally said, before continuing, "and Father Tom, thank you."

With that phone call, on that fateful day, Father Tom's voice ingrained itself into my memory.

And from that simple phone call, Father Tom's magnificent voice continued to harmonize much of the discord in my life. That day alone, in which Cole came through his surgery, Father Tom stood in a circle with us in the family room, hands joined, offering that consoling voice in prayer and reassurance. Later, when I asked him "Why? Why? Why?" my son was chosen to bear his burden, to have to fight for his life at a young age of two, his voice cracked, one of only a few times I have heard this. "I can't answer that, Jim," he had said, "but I can only pray that at some point in Cole's life, on his journey, the answers of why will become more evident." Yes, Father Tom, I can see some of those answers already.

Through those trying years, including an additional year of chemotherapy for Cole when he came out of remission and my mother's eventual death from leukemia, Father Tom, his voice in tow, continued to grace all of our lives. Whether at our home for lunch or dinner, or whether a Sunday morning sermon, his distinguished, distinctive voice, with its classy delivery, never failed me. Even before delivering my mother's eulogy, he approached me. "The grace of God is with you," he had said, clasping my face between his hands at her funeral, "you will do your mother proud as she sits there on your shoulder with you."

Unfortunately, as with our Catholic religion, priests can be reassigned to another parish after several years of service, and this was no different for Father Tom. He moved over an hour away, assigned to another parish, too far for us to travel for services . We did surprise him one Sunday but, otherwise, relied on emails, phone calls, and rare dinners to catch up. It wasn't the same.

I had lost my spiritual guidance, of sorts. I missed the power of his voice and wise words. And I missed my friend.

Thankfully, though, Father Tom informed our family at the beginning of this past summer that he would be returning to our area, to a parish just twenty minutes from our home-base parish. I couldn't wait for the day to arrive.

Today, finally, was that day. Today, on this gloriously cold, autumn day, I was blessed to sit in church, beside my healthy son, my lovely daughters, and my beautiful wife, listening to the voice of an angel.

The missing voice that I couldn't replace in my life.

The voice of Father Tom.

As always, big thanks for reading. Anybody's voice in your life that you rely/relied on? See you midweek...

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...