Friday, April 30, 2010

The Golden Smile

A few years back, I met a very endearing patient. Sweet and likable. Polite and respectful. The interaction was thoroughly enjoyable, fun even, and by the time I had finished treating her in our ER, Miss Claire had wormed her way onto my favorite patient list. Maybe even into my heart.

I had walked into her treatment room not quite knowing what to expect. By the triage report, Miss Claire seemed a little off-center. She had complaints of some shortness of breath for the past two weeks. And she smoked. However, she didn't have any complaints of a recent cough or cold and denied any chest pain or recent trauma. She believed, according to her nurse's charting, that "my next-door neighbors are spraying fumes through the wall that are making me sick." Interestingly, she did have a psychiatric history, although the nurse didn't specify.

Armed with this knowledge, I slid the glass door to her treatment room open, pushing the privacy curtain aside as I stepped in. And as I did, I was greeted by one of the biggest, most genuine smiles I think I have ever seen.

Miss Claire was sitting upright in her cot, alone, just waiting for someone, anyone, to walk into her room. She didn't have a book or magazine. Her TV wasn't turned on. She was just patiently and good-naturedly waiting. And that anyone who walked in? Well, lucky me.

I held out my hand as I approached this smiling patient, feeling a very nice vibe to the room.

"Hello, Miss Claire. My name is Doctor Jim and I'll be taking care of you today."

"Hello, Dr. Jim. I'm sure glad to meet you, sir," she replied, taking my extended hand into the both of hers, warm and soft, and squeezing it gently. Still smiling.

I had a chance to take in her unique appearance as we made small talk. For being on the young side of fifty, Miss Claire certainly didn't look her age. She had smooth, unwrinkled skin, barring the furrowed creases at her lips' edges. Her laugh lines. She had dreadlocks, thickly-braided and black, pulled back from her face and tied in a loose bundle at her neck's nape. She had high cheekbones that danced and small ears that wiggled with each facial expression.

It was hard to pinpoint the exact charm of her warm smile. Her eyes, richly-browned chestnuts, were alive and sincere to the moment. Her smile itself, well, it encompassed the bulk of her face's frame. Full lips outlined her white, rectangled teeth. And the topper? She had a gold-plated incisor that sparkled, with just the slightest head movement, from the overhead lights.

Her golden smile.

I sat on the available bedside stool and got down to business. "Miss Claire," I said, "I read the nurse's notes about what brought you here today. Do you mind if I ask you a few more questions?"

"I would be glad to answer any of your questions, Dr. Jim."

I reviewed her complaints, listening to her patiently explain, again, that she was having shortness of breath, for over two weeks, that she felt was most likely due to her neighbors infiltrating her walls with fumes. "What kind of fumes, maam?" I asked. "Oh, I don't know," she said, not losing her smile, "I guess 'carvon mitoxide' or something like that. And sometimes the fumes smell like frying bacon."

On review, she didn't have a fever. Or a cold. Or chest pain. Or any calf trauma (a cause of lower extremity blood clots that can occasionally travel to the lungs). Nothing suspicious, really, that would raise my hackles to think she might have a serious illness.

"And maam," I continued, "may I ask you about your mental history?"

"Of course you can, Dr. Jim." She had a history of bipolar depression. And sometimes, she admitted, she heard voices. "But I'm on medicine for all of that," she assured me. She was not having any suicidal or homicidal ideations. She had never tried to harm herself or anyone else. She did have a counselor and did meet with him on a regular basis. With all of my questions, she proudly faced them head-on. And with a beguiling pleasantness.

She had even gone so far as to have her apartment supervisor come to her residence and "check things out." Everything had checked out fine, including a normal "carvon mitoxide" reading.

I really liked this woman. And to her credit, she was easy to like.

I proceeded with my exam. Great vital signs. Good pulse-ox. A completely normal exam, including regular heart sounds and clear aerations of her lungs on auscultation. Given Miss Claire's age and waiting time, her nurse had ordered an EKG, a CXR, a d-dimer (a nonspecific blood test that, if positive, increases suspicion for a blood clot), and a carbon monoxide level. Ultimately, the results all returned favorably.

