Wednesday, March 31, 2010

Popsicles & Pudding

I walked by the nurses' station, casually glancing through the open doorway. Happy for what I saw, I immediately came to a halt and backed up a few steps.

Kids. Two of them. Innocent, smiling grade-schoolers. Sitting on blue vinyl-topped stools at the nurses' work counter. They were doodling in thin, grayish, hospital-issued coloring books, crayons spilled to the sides of their pages. In front of each child, a plastic pudding cup sat, a white spoon handle rising from the middle of each chocolate mess. Stickers covered the rest of their counter space, layered like replaced shingles randomly tossed from roof to ground. The kids looked happy, content.

I couldn't help but smile to myself. Another nurse had earned her wings.

As with any other profession, to be in the medical field, you must carry a certain spectrum of talents. A sufficient font of medical knowledge, of course, accompanied by a respectable work ethic. An inherent sense of the happenings in the workplace. Passion. And respect for your fellow mankind, regardless of whatever capacity you encounter them in.

Most important on my list, though? Compassion. Easily. And not just compassion, but compassion delivered with kindness. Imagine, two staff members are each giving a homeless person a turkey sandwich. One tosses the sandwich to him as he's walking out the door. End of story. The other hands the sandwich over, sharing some eye-contact and a smile, maybe even shaking hands or patting the homeless person's shoulder.

Same task accomplished. But which one delivered the compassion with kindness? Was the energy necessary to be kind in this circumstance monumental? Hardly. When I saw these kids sitting comfortably in the nurses' station, I was recognizing a nurse's compassion delivered with kindness.

As it turns out, these children were in our ER with their sick mother. Fever, vomiting, diarrhea, abdominal pain--all symptoms that made the mother nervous. A single-parent household, a single-income checking account. No local family. No available babysitters or friends. No time to be sick. No choice but to bring her two younger kids with her to the ER.

The kids were typical elementary school-age kids. Initially, when they arrived, the kids sat in the lone corner chair of the treatment room, squeezing themselves between the black, plastic armrests. While their mother changed into a hospital gown, had her vitals taken, and had an IV started, these little kids sat quietly, a little confused and a lot scared, I suppose, soaking in all the happenings. After their mother was made comfortable, the nurse ran and got each child an Italian ice and turned the television on to a suitable station for them.

Soon, as kids do, they started getting a little more comfortable and exuberant within their surroundings. The TV remote became their dodge ball. The volume was played with, the channels were flicked randomly, and some minor argument started over which child had more room in their shared chair. Finally, to help the mother get a little rest and receive her treatment in a quieter setting, the nurse removed the children, taking them to the nurses' station and setting them up with some distractions and pudding.

It worked. And that's when I happened to walk by, finding two calm, coloring kids snacking on pudding.

"Hi, guys," I said to them, looking over their shoulders at their colorings, "nice job. You both are really good at coloring."

They both looked up at me, not sure what to make of me since I wasn't their mother's doctor and they had never met me.

"Don't stop coloring on my account," I told them, "I just wanted to say that you both are doing a great job there."

They showed me their shy smiles before continuing on.

Jamie, the secretary at this station for the day, shared with me the kids' story. When she was done, I was smiling big. "Thanks for helping out with the kids, Jamie," I said, "I'm sure this wasn't in your job description."

"Not a problem" she said, herself the mother of a very nice, respectful middle-school son, "this is the fun part of my job."

Jamie told me which nurse was taking care of these kids' mother and, because I had a few free minutes, I sought her out. She was a recent graduate and had just started in our ER this past summer. Already, she had impressed me with her skills and knowledge and work-ethic. Now, I would add compassion to her list of strong credentials.

"Lindsey," I said, standing in the hallway, "do you have a minute?" "Sure," she answered, looking a little nervous, "what's up?" "It's nothing bad, Lindsey," I assured her, "I just wanted to tell you how impressed I am with the way you extended yourself to those children of the sick mother. I'm sure she really appreciates your kindness to her kids."

Lindsey blushed, asking, "Are you being serious?" I nodded my head "yes" as she searched my eyes to make sure I wasn't razzing her, that I wasn't in one of my silly, joking moods. "Completely serious," I finished, adding, "you went above and beyond making those kids feel comfortable while their mother was here getting treated. Well done."

She thanked me for acknowledging her work and then we both continued on with our work.

Before any nay-sayers speak up, I know, I know--we're not running a baby-sitting service in the ER. Flipping that coin, some might dare say that every patient deserves this customized, special treatment. Sometimes the ER setting is so damn busy, though, that despite our best intentions, we just don't have the time to devote to these extended acts of kindness. During those times when the hallways are packed with patients and chaos is smacking us around, we are focused on delivering excellent medical care. Quickly. At these times, unfortunately, the extra kindness and compassion that most of us strive to give may be sacrificed, pushed to the sidelines, to ensure our patients, sometimes with dire illnesses, receive quick, prompt emergency care.

In the midst of that day's shift, an act like Lindsey's served as a reminder of why most of us entered the medical field in the first place--to take care of patients and their families. To provide them the same treatment we would want our family to receive. To not get caught up in the rush of things and remember to be kind and extend our compassionate selves.

Lindsey didn't need to get the kids popsicles and situate them to watch TV. But she did. She didn't need to get them pudding, coloring books, stickers, crayons, and set them up outside of their mother's room, offering up her precious counter workspace and stools. But she did. Jamie didn't need the hassle of trying to accomplish her secretarial work while keeping an eye on the two kids sitting beside her. But she did it without complaint.

Despite the chaos, they extended themselves. And although Mom didn't demand it or expect it, I'm sure she appreciated the kindness shown to her kids while she lay ill in bed. What parent wouldn't?

So, a salute to Lindsey and Jamie. Makes me proud to be on their team.

I hope they treat themselves to a popsicle and pudding for a job well done.

As always, big thanks for reading. Next post will be Friday, April 2. Hope your week is going well. Until then...

Monday, March 29, 2010

The Good Roommate

The patient seemed like a nice enough kid. Really, he did. And I'm sure that before his socializing began the previous evening, he never dreamed that he would end up in the emergency room at 2:30 a.m. But, he did. He started the trend, the first of four college students that would come in during that overnight shift, drunk with a decreased level of responsiveness. And nothing else. No trauma. No assault. Just guilty of drinking too much alcohol.

One of the give-ins, I guess, when you work in an ER in a city that brags of having four colleges.

He was brought to our ER by his concerned, sober roommates. They were having a difficult time trying to wake him, despite their best efforts. And when they finally did wake him, he vomited all over their living room furniture and carpet. "We think he ate taco pizza," the roommate confessed to the triage nurse, painting us all an unfortunate picture.

The nurse and I walked into Room 29 after our triage team escorted this patient back in a wheelchair. His head was slumped to the side and he was sleeping. One roommate was with him, and he appeared quite frustrated with the patient.

Several of us were able to lift this patient from the wheelchair and into a treatment cot. Together, we removed his clothes, looking for any signs of trauma, before dressing him in a hospital gown. No signs of trauma. And no unusual findings.

Well, except for the big chunks of taco meat clinging to this patient's brush-cut. And his clothes. And his roommate's clothing, as well. Obviously, vomitus, by both its smell and look.

"What's going on?" I asked the roommate, on behalf of the nurse and myself. "Was he assaulted?"

"Oh, no, nothing like that," the roommate assured us. "He went to a party at another college and the people he went with dropped him off at our apartment like this. We couldn't wake him up and got scared so, after he puked all over, we drove him straight here." The roommate paused, looking like he wanted to add something else.

"Is that all?" I asked him.

"Well," the roommate spoke, quietly, as he picked some vomitus from his shirt, "I know it doesn't really matter, but he puked all over my car while we were driving here."

He was right. It didn't really matter to us. But still, that sucks.

The patient, breathing comfortably and in no apparent distress, was back to snoring. His vital signs remained stable. I think he simply wanted to sleep and be left alone. But no, I wasn't having any of that, yet.

"Hey," I yelled loudly in his ear while I rubbed his sternum, "wake up, buddy. You need to talk to us." Nothing. I grabbed a couple ammonia capsules, popping one under his nose. That did the trick. Those capsules always seem to come through for me.

He tried to shove my hand and the noxious capsule from under his nose. Purposeful movements--we like that in a patient. "What the..," he muttered, stirring his head from side to side. And suddenly, without warning, he started to dry-heave. Followed by more puking. Lettuce and salsa and orange cheese and hamburger meat. All over his gown. Never mind the looks, the smell was overwhelming.

"Wake up, buddy," I continued, side-stepping his line-of-fire, "you're in the emergency room." That news seemed to unsettle him a little. He looked up, glassy-eyed.

"What? What?" he muttered, wiping off his chin with his bare hand. "I said," I repeated myself, back to yelling in his ear again, "you're in the ER." He stared blindly ahead, before smiling a shit-eating grin. "Yeah, right." He turned his head to the side, closed his eyes, and started snoring almost immediately.

All the while, the roommate stood in the corner, shaking his head. "This isn't like him."

"Does he have a drinking problem?" I asked. "No," the roommate replied, "he's a good guy. He gets great grades. I'm not sure what happened tonight."