At one point, after I had reviewed Miss Claire's EKG and CXR, I stopped in her room to explain those results and let her know that her blood tests should be returning shortly.

She was still smiling.

I decided to slow down for a few minutes and, after walking to her bedside, sat down on the vacant stool. "You know, Miss Claire," I said, relaxing, "you have one of the most welcoming and kind smiles I think I have ever seen. What a great way for you to greet the world."

"Thank you, Dr. Jim. There ain't no sense in showing the world anything else, now, is there?" I nodded my agreement at this wise woman. "And," she continued, "you seem to be smiling as much as me, sir." I thanked her back, flattered by her genuine compliment, before we continued on and had ourselves a fine ten-minute conversation.

After her normal blood work returned, I had two conversations on Miss Claire's behalf. One, to her counselor, who, upon learning I was calling on behalf of Miss Claire, said "Isn't she the sweetest lady?" Her counselor was going to follow up with her the next morning. The second call was to Miss Claire's family doctor. Although I think Miss Claire's complaints were based on a mild paranoia, I wanted her family doctor to follow her closely in the event she needed any further, non-emergent work-up, including allergy testing. The office nurse gave me a follow-up appointment, ending our conversation with "Isn't she a pleasure?" She certainly was that.

I entered Miss Claire's room one last time, explaining to her the disposition and follow-up plan. I assured her that I was quite pleased with her test results. "If you're pleased, then I'm pleased, Dr. Jim."

"I am pleased, Miss Claire," I replied, before hesitantly continuing. "It was a pleasure meeting you today, maam. A privilege, really. And whatever you do, don't ever lose that smile of yours."

After our goodbyes, Miss Claire shuffled down the ER hallway toward the exit, her discharge papers in hand. I lingered in the hallway, watching her leave, appreciating her warm greeting to every person she passed, whether it was a faint "hello" or a friendly nod of her head. Or both. I smiled to myself, watching the wonders of her kindness in action.

What a beautiful individual.

Golden smile and all.

As always, big thanks for reading. A special thanks to Dr. Kevin, from, for kindly requesting and reposting one of my earlier works yesterday. I am honored. Have a great weekend. See you Monday, May 3...

Wednesday, April 28, 2010

Double Crack

There are occasions, in the midst of examining a patient, when I am caught off guard by some meaningless observation or physical finding.

For example, I never would have guessed that an 80 year-old grandmother named Bertha would have a tramp stamp. But, a few weeks ago, there it was, a four-leaf clover tattooed right on the small of grandma's back. It distracted me from appreciating her diamond-studded nose-ring, I'll tell you. A few days later, I treated a very pretty college student who made me wince when she shook my introduction hand within her own man-hand. And, on the same shift, I treated a college guy who didn't have one hair on his entire body, thanks to an overactive Gillette razor. Not one. Heck, even the 50 year-old conservative business man surprised me with his bilateral nipple piercings (I am thinking "ouch" even as I type that). Impressive what a double-breasted suit can hide.

These physical findings rarely play any part in treating a patient or making a diagnosis. They are simply observations that happen to be noticed during the course of a thorough physical exam. Nothing judgemental. No prejudices. Just an aspect of a patient's physicality that jumps out at you when you aren't expecting it. To each their own, I say. Whatever makes you happy and isn't harming the next fellow human being.

I think anyone who does a patient exam can relate to these surprises, though. If nothing else, these findings keep me on my toes. If truth be told, I like these unexpected discoveries--these little secret gems that a patient would probably not commonly share with his fellow man. Seriously.

Picture it. "Um, yeah, Darryl," I imagine a patient confessing at a tavern, an empty pitcher of Guinness sitting between him and his good friend, "I need to tell you something. I have seven toes on my right foot. And, I have your wife's initials trimmed in my chest hairs." Yeah...I don't think so. Lucky me, though--I get to discover those initials when I auscultate this patient's heart.

The other day, I was privy to one of my more favorite observations. Like a rare bird, the sighting of one of these is few and far between. In fact, I can count on two hands how many times I've seen this characteristic in my career. It was very exciting.

I can just picture you now, sitting on the edge of your seat, saying to yourself, "What is it? What did he see?"

Okay. I'll spill. It was the famous (drum roll, please)... "double crack."

Walking into Room 31, I had no reason to suspect that I would, in a few short minutes, be giddy over seeing another double crack. It had been a few years, easy, since my last sighting. And, to be honest, this patient did not fit my usual perception as to who would possess the double crack.

I introduced myself to this patient. A very nice person who had been suffering with some dizzy spells and a chronic cough. Nothing major, but just enough of an annoyance that, after a few weeks, he wanted to be "checked out." After a satisfactory interview, we moved on to the physical exam. Vitals were reviewed. An HEENT exam was normal. Throat and neck, good. The heart, steady and strong with a regular rhythm and no murmurs appreciated.

And then...the spotting of the double crack.

After listening to the patient's heart, I had the patient, who was in a gown, sit up in his cot, leaning forward so that I could auscultate his lungs from a posterior approach.

I had my stethoscope in my ears, listening as I had the patient take several deep breaths in and out, when I casually glanced down along the patient's mid and lower back. And there it was, the double crack, staring back at me, waiting for me to discover it's existence.

To explain the double crack, I am taken back to the first time I had to explain to my giggling kids, at a local zoo, why the baboons' bottoms were bright red. You know that color--the inflamed, captivating shade of a deep, rich sunset. "It's just part of being a baboon," I told them. No other explanation, really, was needed. The baboons' bottoms were what they were. And, as I told my kids, I don't even know if the baboon knew his own bottom makes a bright-red firetruck look dull.

Note to self--don't forget to do a google search on the baboon's red ass.

But, just like the baboon's ass, it is very hard for me to take my eyes from the double crack. And to explain why it exists? I can't. It just does.

So, as I tracked along this patient's vertebrae with my eyes, I spotted his double crack in the lumbar region. Whether it was the way this patient's skin folded, or the way the patient sat, or the way his supporting muscles ran longitudinally along his spinal column, or just where his body decided to deposit some extra fat, I really couldn't tell you. But, when I had this patient sit up in his cot, the sides of his lower back tissue folded up to meet at the mid line, creating a perfect replica of an ass crack.

I kid you not.

Starting around the upper lumbar area, the deep fold ran the length of the lower back, ending just before the tailbone region. There, a gap of about two inches of regular anatomy existed, giving good pause between the impostor crack and the beginnings of the patient's real buttock's crack. Yep, the real crack poked out of this patient's droopy underwear, challenging the impostor crack to a face-off. I couldn't have picked the better crack. Deeply creased and pressed together, that impostor crack looked like the real thing. Perfection, almost.

Thus, the double crack.

I had the patient take a few extra breaths, relishing my sighting while I made sure the patient had good air movement within his lungs.

Like the baboon and his fiery red ass, I don't think this patient knew what he was in possession of. Maybe a good thing, really. I sure wasn't going to tell him.

Could I even bill for that diagnosis? Any coders out there? Acute double crackitis. Code 191.22.3?

I came home that night and looked at my lower back in the mirror. I sat down. I stood up. I rotated. I side-bended. Nope, no double crack on me. I even made my wife look, but she couldn't spot one, either. Darn it. I secretly wanted my own double crack.

"Sorry, Jim," she said, laughing, "you'll just have to suffer through life with one crack."

I guess I'll just have to make myself an appointment to get a tramp stamp.

As always, big thanks for reading (and in this case, tolerating my silly, indecent humor). The well ran dry from a busy weekend, so I took Monday off. Thanks for understanding. See you Friday...

Friday, April 23, 2010

The Complacent Eyes

I walked into Room 35 to find a three year-old lying on the hospital cot. Her father sat alongside her bed, whispering softly to her. The patient appeared quite tired, wiped-out even, and if it weren't for her complacent eyes tracking my every move, I would have thought she might be sleeping.