Well, the patient got an IV-catheter placed by the nurse. We infused a banana-bag, a liter of fluid that is mixed with multi-vitamins and thiamine. We also gave this patient two anti-nausea medications which seemed to control his barfing. We got control of things pretty quickly.

"What should I do now?" the roommate asked me, after things settled. I recommended to just grab a seat in the corner of the room, watch TV, grab a soda. "We'll have to observe your buddy and repeat his exam a couple times until he sobers up and is able to walk on his own in our hallways," I explained.

"Oh," the roommate said, "I can't do that. I can't leave my buddies to clean up all that puke in our apartment by themselves."

"Are you serious?" I asked, thinking back to my own college days. The basic rule then was that if you puked, you cleaned. It was that simple. I have some great college buds, but I would never expect them to clean up after me that way. Not that I ever got to that point. Really.

"If you could smell our apartment," the roommate said, "there's no way you would leave it until morning." Come to think of it, I guess our college house did stink occasionally.

The roommate left. The patient slept. Every hour, the nurse or I woke this patient to check on him, repeat his vital signs, and perform a stable exam. After three hours, he was much better. Awake and talking, able to walk the hallway and go to the bathroom on his own.

"What the heck happened?" the nurse asked him. The patient explained that there had been a very tasty punch at the party, one that packed a lot more than what he had expected.

"Did you eat taco pizza, too?" the nurse asked him, smiling.

"Yeah," he answered, "how did you know?"

The nurse smiled. "Oh," she said sweetly, looking at his soiled gown, "we have our ways."

The roommate had called twice while the patient had been sleeping. What a good guy, huh? By his second call, he had finished cleaning the apartment and his car, and was wondering how everything was going. "Just fine," the nurse told him, "in fact, you can come down and get him. He's walking around our hallways just fine."

We discharged this patient a half-hour later. Very stable. His alcohol level hadn't returned as high as we expected and, upon asking him, the patient admitted that alcohol wasn't the only thing he had abused at the party. We already knew that, though, from the toxicology screens. Like the nurse said, we have our ways.

The roommate proved himself to be a very cool friend, if you ask me. When he came back for the patient, he was genuinely concerned for his buddy and harbored no resentment to the fact that he had been puked upon, that his car had been soiled, and that his apartment had been messed up because of his roommate's choices. Mature beyond his college years, for sure. Or just knew the value of friendship, maybe. I did hear, though, that he had a taxi deliver them home, just in case the patient decided to spray more taco pizza all over the dashboard.

The good roommate turned out to be a smart roommate, too.

Maybe the patient will learn a thing or two from him. Just maybe...

As always, big thanks for reading. Next post will be Wednesday, March 31. See you then...

Friday, March 26, 2010

The Fringe Benefits

I stood in the hallway, outside of the door, and adjusted my scrub top. Satisfied, I grabbed my white lab coat and pulled it on, retrieving my stethoscope from the pocket and hanging it around my neck. Rarely do I wear scrubs or a lab coat, opting instead for comfortable khakis or cords and a knit top. Today was a special occasion, though. I needed to look official.

The door opened. A woman walked out. "Okay, Dr. Jim, I think we're ready for you."

I exhaled a deep, cleansing breath and smiled at the woman. This would be my third and final time for doing this. Made me kind of sad, actually, to think that this tradition would end.

I walked through the door and was greeted with the cheers from...24 third-graders. Looking around, I spotted my youngest child, Grace, standing up and clapping among the rest of her classmates. Her face shined, her smile beamed, and, in that moment, I could think of nowhere else I would rather be.

The annual Third-Grade Parent Occupation Day.

It all started a few years back, when my first child, Emma, was in third grade. A note came home in her book bag asking parents "with interesting jobs" if they might be willing to come in and spend 30 minutes explaining to the class their occupation. "What do you think, Jim?" my wife asked. "Please, Daddy, it will be really fun!" exclaimed my daughter. As much as I tried to convince the two of them that my job was "not interesting," they knew better. "Well, then," I said, caving to my daughter's pleas, "I would be honored to come and speak to your class, Emma."

And guess what? I LOVED it. Seriously, the kids were absolutely enthralled with my stories about the emergency room, the path of education taken to get there, and the hospital setting in general. I learned that entertaining a class of third-graders was much easier than handling a caseload of emergency room patients. Any day. Especially if you brought some "free stuff" with you to hand out afterwards. And had some "fun x-rays" of broken bones to show the kids, too.

After Emma's class, I was called two years later to do the same for Cole's class. Again, it was just as rewarding with his class. I was learning that third-grade is quite an impressionable age, and these kids seemed to hang on my every word. That's never happened before to me!

Finally, this year, when Grace's class was planning this day, I knew I would do it, without question. I walked into the classroom, amidst the cheers, and was introduced by Grace's teacher, Mrs. M., the woman who greeted me in the hallway. "Grace," she continued, after my introduction, "why don't you come and stand up by your father while he talks to us." Oh yeah, I thought to myself after seeing her smile and skip to the front, this was definitely worth it.

It's quite easy to navigate through 15 or 20 minutes of talk time with these kids, much easier than you would think. I shared with them some generic stories of sick kids (their age) that I've treated. Maybe with a little embellishment, of course. The kid who fell off the swing, breaking his arm and conking his head. The kid from the car accident who wasn't hurt because he wore a seat belt. The kid with tummy pain who had to have his appendix out. The kid who braved through a strep collection for his sore throat. You get the picture, right? These kids were hypnotized and spellbound.

Following my little spiel, they asked me some questions, including how long it takes to be a doctor. They're always amazed to learn that, including kindergarten and excluding residency years, it takes 21 years of education to become a doctor. "You mean I only have 17 more years after third-grade?" the math whiz of the class asked.

More questions and statements followed, in rapid-fire style:

"Have you ever rode in an ambulance or helicopter?"
"Do stitches hurt?"
"Do you give shots?"
"Does blood scare you?"
"Does blood really look like ketchup?"
"Do you make a lot of money?"
"My mom works in the ER, too. Do you know her?"
"I broke my arm last summer!"
"I had my appendix out when I was five!"

Trust me, even at their age, they can engage in some serious "who caught the biggest fish" stories, too. "I broke my arm twice!" "My mom has had five surgeries." "My dad has been to the ER ten times." "I probably know him, then," I said, chuckling to myself. You only let a couple of these stories slip in, though, or else you can lose control. Real fast.

Next, we moved on to some x-rays I brought along. After everyone shifted over to the classroom window, I held each one up to the light for them to see. I showed them a full body x-ray of a recent newborn, which amazed them. "Look how little," they sighed. Then I showed them an x-ray of the heart and lungs of a kid their age, before showing them an adult chest x-ray (don't worry, no foreign body x-rays for this crowd). Following these, we moved on to broken bones--arms, legs, ankles, wrists, skull--you name it, they loved it. The war stories started again, but I skillfully nipped that. While we talked and looked at x-rays, I passed my stethoscope around, the kids enjoying the "drum beats" of their heart.

Finally, the best part--I handed out "stuff." In previous years, it's been pens, gloves, books, masks, water bottles, all courtesy of my hospital's PR office. This year, besides all the usual, I was set-up with some very cool knapsack/shoulder bags. Grace was in charge of hand-outs and, before I knew it, her classmates were dressed in their gloves, foot covers, masks, and caps. Even I was impressed with how good they all looked. I wouldn't be surprised if there were several future medical careers among this class.

The half-hour flew by. And after one more round of cheers, I was done. The end of a tradition. I gave Grace a goodbye hug. As I walked out the door, the kids yelled their final goodbyes and thanks to me. Music to my ears.

The guidance counselor greeted me in the hallway, a very sweet woman. "This is your last time, you know." Oh, I knew alright. I didn't need to be reminded of that. "Thank you for coming in. You are always a big hit with the kids." That's how I felt, too, but a deeper part of me knew it was probably just the "stuff" and the "fun x-rays." But still...

I will miss this tradition. Losing this tradition makes me kind of sad, reminding me of just how fast these kid-filled years seem to be passing by. Big sigh. If only there were some brakes I could jam on to slow these precious years down.

The other day, Grace came home with a pile of thank-you notes from her classmates. Hand-drawn pictures and all. It's a pile I will save to give back to her when she grows up. Listen to some of these thank-you comments:

"I think I will be a doctor now. My mom wants me to be a chiropractor but I will stick with doctor."
"Your job is the coolest. I think I might have it as a job."
"I will not be sick."
"I really learned a lot about doctors. Break a leg!"
"Dr. Jim, thank you for all the stuff. We like presents."
"Thank you for the gloves, I haven't taken them off all day."

The best one? Easy.

"Dear Dr. Daddy. Thank you for taking time out of your day of work for my class. I Love You. Love, Grace." Her words were accompanied by a big red heart.

Another big sigh. Yep, I'll miss this tradition...

As always, big thanks for reading. Next post will be Monday, March 29. See you then. I hope you all have a nice weekend...

Wednesday, March 24, 2010

Perfume And A Purse

Have you ever been so overwhelmed with a stranger's perfume or cologne that you got downright nauseous, the pit of your stomach wrenching?

Welcome to Room 31. I walked into the treatment room to find a pleasant-appearing, tightly-permed, elderly Christian woman who had decided to pay us a visit after Sunday morning mass. She was alone. She was lying on the bed, her gown on backwards, her two stocking-covered legs, still capped by her sensible shoes, poking out. Her floral dress was neatly folded on the counter.

To her belly, she clutched a worn, black patent-leather purse. I imagined its precious contents--a change purse, a lace-bordered handkerchief, a decade-old lipstick tube, a rosary, some hairpins, and a brown prescription bottle with an assortment of expired pills. Probably some sugar and jelly packets taken after her last restaurant meal. And a little bottle of perfume.

Make that an empty bottle of perfume. Her room smelled like a Macy's perfume counter during the holiday season. It was thick and heavy and flowery, and it was giving me a headache.

"Hello, Mrs. Brown," I said, introducing myself, "I'm Dr. Jim, and I'll be taking care of you." I struggled with the words, desperately trying to breath in through my mouth and not my nose.

She responded kindly, before proceeding to share that she had not been feeling well since awakening that morning. "It's probably nothing, dear," she said in a sweet, chirpy voice, "but I think I might have a little..." Here, she paused, lowering her voice to a whisper before leaning in to where I stood, "...diarrhea." Clearly, by her flushing cheeks, saying this word had embarrassed her. The dreaded "D" word.

I asked my standard questions. Any blood? Any antibiotic use? Fever? Abdominal pain? Were the stools watery? A certain color? And so on. With every question I asked, I felt my lungs burning and my eyes stinging. I worked hard to be thorough but brief in my questioning.

After every question I asked, she answered with a grandmother's grin and shake of her head. "No." She seemed very content and comfortable. "Dear," she summarized, "they were just a little loose, that's all."

Before moving on to her physical exam, I held out my hand. She knew what I wanted. She handed over her purse and I took it from her. It was surprisingly heavy. I added four rolls of quarters to my imagined content list. "I'll set it right here on the counter for you, okay?" She nodded, glancing over to make sure it was in her clear view.

Her vital signs were stable, without a fever. Her full-body exam, also normal. Focusing on her abdomen, I couldn't elicit any pain or abnormal findings. She looked darn good. Maybe going to church had cured her symptoms.

I explained her stable physical exam to her. Her blood work, ordered by a proactive nurse, had returned with stable blood counts and electrolytes. All that was left to do was a rectal exam. "Oh, dear," she muttered. I reassured her that it would be quick. "I'm just checking to see if there is any blood, maam."

I stepped out of her room. I took a deep breath of hallway air. Glorious, recirculated, air-conditioned hospital air. I forcefully exhaled before gulping down another big breath, washing the perfume from my lungs. Unfortunately, I still tasted it.

I found Mrs. Brown's female nurse, asking her to accompany me during the rectal exam. In training, I was taught to always have a female nurse during a pelvic or a rectal exam of a female patient. Good advice.

Before walking back into Mrs. Brown's room, the nurse commented on how strong Mrs. Brown's perfume was. "I know," I said, "I can hardly breathe in there."

The nurse was ready. From her scrub pocket, she pulled out a face mask. "How's this?" she asked, chuckling. "Or this?" she continued, pulling out an ammonia capsule. She wasn't done. "Or maybe some of this?" She held up a small container of Vick's Vapor Rub. "A small dab of this under your nose will save your sense of smell, you know." I thought she was joking, but I swear I saw some glistening ointment just above her upper lip. I passed on her offers, as tempting as they were. I would tough this one out, since the bulk of my treatment was done. I pocketed the ammonia capsule, though, just in case.

We walked into Mrs. Brown's room together, the nurse and I, and, as expected, the smell of her perfume attacked us, its invisible fingers clawing at our eyes and ripping at our noses. And there sat Mrs. Brown, smiling her sweet, innocent smile. Clutching her purse tightly against her abdomen. Again.

"Hey," I said, "how did you get your purse off the counter." An aide had come in, she explained, and she asked "the handsome young man" to hand it to her. "He was quite a dear," she added.

While I prepared for the exam (gloves, hemicult cards, lube), the nurse covered Mrs. Brown with a blanket before having her roll to her side and dropping her drawers. "If you don't mind," Mrs. Brown said, lying in her compromised position, "I'll just keep my purse right here with me."

We now interrupt this post while Dr. Jim performs a rectal exam.

Whew, I'm back with good news. Mrs. Brown's rectal exam was uneventful. No blood, no pain, normal stool color, good tone, no abnormal smell (because of her perfume, I can't be 100% sure on that one, although I think her shit smelled like, well, shit). She passed with flying colors.

We discharged Mrs. Brown with instructions to follow closely with her family doctor and return if any symptoms changed or worsen. I also wrote on her instruction sheet, "Do not wear perfume. Ever again. And don't ever let go of your purse. If you do, someone will steal it." The nurse made me delete that line, though.

Upon discharge, her trail of perfume followed her down our ER hallway and into our waiting area, where a friend was waiting to take her home.

Although I thought her perfume would linger for hours afterwards, housekeeping was able to clear the smell out pretty quickly. The secret weapon? Our heavy-duty, industrial strength, apple-scented room deodorizer. Of course.

I took the ammonia capsule from my pocket. And used it.

As always, big thanks for reading. Next post will be Friday, March 26. See you then...

Monday, March 22, 2010

Save The Scowl

During yet another busy shift in our emergency department, our staff was on the receiving end of multiple scowls by patients and their families. None warranted, mind you, and none were taken personally. But, nonetheless, it seemed to be the theme of the day.

What started the scowling? Simultaneously, we had three ambulances arrive to our ambulance bay, within minutes of one another. A chest pain patient, a stroke patient, and a trauma patient. Our staff, always ready to rise to the occasion, planned our divide and conquer.

I treated the stroke patient. A 60 y.o. male, normally healthy except for his smoking history, had a sudden onset of slurred speech accompanied by some extremity weakness. His symptoms had started within the past hour and were witnessed by his wife.

"We were sitting in our Lazy-Boys, watching our favorite show, The Wheel of Fortune, when he started having these problems," she said, frightened. "Is he going to be okay, doctor?

We called a "stroke alert." Similar to treating a multiple-trauma patient or an actively-infarcting heart attack patient, we have an emergency response team composed of ourselves, an in-house neurologist, multiple nurses, and the IV team. Our goal? To stabilize a patient, get imaging studies (especially a CT scan), and intervene as quickly as possible. With the right circumstances, we have several treatment options that can reverse such devastating symptoms.

Well, my patient did have a stroke. His CT scans were negative for any hemorrhaging and he qualified for tPA, a clot-buster used very cautiously but effectively to treat ischemic strokes. Simply, this type of stroke is usually caused by an embolus (or clot) that travels to the brain, occluding an artery and preventing blood supply to the brain tissue beyond. tPA can dissolve this clot.

It worked. Within the hour that followed, all of my patient's symptoms resolved.

The cardiac patient went to the cath lab. Unfortunately, the trauma patient died. And, all the while, patients began to back up, waiting for their emergency care. This, I'm afraid, was probably the moment when scowling became an epidemic.

Outside our triage station (the nursing station where a walk-in patient is first greeted and evaluated), patients lying on cots started backing up, lining the hallway. A bad sign that we were getting crowded. Between the patients and their accompanying family members, you couldn't walk down that hallway without having several people give you dirty looks. This, despite them being able to see how we were all rushing around, working hard.

Several patients later, I walked into a very unforgiving room. Lying in the cot was an elderly man with enough piss-and-vinegar to last me a lifetime. Pacing the room, his son. Sitting in the corner, his wife. They were upset with their wait. They had been sent to our ER by their family doctor (so they said) for a problem that was chronic in nature. Specifically, continued urinary problems from an enlarged prostate. Nothing new, they simply called for an appointment and couldn't get one for a week.

"I don't understand how you can make people wait like this," the patient started, before I even had a chance to acknowledge their delay. After assuring them that we were all working quite hard, I simply focused on this patient's history and physical. All stable. With the delays in care, the triage nurse had ordered a UA and blood work, also normal. I explained in detail my exam and the results of these tests, reassuring the patient and his family that everything looked okay.

Three scowls greeted that news.

Finally, just when I thought the scowls were slowing down, a mother walked out of her child's treatment room, quite gruff, while I was handing a chart to our secretary.

"Can someone give me the access code for the internet? For some reason, I can't sign on," she said, clearly annoyed with her wait, her eyes rolling.

Wait a second. We give out turkey sandwiches and lemon pudding. We pass out warm blankets by the dozen. We reimburse parking. And we even have a TV in each private room. When did we start having available internet access for patients and their families? Did I miss something? Do we have a coffee bar I don't know about, either?

"We don't have internet access in the ER, maam," our secretary answered the mother. "Sorry about that."

The mother bore her angry eyes into us. And scowled. "That's ridiculous," she mumbled, before turning and stomping back into the room.

Eventually, during that shift, we caught up with our patient-load and the scowls lessened. In fact, I might have even seen a few smiles. Always a plus

Truthfully, the scowls don't bother me. Well, okay, maybe just a little. But only because they seem to be accompanied with a sense of entitlement. Yes, I understand that when someone is sick, it might be hard for them to comprehend that their symptoms may be less urgent than the next patient. We aren't minimizing the symptoms, simply prioritizing them. We are an emergency department. We don't ask people to come in. We would never deliberately make a patient wait. The scowls being given to us are for things that we, the ER staff, can't control.