She was visiting our ER because, after a few days of cough and congestion, she had developed a fever. 102.2. Not such a big deal, usually, for a healthy child. Unfortunately, this child was not healthy.

She had leukemia. Acute lymphocytic leukemia (ALL), to be exact. And because she was currently receiving chemotherapy, a fever with an immunocompromised system could signify tremendous trouble for her.

Because of my experiences with my middle child, Cole, who sadly spent two of the first six years of his life battling his own life-threatening illness with multiple chemotherapies, I was well-aware of the concerns of this family. Besides the concerns, I was also well-aware of the lessons of bravery and love, of sadness and heartache, that came with this child's illness. Immeasurable. Five years after our own journey, I can easily see that I am a better man and a better physician from our experience. A better human being, actually.

I knew how to help this family through this crisis.

This beautiful little girl, with her brown, wavy, returning hair, had been diagnosed with ALL last summer, following symptoms of significant fatigue. She had been transferred to Children's Hospital, where she had a mediport placed and began an aggressive regiment of chemotherapy, high-dose steroid therapy, and prophylactic antibiotics. And, happily, she responded well. Her chemotherapy, just eight months after her diagnosis, had just been reduced to the maintenance phase. Instead of receiving IV chemotherapy every week, she now only needed to receive it once a month. The steroids, the antibiotics, and the oral chemotherapies were continued on their regular schedule.

So, her fever--where did come from? The typical cough and cold symptoms had passed through their house. Mom first, then Dad, and then this patient's younger sibling. Against offered prayers, she was the last to get the runny nose, the congestion, and the coughing. Ten hours before arriving at our ER, she had developed a concurrent low-grade fever that steadily climbed until her presentation for treatment.

Dad brought his precious daughter to us, entrusting us to do right, while Mom stayed home with the younger sibling. He walked through our ER entrance, explained to our triage receptionist and nurse what brought him and his daughter to our ER, and was immediately escorted from our busy waiting room, where his daughter might be exposed to other illnesses, to an isolation room. The door was shut and reverse isolation warnings were placed. Until we learned the status of her immune system, we would take no chances of this little girl getting exposed to any further illnesses.

Anyone who wanted to enter Room 35, while this little girl was being treated, would need to don a mask and gloves and a sterile gown. That included myself, the nurses, the IV team who would access her port, the radiology techs who would take her portable chest x-ray, and our phlebotomists.

So, this is how I met my brave little patient and her father, wrapped in a sterile, disposable, pale-yellow gown, with a blue mask clinging over my mouth and rubber gloves snugly fitting my hands. Hardly a welcoming outfit, but necessary.

"Good morning, Meghan," I said, speaking through my mask, watching the little girl's eyes slowly follow my movements, "I'm Dr. Jim. And I am going to help you feel better today, okay?" I looked for a little spark in those complacent eyes, but, sadly, there was none. Between her fever, not feeling well, and probably expecting to be poked and prodded, she looked miserable.

After talking with Dad, he with the heartfelt smile and calming voice, I performed my exam on Meghan, who appeared so fragile and tiny lying within the cot's hospital blankets. She had an obvious cough, somewhat wet. Looking in her ears, I found a whopping left ear infection. Crusty nares. A patent, non-reddened throat. Her heart and lung exam was perfect. No abdominal pain. Her extremities were unremarkable. Most importantly, she had no rash.

Interestingly, her mediport was not near her collarbones, or clavicles, where I usually find them. Instead, it was on her right lateral mid-abdominal section. "They had a hard time placing one up by her neck," Dad said, "so they put it there instead." The mediport is basically a little pin cushion, placed under the skin, with tubing that is inserted and anchored to a larger vein. When accessed with a needle, it can be used to administer fluids or medications and withdraw blood. Basically, it functions as a permanent IV. After a successful outcome, the mediport is removed, leaving a battle scar about 1-2 inches long.

My son has two, one near each collarbone. Two battles. We won that war.