Well, short of getting internet access in the ER, that is.

As always, big thanks for post will be Wednesday, March 24. Interestingly, as I finished this post, the health reform bill passed...more scowls to come...

Friday, March 19, 2010

A Memorable Ride

Undoubtedly, part of the charm of Hilton Head Island is her fondness of bicycling. Riding paths weave throughout her landscape, the warm and welcoming wrinkles of her proud face. They meander through her plantations, along her roadways, and frame her edges. They are her "laugh-lines," proof to the years of living she has witnessed, of the families she has embraced.

Like the two previous years, five rental bikes, complete with handlebar-baskets, awaited our family's arrival last Saturday, chained together outside of our beachfront condo, eager to shed their shackles and reacquaint us with Ms. HHI. Barely finished with carrying in our suitcases and supplies, the kids could hardly contain their enthusiasm to go for a bike ride. My wife, despite her sniffles and cough, led the charges.

"Come on, Jim," she said, froggy-voiced, "we have to go. Look at your children!"

Oh, I was looking, alright. Their excitement, their joy, their anticipation--how could a father not jump on that band wagon of happiness. Isn't this what family vacations are all about?

I teased them a bit, plopping myself into a lumpy, over-sized reading chair. "Hey kids," I said, lazily, "why don't we just grab a bite to eat somewhere and, afterwards, come back to the condo. Relax a little. Take a nap. The bikes will be here all week for us." Their collective "noooooooo," moaned with much exaggerated anguish (I'll admit, their flair for drama is my fault), was anticipated. Still, kids, well done.

We went for our first bike ride of the season. And, believe me, it didn't disappoint. There is a bike path along Mooring Buoy in Palmetto Dunes that is, if I may quote my eleven year-old, "Awesome!" No boring trail, this path winds around trees, through neighborhoods, over bridges, and, occasionally, offers up a small puddle or mound of wind-blown sand that must be plowed through. Hairpin turns and S-curves are included. If I was needing to unwind a little bit on this vacation, it was accomplished that first day. I was ten again--a smiling, innocent, fast-pedaling, wheelie-popping kid trapped in a grown man's body.

By Tuesday morning, after conquering most of the bike paths in our area, we decided to bike on the beach. Hard-packed sandy paths, a rising sun, and playful dolphins just yards from the coast beckoned us. No, you didn't have to twist my rubber arm to get me to go along with this plan.

We walked our bikes from our condo, through some loose, white sand, a work-out unto itself, until we arrived to the ocean's edge. The whispering breezes were westbound, and we decided to take them head-on. Just as we expected, the biking was superb. Starfish served as orange caution cones, and we maneuvered around them expertly. As pelicans regally swooped off the shore for their breakfast, new morning shells enticed us to slow-down and inspect their states of imperfection. Morning waves lapped at our tires, their white crests dispensing infinite prisms within foamy bubbles. Yes, life was good, despite having the back tire kick sand and water into the crack of my shorts.

We weren't biking on the beach for all of ten minutes when we noticed something peculiar in the distance ahead. Approaching, we were able to make out yellow tape, scant crowds, and the police. And...a small plane lying on its belly, facing the water.

Say what? A plane? Yes, a plane. Crashed on the shore. An obvious emergency landing. Appearing intact but for the propeller lying near it's front and, from what my non-expert eye could see, some right wing damage. Anchored to the dry shore by its tail, probably to keep it from being swept away. Saving it from drowning itself.

We approached the wreckage site cautiously, my kids asking whispered questions that my wife and I had no answers to. "What happened?" "Did anybody die?" "Where are the people from the plane?" The plane's nose bobbed with each incoming wave and, suddenly, all the recently observed glories were forgotten.

It was a heartbreaking scene to happen upon. Even though I didn't know specific details, a few minutes of scene-watching made it evident that this plane crash didn't just happen. No smoke from the wreckage, no EMS services, no panic. Just an eerie calm blanketing our disbelief.

The who, what, where, when and whys would have to wait--I didn't want to hang around and listen to any of the speculative chit-chat or idle gossip. All I wanted to do was turn my family around and get back to the safety of our condo, to our vacation life. We pedaled hard, the wind at our back, and returned within minutes.

We were all quiet walking into our place. We turned on the news and surprisingly, couldn't find any news-breaks explaining anything. We accessed our computer and, low and behold, my first breaking news of the recent events was from a very cool reader, Jacqueline. Just checking to make sure, via email, that my family was okay. Big thanks, Jac. She had heard on her news reports that a jogger was killed on Hilton Head Island Monday night.

So now, here we are, on vacation, and a jogger has been killed and an airplane has crashed. Hardly the stuff that helps one unwind. After several googled news reports, we found the answer that tied all the facts together. As reported, a 38 y.o. man, here for business, was jogging on the beach Monday evening, listening to his iPod. A single-engine plane had "oil problems," had lost its power, and was attempting an emergency landing at the local airport. The plane never made it. Essentially, by news reports, the pilot, struggling to see through an oil-splashed window, glided the plane in along the shore and, unfortunately, landed his plane on this unknowing jogger. Dead instantly. A father of two. A daughter's third birthday to celebrate this week. A family to support. To love. To grow old with.


I work in an ER. I know how suddenly fate can change one's life. I came down here to get away from all of that. And yet, for all the misery and heartaches I've witnessed, this story struck a nerve. We walk this beach, we bike this beach, we hang in the same spot for hours on this beach. Why this guy jogging? Why not one of us? Or, for that matter, anyone else down here? Why the beach? Why couldn't the fates just let this father, this husband, this son have his casual jog while listening to some favorite music? Why? As with so many other tragedies in life, this seems so senseless.

We don't know this man or his family. But that won't keep our family from sending well-wishes, heartfelt prayers, and good energy their way. We can only hope that their lives will someday recover from this tragedy.

Back to the biking. As you might have suspected, we have given up beach biking for the remainder of this trip and are back to Ms. HHI's trusted, familiar bike paths. And after a couple S-curves and some wheelie-popping, I am once again a ten year-old trapped in a grown-man's body. Relaxed and ready to head home and face my everyday life and job with renewed vigor. A new appreciation of sorts.

Ms. HHI, I thank you--you didn't disappoint. Although I'll be taking one sad memory home with me, it will be tucked within a bundle of amazingly happy ones.

As always, big thanks for reading. Next post will be Monday, March 22. Have a great weekend and I'll see you then...

Monday, March 15, 2010

My Spinning Head

My head is spinning. Seriously spinning.

Let me see. A combined twelve years of elementary school and high school. Four years of college. Four years of medical school. One year of internship. And three years of residency. Oh yeah, don't forget about the thirteen years of "life" I've had since all of this formal schooling and training has finished.

Yet, for all of this experience and hard work, I felt abandoned. Confused. Wayward. Standing in the middle of a store aisle. I ended up looking to my left, ready to plead for a stranger's help. I looked to my right, hopeful that some angelic vision enveloped in a bright, shining aura would proclaim the answer to my question. And I looked ahead of me, acutely aware of all of my options.

Which cough and cold medicine should I buy?

You might laugh but, seriously, how does the common person do this? Here I am, with all of this medical knowledge and ER experience in my back pocket, and even I can't make a decision to what I should buy in this endless cough and cold medicine aisle.

It started out simple enough. Traveling down the fourteen hours to Hilton Head these past few days, staying in a hotel room halfway through the trip, lots of car time with some lingering kid-coughs, closed continuous car circulating air, and, before I could blink, my wife has a runny nose, sinus congestion, and headache. And is feeling rundown. And is achy everywhere. And has a sore throat. And a fever, "well, maybe I don't have a fever but I feel warm." I'm sure it was brewing before we left but, unfortunately, presented itself at the start of our vacation.

The thing is, my wife never gets sick. Seriously. She takes her vitamins, she exercises, she eats her vegetables, and not from a can, mind you (that would be me and my love-affair with young, tender peas). She consistently partakes in all the things that I only do on a sporadic basis. But, here we are, on vacation, and she's the one whose ass is dragging. I would take one for the team, in a heartbeat, if I could spare her this misery. But, I have to admit, for once, it's nice to not be the adult in the house getting the kids' spill-off illnesses.

She's not a complainer (of the two of us, that would be me), so when she asked me if there were any medications she could take to feel better, I knew she was not feeling well.

We went out as a family to WalMart to buy her some medication for her symptoms. The irony of it--driving fourteen hours to go to a store that exists five minutes from our home--was not lost on me. But to our credit, we did try the local grocery store first.

I walked into the store, very clear about what kind of medicines she needed to get back on track. How hard could this be, really? She and the kids grabbed a cart to fill-up on our needed supplies for a week of condo-living. I searched out the pharmacy section. "I'll meet up with you in a few minutes," I had said. On hindsight, a stupid statement.

I found the cough and cold medication aisle quickly. I started picking up the boxes to read the active ingredients. Cough suppressant? Cough expectorant? Nasal decongestant? Antihistamine? After sorting through all of those options, then, I had to decide if I wanted acetaminophen (Tylenol) or ibuprofen (Motrin or Advil). Okay Jim, I comforted myself, just take your time and start over.

I decided a different approach--let's go with the proclamations on the front of the box. Cold Multi-Symptom (regular or severe), Sinus Congestion, Headache and Sinus, Cough and Headache, Sore Throat and Cough, Sore Throat, Cough, and get the picture. If nothing else, I appreciated the selling of every single variable you could squeeze out of the common cold.

So picture it, you are at the store shopping and you see a guy scratching his head, rubbing his chin, pacing back and forth, picking up a box off the shelf just to replace it back in seconds, and that would be me. With all of my infinite medical wisdom.

I finally sorted through all of these options before realizing, "Wait, she'll need both a daytime and a nighttime medication." I sure didn't want my wife to get tired in the daytime during our time at Hilton Head, right? Possibly risk sleepwalking through our vacation? So, guess what? She'd need the nighttime version, too. Unfortunately, though, the daytime formula I had decided on didn't have an alternate nighttime version (it's usually just an addition of some form of antihistamine). So what did I do? Well, of course, I started over.

The minutes dragged, the active ingredients blurred, and the box-front symptoms united to form one big blob of an illness. Finally, after much frustration, I picked out what I thought was the best option for my wife's illness.

"Daddy," I heard my youngest call, just as I was wrapping up my choice. Looking down the aisle, I saw my smiling family approach me. "What took you so long?"

I held up the boxes I chose for my wife to see. I must have looked like the village idiot, extreme pride radiating from my pathetic face, eagerly anticipating my wife's approval of the two $2.68 boxes of miracles. Please, please, I remember thinking, tell me how good I did.

What she asked next was like fingernails on my brain's chalkboard. "What about the liquid, Jim? How's that?" I think I stomped my feet, my mind screaming "No, no, no" while my voice remained silent. "Or," she continued, walking down the aisle, scanning the options, "maybe I'll just do gel-caps." She looked at several boxes quickly, scanning each's front and back in just short of ten seconds. "Yeah," she said, "I think these will do." She had found a combo-box of both daytime and nighttime medication with, evidently, just the right active ingredients to treat her symptoms.

I think I'll just place this whole experience in the "knows too much," category, thank you very much. I might just be giving myself too much credit, though, on that one.

Now, if you don't mind, I have to go take a couple Tylenol for my headache. Or maybe Motrin. Oops, I mean Aleve...

As usual, big thanks for reading. Next post follows on Wednesday, March 17. Hope everyone is well...see you then...

Friday, March 12, 2010

Grandpa's Grandkids

They were both teenagers, out-of-town grandchildren, a girl and a boy, spending several weeks of their summer vacation visiting with Grandma and Grandpa. They had been doing it for years. It was tradition.

It was their first time to our ER. An unplanned visit, of course. For all the summers and all the weeks spent in our town, never once did either teenager or their grandparents have to visit us. No lacerations. No broken bones. No typical summer injuries that required our attention.

They were sweet, this girl and boy. Despite their tired and worried faces, they smiled and spoke kindly to one another. And to us. They showered their attention on their grandparents, clearly comfortable and unabashed in showing their deep love and respect. The way it should be.

Their Grandpa was sick. They hadn't planned on Grandma and Grandpa waking them in the middle of this night. But Grandma did wake them, right after she had called the ambulance to have Grandpa brought to us. Pillow creases etched their innocent cheeks, their yawning but feeble attempts to wash their tiredness away.

Their Grandpa had awoken from his sleep with severe and sudden abdominal pain. He hadn't eaten anything unusual, nor had he been ill. No fever. Never had anything like this before. But Grandpa did have hypertension, adult-onset diabetes, and hypercholesterolemia. And his blood pressure readings were dangerously low. Most alarming, Grandpa had diminished leg pulses when compared to his arm pulses. This was serious.

Grandpa had a ruptured abdominal aortic aneurysm. A life-threatening diagnosis

I performed a quick ultrasound to confirm the problem, all the while giving Grandpa aggressive IV fluids, low doses of pain medication, and starting blood transfusions. The cardiothoracic surgeon was called in emergently and the OR was prepared. We worked quickly and efficiently, time not our friend.

Tenderly but urgently, I spoke with Grandma and Grandpa and the two grandchildren about my concerns with Grandpa's symptoms. I explained that a dissecting abdominal aortic aneurysm is life-threatening and, similar to a sprung leak in a water dam, Grandpa's abdomen was filling with blood leaking from the ruptured wall of his aorta, our body's biggest oxygen-delivering vessel. That time was of the essence. That this leak would only get bigger until it ruptured, without emergency surgery. That Grandpa's life was at stake.

Grandpa's grandchildren, with Grandma, stood in the corner of the room, their faces transforming before me, their innocence circling the drain after being bathed by the harshness of reality. Grandma held each of their hands within hers. Eyes began to glisten as tears silently filled their corners, spilling over. Prayers were whispered.

I offered the grandchildren the option to step out and be comfortable in the family room, maybe something to eat. Just a few minutes away from the commotion. They declined, opting to remain in the comfort of Grandma and Grandpa's presence, in spite of the circumstances, rather that keep company with a floral-print love seat and seafoam painted walls. The right choice.

"But," stammered the younger of the grandchildren, the boy, "I don't understand. If Grandpa's this sick, how can he still talk to us? How come he is still awake?"

My heart was heavy as I watched this boy's hopeful eyes. His older sister stepped up to his side, wrapping her arm around his shoulder.

I reassured the boy before explaining to him, as well as the rest of the family, how we were fighting hard for his Grandpa, how we were giving him IV fluids, blood transfusions, and other medications. How these things were helping Grandpa temporarily. How we all wanted his Grandpa to do well and were using everything in our power to make that happen. "But," I said, cautiously and honestly, "there will be a point where we can no longer keep up with the blood he is losing from his leaking aorta, and that will be the scary moment. That is why we are hurrying to get him to the operating room."

They nodded their understanding to me before embracing one another, leaning over the cot's rail to include Grandpa, who was getting visibly weaker. Grandma tenderly stroked his scalp, front to back, as she whispered in his ear. He smiled from her words. The grandkids caressed his hands. He smiled from their touch. I walked out of their room, quite affected by their expressions of love. Especially in the midst of their pain.

Usually, when death is an imminent danger and time is precious, I make it a point to express to the family to share their emotions and thoughts, share those words and feelings that may have been assumed or bottled through the years. Share their love. Watching these grandparents with their grandchildren, though, I felt no need for that. Clearly, they had been sharing their love all along. Right to the end.

Grandpa lost consciousness on his way to the OR. CPR was started in the elevator. Emergent intubation was performed in the hallway that lead to the OR (this had been held off in the ER because the family had requested as much time as possible to talk). Blood transfusions were continued. Pulses, heart rate, and breathing remained fragile.

Despite each of our best efforts, Grandpa lost his life in the middle of that awful night on the OR table.

Damn it all.

At some point, as we expected, his aortic wall just gave out and there was nothing further that could be done. His small leak had progressed to a full rupture, and he essentially bled-out from his aorta into his abdomen.

When I think back to those grandchildren on that fateful night, I still hurt for them. Imagine spending a nice summer day with your grandparents and, at the end of the day, climbing into a quilt-covered, lumpy bed to go to sleep. In the middle of your sleep, you are urgently awoken to accompany your sick grandfather to the hospital. And there, you watch him die an unsettling death. Talking one moment, and gone the next.

I remember the grandchildrens' faces the most. Their pitiful expressions. Their caring. Their pain. Their disbelief. Their worry. Their tears. Their sadness while watching their grandfather grow weaker. I can only hope that those faces are smiling again. That time has been kind. That their good memories have survived, sprouting wings to fly above the breezes of the bad.

You know what most reassures me to think that this family is fine? That they have survived and moved on? It is the simple truth that Grandpa had loved his grandkids. And they had known. Their final moments together reflected this love. Grandpa could give them no greater gift than this, a gift that, I hope, they will carry with them through their life's journey.

A grandfather's love for his grandkids. How privileged was I to bear witness during their darkest hour?

As always, thanks for reading. Next post will be on Monday, March 15. See you then...and watch out Hilton Head, here we come!

Wednesday, March 10, 2010

Being Threatened

How many of you have a job where you could, at times, be physically or verbally abused? And threatened? And pushed beyond your limits of self-dignity?

Welcome to the ER.

Anyone who has ever worked in an emergency department or a trauma center has a story to tell about being threatened. It's not a good feeling and, in fact, is something that one can carry with them long after the event, dwelling on their minds and weighing down their hearts. We all, I think, have a little part of our self-worth damaged at times like that. And even though you did nothing wrong, you still ask yourself repeatedly "What did I do to deserve this?" or "Could I have done something different?" Nine times out of ten, that answer would be "no." But that crazy thing called guilt can flip the coin and make you feel like you were responsible.

For example, when an alcoholic or druggie comes in and threatens to "beat the shit out of you" or "find out where you live and come carve you up," it's par-for-the-course, something we have all been trained to deal with. We are asked to look beyond the abuse and realize that it's "not the patient talking" but, rather, the drugs and alcohol. Yeah, okay. For the most part, I can buy that. But we all have limits, and it takes tremendous professionalism and restraint to continue treating that patient. And of course, we always do.