With Meghan, we accessed her mediport and obtained blood to check her white counts and for cultures. We obtained a urine specimen to check for infection. We performed a chest x-ray. After all of that, we administered a dose of IV antibiotics and a dose of Tylenol.

Happily, her test results returned in her favor. Her chest-ray was negative, absent of any infectious findings. Her urine results were clean--no infection. And her blood counts? They were low, as we expected from her chemotherapy, but not dangerously low. She had a sufficient immune system to fight off this infection.

I called her hematology/oncology team and shared our workup and findings with them. Meghan had the same team as my son, and I was familiar with the person on the other end. They were appreciative of our efforts and we arranged Meghan to be seen by them in two days.

I walked back into her room, smiling, ready to deliver some good news for a change. I no longer needed my gown, my gloves, or my mask. Hopefully, Meghan would be able to see my happiness for her, plastered all along my face's edges. I had a bounce in my step.

If I thought I was happy with her results, seeing Meghan after we gave her fluids, antibiotics, and Tylenol simply made me ecstatic. She was a different child. A beautiful, smiling, interactive toddler was sitting upright in her cot, playing with stickers, eating a blue Italian ice, and watching a funny cartoon on the room's TV. Her fever had obviously broken. And looking at Dad, ten years had been erased from his face.

For a split moment there, I forgot about Meghan's fight for her life.

And in this moment, a spark had returned to her complacent eyes.

After spending some enjoyable time with both Meghan and her father, I walked back to my hallway desk, lost in my own thoughts, suddenly thinking about the five years that have passed since my son's complacent eyes regained their permanent spark. And I said a few silent prayers. One for my son. One for Meghan. And one last one, for every child who's eyes have lost their spark.

May they someday get it back.

As always, big thanks for reading. May your weekend be a great one. See you Monday...

Wednesday, April 21, 2010

The Hallway Seat

Our emergency department, including our express department, consists of thirty-six rooms, four nursing stations and three physician stations. Within the three physician stations, there are nine available computers strictly to be used by the ER team--the attendings, the residents, and the PA/NP extenders--during their shifts. We also have a consult area, a comfortable room with five more available computers, to be used by physicians visiting our ER to admit their patients.

You would think that with so many available computers, there would not be a lack of space to sit down and accomplish your work. But, unfortunately, this is simply not true. Because of the ever-evolving list of admitted patients, the consult room is typically filled with ancillary-service physicians. And between our emergency department coverage of multiple ER attendings and residents, it is rare to have an open, unused computer in our physician stations.

Sometimes, when I show up for a shift, it may take me fifteen minutes to sort out who is working at each computer station and which one might be available for my use. Although I don't enjoy it, I've even had to pull rank on some of the interns and medical students, kicking them off, just to have a place to sit. They understand my predicament, of course, and I try to do it in a respectful way. Still, though, that wasted time and energy can be a frustrating start to a shift.

One of the working solutions? As a result of the shortage of physician computers, we now have three additional laptop computers. They sit on a wheel-based pedestal and are easily plugged in and transported through our ER.

Enter one of my partners and her brilliant idea.

One day, out of her own frustration, my partner decided to set up her own work station. She grabbed one of the laptops, plugged it into an outlet in the main nursing station, and set up the computer just outside of the station, along a stand-up work counter. She got an extra phone and set it on the counter, facing her. She also found a two-foot by three-foot wood-paneled tray and cleaned it off, creating her own little desktop. A comfortable chair completed her newly-furnished work area. To really add a polished touch, she ran to the gift shop and bought herself a couple of carnations, trimming their stems and placing them in a make-shift dixie-cup vase alongside the phone. Compassionate and classy. What a combo.

Not only did she have her own work-space, but it was also an ideal setting for her to keep her finger on the pulse of the ER's activities.

It took a little getting used to, but slowly, the presence of her sitting in the hallway along the counter, just outside of the busiest nursing station, gained favor. From her viewpoint, she could see ambulances arriving and departing, talk directly to the nurses responsible for the most critical patients, and, most importantly, have direct access to the most important person in our department, the unit secretary, who sat just ten feet away. How perfect. And from the staff's point of view, it was nice to have an available physician right in the open.