Likewise, if a psychiatric patient presents during a crisis, a break from reality, they may lose the ability to discern between what is normal, accepted behavior and what is harmful, threatening behavior. And again, the ER staff is usually on the receiving end of their irrational actions or words. Recently, a schizophrenic patient sprayed us with her saliva while glaring at us with her distant, disconnected eyes, spatting away and trying to bite or hit anyone near her. Even after a face-mask was placed, she still managed to hurl some extremely hurtful, vulgar comments at our staff, particularly at a medical student who had some acne issues and a female guard who was not a size 8. One of our nurses ended up with a bruise.

Hell, about ten years ago, I even had a psychiatric patient tell me that he was going to find out where I lived and "take you out." I hadn't been the first doctor and I'm sure I wasn't the last that he threatened but, trust me, you don't sleep well after something like that.

We accept these words and these blows, these mean-spirited, personal insults delivered with flailing arms and legs, because we signed-up for our jobs in the ER. But, we are still human, and there are days when this type of threatening or abusive patient is harder to accept and deal with.

The hardest part, though, isn't the expected threats, such as from the above patients. Rather, it's the unexpected threats from the sane-appearing patient who decides to take out all of his frustrations on the ER staff. For this reason, I rarely let a patient get between me and the treatment-room doorway.

A while back, I signed on to treat a twentyish male who had waited for about two hours for a complaint of one week of cough and cold symptoms, exacerbating his asthma. He continued to smoke despite feeling that his symptoms were getting worse, per the nursing triage note.

As I walked down our brightly-lit corridor, towards his room, I exhaled a deep, thankful breath, happy to have my last patient survive her stroke. Unknowingly, though, I was walking towards a room of rage.

I pushed the curtain to the side and walked into the room, all while extending my hand to introduce myself. Lying on a cot in the dimly-lit treatment room, watching the small TV in the upper corner, was a young man who looked very pissed-off. He may have weighed 130 lbs. wet, 5'7" or so. After I entered, he shifted his glaring eyes onto me.

"Hello," I started, "I'm Doc..." Unfortunately, I didn't get to finish. In a flash, this patient had jumped off his cot and towards me, his arm cocked-back and his fist balled. He stopped a few feet in front of me.

"I had to wait almost three hours for you to get your ass in here. Can't you see I can't breathe?" He yelled in full sentences, no distress evident. By triage notes, he was stable and had had an excellent oxygen reading. There was no mention of this patient being unreasonable, although I later learned that security had to approach him in the waiting room to calm down. He continued. "You motherf...ers are treating everybody but me."

Yes, my heart was racing. And yes, I was completely caught off-guard. We had a brief moment of silence where our eyes locked, and I could see his extreme rage.

"Put your fist down," I said firmly, holding my ground, shifting my eyes to his cocked-arm. "If you touch me, I promise you that you'll be covered with cops and security before you can blink." Instinctively, while speaking, I raised both of my hands, preparing to catch or block a thrown-fist. Why didn't I retreat? I'm not sure, exactly. Although I had about 70 pounds and six inches on this patient, that would mean nothing if this guy had a gun or knife. But frankly, during a moment like this, it's hard to fully grasp all that is happening.

The patient continued to keep his arm cocked as he ranted. "Motherf...ckers, sons-of bitches, assholes," he yelled, "making me God-damn wait like this. I want some God-damn treatment and I want it now." Finally, after his rant, he took a step back towards his cot.

By now, because of the commotion, I knew that security would be rushing to the room. And they did, but not before one of our techs, a 350 lb. brute, came in first to back me up. Security soon followed and, after we offered some very brash options of either being arrested (if he continued his behavior) or cooperating or leaving on his own accord, the patient requested to be treated. Since I'm not easily intimidated and wasn't sure how ill he was, I agreed to treat him, but not until after I spelled out in exact terms how we expected him to behave. He hesitantly agreed to our terms.

Under watchful eyes, I obtained a history from this patient and performed a thorough exam. I tried my best to maintain my professionalism and act as if this patient hadn't wanted to jump me mere minutes before. Fortunately, I found him to be just as the triage nurse had noted. He had been appropriately placed behind our more critical patients for treatment.

The respiratory therapist came down, soon after, to give this patient a breathing treatment. Before she entered the room, I explained to her why security would be sitting outside of his room in the hallway. We both walked to the room together, only to find no security sitting outside.

"Go back to the station," I said, "I'm not sure what happened."

Well, as it turns out, this patient, following another angry outburst aimed at our security, had decided to leave without any further treatment. And wouldn't you know, the next day he returned. I wasn't even aware he was back until I heard a big ruckus. Again, a lot of verbal abuse towards one of the ER nurses and one of my partners. Our security was ready, though, and the police were notified.

Although we'll never know for certain, there did not appear to be any alcohol or drugs involved. No psychiatric history, either. He simply was a very disgruntled, angry man who wanted his medical treatment immediately, for symptoms that had been present for almost a week. In order to jump the line of waiting cardiac, stroke, and trauma patients, he had been willing to risk threatening several of us.

At times, we can face some real dangers with our ER jobs. My hat is off to all of my fellow ER comrades, from the secretaries to the techs, from the nurses to the docs, and from the security to the police. I salute your continued resilience and professionalism, especially during these abusive moments.

As always, big thanks for reading. The next post will be Friday, March 12. Until then...

Monday, March 8, 2010

How Do You Sleep?

One of the more common, non-emergent complaints I hear in the ER is about sleeping, or the lack thereof. Although the patient is usually being seen for a more serious, emergent issue, if their sleep is not solid, they tend to skillfully bring it up regardless of what else is going on.

"Maam," I said, "it appears by your EKG that you are having a heart attack."

Despite chest pain so intense that my patient was clutching her chest, she still stammered, "But what can we do about my sleep?"

Or, imagine my elderly male patient in the midst of a stroke, with the left half of his face drooping, his speech slurred, and drool sliding down his chin. "I shant schweep adt nichte."

"Pardon me, sir, but what did you just say?" I asked.

Thankfully, the nurse starting his IV understood him. "He said, 'I can't sleep at night.'"

See what I mean? I've even had a patient share her insomnia issues during a pelvic exam. Maybe if she had slept more and fooled around less, I wouldn't have had to do this exam for her itchy, malodorous discharge in the first place.

Barring the situational, temporary reasons (for example, a death in the family), sleep disorders are typically viewed as chronic, long-term illnesses and, as such, should be treated by one's family doctor. Sleep studies may be necessary, and there are several options of treatment to prescribe, all requiring close follow-up. All reasons for me not to treat a patient for this disorder. I will, in a pinch, prescribe a few days worth of medication for a patient if their daily life is being severely affected, but that's about it.

Several years ago, after some prompting by my wife, I underwent a sleep study. It seems that I was having bouts of snoring and gasping for air in my sleep, per my wife. I'm not sure how she knew this, seeing that her head hits the pillow and a six-to-eight-hour coma immediately follows. But yes, she insisted, this was happening. So I took her word for it and pursued the testing.

I arrived at the sleep lab suite around 7:30 p.m, nervous and not sure what to expect. After checking in, I was shown to a huge bedroom, professionally decorated, with a queen-size, pillow-top bed beckoning for my company. "Come, Jim" it whispered to me, "come and let me wrap my big, down-filled arms around you." I think I heard the 40-inch TV calling, too, but I could have been imagining that.

After the tech showed me to my private bathroom, I changed into some appropriate sleepwear. You might be asking yourself--what's appropriate? I'm going to let your imagination answer that question. Just be aware, though, that they videotape you through the night as you sleep. And then post that video on YouTube. Just joking. Suffice it to say, I would suggest that one wear more than just the usual home sleepwear. And newer, too. Please, on behalf of all the sleep-lab techs in the world, don't show up in a stained, big-daddy Hanes t-shirt. Or tighty-whiteys. Or a moth-eaten thong. Or nothing at all. Especially nothing at all!

After changing, I climbed into bed. Soon, the tech came into the room. I was nervous, obviously, and likened this anxiety to how a 60 year-old fat, balding guy must feel while lying in his hotel bed, waiting for his prostitute to arrive.

The tech, a nonchalant, easy-going guy, explained the whole process to me. "First, we 'll attach these electrodes to your head, then your chest and finally your arms. After that, we'll leave you alone. You can do whatever you want--watch TV, read a book, whatever--until around 10 p.m. If you aren't sleeping by then, we'll ask you to turn off everything. Don't forget," he continued, "besides monitoring you, we'll be watching you on video." He pointed to the cameras in the upper corners of the room while he spoke. "Any questions?"

No questions, but just a silent prayer. "Dear God, I beg of you, keep me from scratching myself or making a fool of myself tonight. Amen." I added a bargain for good measure. "Oh, and if you do, God, I promise to give every ER patient a turkey sandwich, a warm blanket, and unlimited lemon pudding during the next week."

The tech left the room. I looked around, all this comfort surrounding me, and all I could do was think "How the hell am I going to sleep with all these wires hooked up to me?"

Well, I read a little, I flicked through the 1000 available TV channels, and finally, around 10 p.m., I turned off the lights. There's no way, I thought to myself, that I'm going to fall asleep. I pictured my wife at home, smiling, arms and legs spread out, sleeping soundly alone in our bed. I had the bad feeling that I had been set up.

Next thing I knew, though, I was being nudged in the shoulder. "Hey," I heard, "it's time to wake up." Through groggy, squinting eyes, I peered slowly around, clearing my mind's disorientation. That's right, I reminded myself, I was in the sleep-lab and, wouldn't you know, just had my best night's sleep in about ten years.

"You did great," the new male tech said. "Let's get you up and out of here." I got up, moved to the side of the bed, and he removed all of my electrodes. I got a quick shower, cleaning all the gel off of my head and body, brushed my teeth, got dressed, and headed home. I didn't need to hear the official results, I already knew--everything would come back normal.

Yeah, well, I'd like to call a penalty--the sleep-lab guys cheated. Unlimited channels, private room with bathroom included, big pillow-topped bed with down-filled comforter, the bed all to myself--who the heck couldn't sleep within those luxuries? The wires were but a mere distraction.

Have any of you had a sleep-lab study done? Similar experiences? Would you like to share how it went? What you wore? Let me lower my voice three octaves, like the great Barry White's, to a whisper and ask again. "Hey you, yeah you, how you doin'? What did you wear during your sleep lab?"

It took me some time, but I have my sleep all figured out now. Three, no four, things work for me. One, no alcohol. It's been shown to interrupt your sleep cycles, so I cut out my nightly glass of wine. Two, a great book. Three, Tylenol PM. Just one, occasionally. And four, in a pinch, 1/2 of a 10 mg Ambien tablet. I still have half of a thirty-day supply prescribed from last November. Take it on an empty stomach and within a half-hour, I'm a little woozy. Next thing I know, I wake up and it's morning time. And life is good. Bring on the day!

This isn't medical advice, just what works for me. Sometimes, though, it works too well. After taking a Tylenol PM several nights ago (I'm in the midst of several busy ER shifts), I woke up the next morning, horrified. On the ottoman beside our bed, my laptop computer sat with the top opened. Here, after taking my Tylenol PM, I had the brilliant idea to email a few people about their kind comments left on my blog. Rereading those emails this morning, I could only laugh and send those readers a follow-up email, apologizing for the ramblings. Forgive me if you got one.

Okay, I gotta run. I feel the Tylennnnnolll PPPPPMM kkickkkkkingggg innn aaagainnnnnnnn. Seriously. As we used to say when I was younger, "Good night, sleep tight. And don't let the bed bugs bite."

As always, big thanks for reading. Next post will be Wednesday, March 10. See you then...

Friday, March 5, 2010

The Appreciative Cashier

Sometimes, in the midst of a crazy shift and six-hour patient waiting times, I can easily forget that I signed up for this job. This forgetfulness can lead to extreme frustration, which only leads to a vicious cycle of being more and more short-fused and less appreciative of our jobs. I don't like these types of days, and I am grateful when I'm reminded that our jobs are not isolated in these frustrations.

A few years back, I was at a local store waiting in a very long cash-out line. It seems that several cashiers had called in sick and the store was trying to cope as best as they could. I picked the shortest of the waiting lines and still was about eight customers back.

I clearly remember the grumbling. It seems that everyone had an opinion of either how to make things go quicker or shared their thoughts they they would never return to this particular store again. How dare them make us wait like this? What were we, cattle or something? I smiled, correlating this to how our ER waiting room mood must be on those hectic days.

Slowly, but steadily, my line advanced to where I was next, following a gentleman who wore an armed-service ball cap. He had grumbled along with everyone else and, by the look on his face, was tired of the waiting. He placed his merchandise on the counter as the cashier greeted him.

"Hello, sir," she said, with a warm smile, "I'm sorry about your long wait. Did you find everything you were looking for?" Her pleasantness, apparently, remained unscathed.

The gentleman ignored her as he pulled out his wallet and a few bills. The cashier, her hair mussed and her make-up long past the point of retouch, was not to be deterred. She continued scanning his merchandise while she spoke. "Oh my, is that your hat, sir?" she asked, pointing to his cap. "I see it states that you are a veteran of the Army."

He touched the brim of his hat as he sized her up, finally returning her smile. "Well, yes, I was in the Army during the Korean War."

"Well, then," she said, now pausing and giving him her undivided attention, "I would like to thank you for your service to our country."

Hey, wait a second here! I had just witnessed something pretty special and neat. I was so caught-off guard and pleased by this cashier's actions that I could only imagine how this gentleman now felt. In fact, he was a completely different fellow after that--talking and joking around until she finished cashing him out.

I was next. "I have to tell you," I said to her after her kind greeting, "that how you handled that gentleman was great. You made his day with your kind words."

"Thank you, but I really do mean it. My grandfather and my father were both in the Army, and my brother is in Iraq right now. I can't even imagine what it would be like to go to war, you know?" She went on to tell me that every customer who goes through her line wearing some form of armed-service clothing gets a "thank you" from her.

She was an inspiration. Despite everything falling apart around her, she never once thought to be huffy or rude and, more so, was handing out compliments and immersing her customers in kindness. She demonstrated that grace-under-fire is not a lost art. If I could, I would have offered her a job in our ER. And lots and lots of money.

Several weeks after this, my wife, my kids and I drove a few hours to a nearby city's zoo, much larger than our local one. We were having a perfect zoo-kind-of-day, sunny and warm, with all the animals out and about within their exhibits. As we were walking down a paved, gently-sloping pathway, away from the exhibits of pacing polar and grizzly bears, we approached a gentleman in a wheelchair, coming from the opposite direction. He had bilateral below-the-knee amputations and was being pushed by what looked to be an adult grandchild. The man was wearing a matching t-shirt and baseball cap.

They read "United States Army."

As we were about to pass him, I stopped and looked at the both of them. "Excuse me," I asked, "but do you need any help pushing your wheelchair up the hill?"

"Why, no," the man in the wheelchair answered, his grandson nodding his agreement, "but thank you for asking. He looked at my children, who had halted by my side, and gave them a crooked, toothy, friendly smile.

I have to admit, I was nervous about what I said next. "Sir," I said, focusing on his clear brown eyes, "I can't help but notice your shirt and cap. Did you serve in the Army?" Was it any of my business?

He didn't seem to mind my question, although he did seem surprised that I had noticed. "Yes," he answered, "that's where I lost both of these." He nodded his attention to his partial legs before clasping his hands to his denim-covered knees. "Lost 'em in Vietnam when I was 24."

"Well, sir," I said, taking a note from the department store cashier, "I thank you for your service to our country. Because of you, my family knows what freedom is." I held out my hand and he took it, shaking it vigorously. I shook his grandson's hand next, and then we parted.

Walking away, I turned back for one last look at an everyday hero, a war veteran. Lucky for me, he was doing the same. Our eyes met. I'm not sure what he read in mine, but I saw the gratefulness emanating from his. I smiled before turning back to my family.

My kids, ages nine, seven, and five at the time, were completely mesmerized. "Daddy," they asked, "did you know that man? And what happened to his legs?" No, I didn't know him, I answered them, before trying my best to explain how he had lost his legs, fighting for our country and defending our freedom.

After my wife and I answered our kids' questions the best we could, we continued on with our day, enveloped in our freedom, each of us walking on two good legs. My family on the paved path, me on a cloud. Man, did that interaction feel good!

As a result of the appreciative cashier, I try to greet every ER patient who has served in the armed forces with a heartfelt thanks. Try it will make their day. And yours, too.

To think, this happened only because some cashier, during a busy, hurried moment, was able to remember the more important things in life. She made a difference. And I was there to witness it.

And as always, big thanks for reading. Next post will be Monday, March 8. See you then...

Wednesday, March 3, 2010

My John Deere Cap

I am a small-town boy now living in a big town. I graduated high school with 92 friends and, although I enjoy my big town, I miss the values and ways that accompany small-town living. Apparently, I'm not alone in my thinking, since four of my six siblings still live in our small town, all within a few miles of my parents' home.

Part of being small-town is that the work and entertainment varies greatly. Work, besides the obvious, may also include mill and factory work, forestry, and farming. Entertainment may include cow-tipping, four-wheeling, snowmobiling, hiking, fishing and hunting. And sports. How did I almost forget about our small-town sports?

Most recently, after visiting my family, I brought one of my dad's baseball caps home to big-town with me. It was a bright-green John Deere hat, one I had borrowed to wear outside for an afternoon while visiting. Besides breaking-in easily, it fit well.

Now, how many of you are familiar with farming? And forestry? John Deere is a stellar company, one that has stood up through the worst of our economy. My father's business relies on the excellence of their heavy-machinery products, especially their skidders and bulldozers. The people who don their John Deere hats are typically farmers and industrial sorts, salt-of-the-earth types. In my small-town hometown, when you wear a John Deere cap, you wear it with pride.

Returning home to big town, it didn't take long for me to learn that wearing a John Deere hat in a suburban area seems to make certain people assume that you are "slow" or "a hick." Or that you are a country-music lover. Or that you pick your nose freely in a big crowd.