One day, a few weeks later, after she had finished her shift and I had arrived for the start of mine, I couldn't find an available computer. I looked at Shirley's work station, immaculately clean and empty, and decided to give it a try.

"Shirley," I said, calling her cell phone from the counter phone, "it's Jim. Do you mind if I sit at your work station during my shift today?" I felt I owed her the phone call, out of respect for her diligence in making this new space. Shirley couldn't have been any more gracious. She was actually excited about someone wanting to experience her invented area. "Of course, Jim. And thanks for calling and asking. Anytime I'm not there, feel free to use it."

Slowly, I started using this work-space when Shirley wasn't. It quickly became apparent to me why Shirley enjoyed this spot so much. I didn't feel walled-off from the ER's flurry, sitting in the closet-sized physician stations. Instead, I sat quietly within the hectic pace of the ER, thriving off the frenzied energy that surrounded me. I accomplished my work with a new vigor and gained a new appreciation for our hard-working staff.

I knew I became a mainstay fixture, like Shirley, when I came in one day to find several folded, colored Kleenexes stapled into the shapes of flowers, sitting on the counter and welcoming me to a new shift. I looked at all of the laughing nurses, wondering which one learned such a useful talent in high school while serving on the prom committee. Probably Ken.

Still, there are some downsides to sitting out in the open. Sometimes, on the crazy days, the spillover patients from triage, at the end of the hall, will direct their angry gazes at me. Because I sit in the easiest-to-find place, nurses will often run to me to ask me to see a critical patient or show me a concerning EKG. Likewise, I might be the first one a patient or their family encounters to complain or ask a favor from. Sometimes, I return to my workspace to find a closed-container of urine or vials of blood sitting on my desk, waiting to be sent via our tube system to the laboratory. Just a few shifts back, while waiting for a room to open, the paramedics had taken my empty chair and given it to a drunk guy, who had just shit himself , to sit on. UGH!

Yesterday, though, was probably one of the hardest times I've had to date. While a family mourned the unexpected loss of their mother in the room directly across from me, a schizophrenic patient in the room next to them was yelling obscenities and acting out in the worst of ways. Despite closing his glass door and administering intramuscular medicines, he totally disrupted any peace we attempted to create for the saddened family. We had no other available rooms to move the schizophrenic patient to, unfortunately, and watching this family's misery deepen from his erratic behavior and yelling was upsetting to all of us.

I would not have witnessed this had I been in my corner of the physician's workstation.

Still, the good outweighs the bad, and I thoroughly enjoy my new seating arrangement. I wonder, though, if any of you have had similar problems in your work environment. Especially the ER setting. If so, how have they been solved?

Thanks, Shirley, for a great alternative. I owe you a bouquet of carnations!

For the next few days, if you need to visit your local ER and just happen to find a doctor sitting in the hallway doing his or her work, it's probably Shirley or myself. A buzzcut? That would be me. A pretty woman with highlighted, straightened hair? Shirley. Feel free to stop by and say "hi."

Just don't complain...

As always, big thanks for reading. Next post will be Friday, April 23rd. May the rest of your week by good...

Monday, April 19, 2010

Pretty Gassy

I walked into the central nursing station to find the chart for Room 34, my next patient, and was greeted by Nurse Laurie.

"Dr Jim," she said, handing me the chart as a wave of smile splashed across her face, "I see you signed up to treat my new patient. Good luck. You're going to love this one."

Ugh. A statement like that can be a double-edged sword. And at 2:00 a.m., I could only hope that Laurie meant it in a good way. But, truth be told, her smile scared me a little.

I walked down the hallway, lightly knocked on the partially-opened door to the room, and entered. Lying in the cot, passed out, was a 22 y.o. college student. Beyond the room's dim lighting and this patient's evident sloppiness, I could still appreciate that this was a beautiful young woman.

She could have been a beauty queen. Or an actress. Or a model. Maybe she was a hero among us--a loving granddaughter who visited her grandmother every day in a nursing home or a big sister who watched closely over her younger siblings while she was growing up. Maybe she was that daughter who gave her daddy his laugh-lines.