That assumption would be wrong. Completely off-base, actually. Frankly, though, I couldn't care less what other people want to assume, but I find it surprising that this assumption actually exists. Anybody who is familiar with farming or knows a farming family is aware that these are some of the most intelligent, brilliant, and hard-working people you will ever come across. What one assumes might be a simple mind could actually be quiet confidence, introspective intelligence, and humility. I'll take this person over a dim-witted owner of a suit and European car any day.

My father and my brothers? Kind and humble, intelligent and easy-going. After obtaining their college degrees, my brothers chose to follow in my father's successful forestry footsteps. If someone chooses to judge them based on the cap they're wearing or their Carhartt overalls, it won't take that person long to realize that their judgment was premature. And it will only take minutes for my brothers to intellectually bulldoze through those wrong assumptions.

Anyway, back to the John Deere cap. I returned to my big town and proudly started wearing my green baseball cap everywhere--to hockey games, the local mall, my children's sporting events, and restaurants. About the only place I didn't wear my cap was at work in the ER. Don't think, though, that I didn't give that some thought.

The first time I noticed that I was being treated differently, for lack of a better word, was in an up-scale department store check-out line. The cashier spoke freely, easily, to the people ahead of me. Then it was my turn. And it was as if the cashier had a control switch to slow down her voice. And s..l..o..w.. down she did, even going so far as to raise her slowed-down voice while she gave me my change back.

"H..e..r..e.. i..s.. y..o..u..r.. c..h..a..n..g..e.., s..i..r..," she shouted, nearly exhausting herself.

I thanked her and walked away scratching my head, puzzled, and not quite connecting that it was all about my John Deere cap.

Next, I was at a local hockey game and the beer caller--you know, the one walking up and down the aisle with a tray of beers to sell--kept stopping beside me and asking if I was ready for a beer yet. Why, I wondered, was he just stopping to ask me? And again, he talked slower. And louder. I would have given him the benefit of the doubt, except I had heard him talk in regular voice to the people across the aisle from me. As bad as I wanted that damn beer, though, I passed each and every time.

More scenarios followed and by then, I knew the reason. My green John Deere cap. Each time, I walked away not knowing whether to smile at these sporadic ignorances or just brush off them off. I do have to say, though, that it was enlightening, this social experiment for one that I was conducting, to see how certain people responded to my cap.

Most recently, I was at my eleven year-old son's basketball game. I, with another father, had run the clock and kept the score during the home games all season. Before the start of this particular game, the referee approached our table to review some last-minute rules. Of course, he talked in normal voice to the other father before turning to me.

"D..o..n..'t.. f..o..r..g..e..t.. t..o.. s..e..t.. t..h..e.. c..l..o..c..k.. f..o..r... ." You get the idea.

After the ref finished and walked away to start the game, the other father turned to me and asked "What was that?" I pointed to my hat and he looked up, read it, and said "You're kidding, right?" He must have been a small-town boy himself. But no, I assured him, I wasn't kidding.

Well, I'm still wearing my hat. Only now, I don't give much thought to the occasional slow-talker whom I may encounter. This experience has enlightened my perceptions of how quickly others can judge you without knowing you. It's not only my John Deere cap, either. It can be cowboy boots, a certain hairstyle, the car you drive, where you're from, your accent, and how you're dressed, among many other things. That list is l..o..n..g.. .

If anything, now I'm a bit more guarded about my first impressions when I walk into a patient's ER room. Heck yeah, first impressions matter. I'm not denying that. But we should give the person an opportunity to show their true colors before we label them as a simpleton, or otherwise. In fact, why do we even need to label them? And what's wrong with being a simpleton? The medical field seems to be filled with them.

So, if you own a John Deere hat, wear it with pride. Let me hear you yell, "Hell, yeah!" Or, better yet, yell "H..e..l..l.. y..e..a..h!"

And if any of you know a good place to purchase some Yosemite Sam mud-flaps, I would be anxious to hear from you. I've been looking for a set to put on my European car.

As always, big thanks for reading. Next post will be Friday, March 5. See you then...

Monday, March 1, 2010

Hackles Up

The city in which I work is probably, I would say, medium-sized. We have our own collection of restaurants, cultural events, sporting arenas with minor-league teams, several hospitals, and four major colleges.

You would think that our city would be large enough to not run into patients whom I have treated in the ER, but this is simply not true. There are way too many places to be recognized.

"Hey, doc," they'll say to me in a Walmart line, "do you remember me? You treated my hemorrhoid in 2003?"

Oh, that's right. Of course I remember you now. NOT! And please, sir, whatever you do, don't show me your buttocks to refresh my memory.

I do seem to have a good memory for people's faces, though, and even a better memory of their illness (as long as it's more recent than 2003!). I am much more likely to remember your heart attack, the cauliflower growth on your ear, your thickened, fungal toenail that grew overnight, or the way you cried when our most-skilled nurse put in your IV (along side your ten inch forearm tattoo!) than remember your name.

And, for the most part, if I am not pressed for time, I do enjoy seeing some of these former patients. They are usually gracious and complimentary--who wouldn't enjoy that? We don't get a chance to follow-up with ER patients like an office-setting practice does, so I appreciate hearing about how they are doing and what worked in successfully treating their illness.

There are, however, a few circumstances where I would rather not be approached.

For one, the gym. I appreciate my gym-time immensely and rely on my workouts to keep me centered. Since I have treated multiple patients who frequent my gym, I usually wear a baseball cap pulled practically down to my upper lip to remain incognito. The only problem with that, besides bumping often into the weights, is I'm not quite sure if people are looking at me because I look familiar to them or because I look like the ultimate dork.

My other issue about the gym is this: if you see me standing naked (pre or post-shower) in the locker room, please let me finish what I am doing (translation--let me get some underwear on!) before you approach and share with me. Especially if I'm bent over drying my toes! I'm not shy, really, but rarely can someone give me a good hemorrhoid or constipation story in less than ten minutes. If it is a heart attack or stroke story, I know I'm committed for a good 20-30 minutes. Let me tell you, I can grow a whole crop of goose bumps like you've never seen in that time!

So, obviously, the gym is out.

My only other issue is that I do not want former patients to share if my kids are with me.

A few years back, I was on a date with my three young kids. Just me and my kids. We had ourselves a nice meal at The Olive Garden and then went to the movies. On our way home, we stopped at the local Target to buy fingernail polish (for Daddy's famous manicures) for the girls.

A woman who works in the pharmacy section of the store is a former patient. In fact, not only have I treated her multiple times, but I have also treated her troubled, teenage children several times. The last time I had seen her was at her daughter's bedside. Unfortunately, her daughter had to be transferred to a psychiatric hospital for further care.

Now, I have never had any bad interactions with this woman or her children and, in fact, I remember having gone out of my way to show them extra kindness because of their many problems. However, as a result, this woman has tailed me through the store on several prior occasions, giving me updates, sometimes graphic, of their follow-ups. I remember being quite uncomfortable, at times, through these conversations.

On this particular day, as the kids and I were holding hands and happily walking through the store, I was hopeful that I wouldn't run into this woman.

Wrong. She spotted us almost instantly.

She came running up to us from behind, startling my kids and myself. I said hello to her and gave her a warm smile. My kids, inherently shy with strangers, crowded for space behind my back. I skipped their introduction.

"I know you'd want to know about my daughter," she started, speaking quite loudly.

"I sure would," I said quietly, kindly, "but maybe another time when I'm not with my kids, okay? We're on a date and just ran in to pick out some fingernail polish. I sure hope she's okay, though."

"Oh, sure, she's," she answered, gruffly. She didn't stop there, though. She started to tell me, in embarrassingly explicit language and detail, how her daughter had acted-out and had gotten into more recent trouble.

As she spoke, I could feel my protective hackles coming on. My kids cowered into the back of my legs, gripping my pant-legs and tugging me into them.

I interrupted her. "Maam," I repeated, now emphatically , "I am on a date with my kids and, frankly, don't feel comfortable with how you are talking in front of them. They don't need to hear of your daughter's problems."

"Well," this woman said, somewhat affronted, "they need to learn about this stuff sometime." Learn what? I thought. About your daughter's acting-out? Or, from you, how to use a swear word? Either way, I don't think so.

"No, maam," I answered, struggling to keep my cool and smile, "you're wrong. My kids don't need to learn about your family problems. And they don't need to hear such explicit language, from you or anyone. I would never condone this type of language in front of them."

The woman huffed and seemed slighted, but I didn't care. "I wish your family well," I said with sincerity, "but I'd appreciate it if you let us keep moving here. Have a good day." Without waiting for a reply, I eased my hands into my children's backs and guided them onward, toward the make-up aisle.

Although I've seen this woman several more times in Target since that interaction, I have not seen her or her children in the ER since. She does not approach me anymore, either, although several times I have nodded a "hello" to her. I do hope her family is well.

I often wonder if I handled this interaction appropriately but, at the end of the day, I need to protect my kids in the way I deem necessary. They don't deserve the intrusiveness of my job. And they certainly don't need to learn their swear words from Daddy's former ER patients.

Would any of you handled this interaction differently?

There is a silver lining in all of this, though. At least I wasn't standing naked in a locker room when this conversation happened!

As always, big thanks for reading. Next post will be March 3. See you then...