Maybe. But right then and there, in our ER, she was just another drunk college student. Her hair was mussed up, some grass mixed within her blond, tangled curls. Her lipstick was disheveled and thick. Her mascara had bravely abandoned her lashes, streaking down to visit her jawbone. Her clothes were in a disarray of tucks and untucks. She was a drunken mess.

I turned on the room's overhead fluorescent lights before walking to the right side of the cot. I raised my voice. "Hey, Tiffany," I said, "it's time to wake up and talk to me."

She stirred slightly, moving her head away from my noxious voice and the overhead lighting. "Tiffany," I said, now rubbing her shoulder, "you need to wake up and tell me what brought you here tonight." I padded my khaki's pockets to see if I had any weekend ammonia capsules left. I didn't.

She stirred a little more, this time opening her eyes and focusing on me. I smiled at her. "Where am I?" she mumbled, trying to absorb her surroundings.

Before I could answer her, though, she brought her right hand up to her mouth. I thought she might be ready to vomit or have dry heaves, but she didn't. She simply belched. Big time. It was disgusting and, yet, thoroughly impressive. And as if to let me know that it was no fluke, she belched again. After the second belch, an inebriated giggle and grin escaped her.

Laurie walked in, the smile still frozen on her face. "I thought you could use some help," she said. Yeah, I thought, help me pencil in the eyebrows that this patient just smoked off of my face.

I had read Laurie's nursing notes on this patient but, since the patient wasn't capable to answer my questions, I had Laurie, who had been privy to the prehospital report, fill in all the blanks for me. It seems that this patient, at a local tavern, had just helped a friend celebrate a birthday by downing several shots. After leaving the bar, she simply laid down on a nearby lawn to "go to sleep." Her friends, worried for her, had called 911. She was transported to our ER.

Tiffany's exam, performed with Laurie present, was benign. Well, except for her obvious intoxication. Her vital signs were stable, she had no evidence of trauma, and all parts of her systemic exam were within the normal limits of my expectations. With enough prompting, she was able to talk to Laurie and I in a slurred voice, confirming that she had been out to the bars with friends that night, drinking just "a little bit." She pinched her thumb and index finger. "Just a little," she repeated. She giggled, as if she thought she were successfully fooling us. Upon pressing her, however, she remained amnestic to lying down on the grassy ground.

While Laurie and I got her more comfortably situated, Tiffany closed her eyes to continue her nap.

And that's when the shit hit the fan. No pun intended.

Without warning, while she was napping comfortably, Tiffany let out a long, muffled, fluttering fart. Seriously. It caused both Laurie and I to jump back. Again, like her belch, it was disgusting and, yet, thoroughly impressive. And within seconds, from the stench, I suddenly wished that I could lay claims to such bragging rights as this patient. Someone, please, call the producers of "America's Got Talent."

Laurie looked at me, her gaping mouth mirroring my own. "Oh no, she didn't just do that." I nodded yes, trying to stifle my amusement, as Laurie continued . "That's just gross. If she shits herself, I'm not changing her."

I knew better. If this patient needed cleaned and wiped up, I had every confidence that Laurie would indeed do the right thing. Maybe, to rebel, she would wipe back to front, but still, she would do it.

So, imagine it. This beautiful inebriated girl, all dolled up and resting comfortably in her cot, letting one rip. So unladylike. So disgusting. And yet, so impressive (have I said this already?). Trust me, in Tiffany's case, it was not "what's on the inside" that counted. Thanks to her sharing her insides with Laurie and I, we could confidently say that her outside was probably the better bargain.

Well, Miss Tiffany didn't stop there. Before we left the room, round two occurred. And, while a family from a nearby patient room waited in the hallway while their mother got her EKG done in privacy, Tiffany decided to rip round three. Rounds four and five happened, fortunately, while Tiffany was over in the radiology department getting a head CT. Rounds six, seven, and eight, though, occurred after she returned back to Room 34, much to the dismay of Laurie and all of the central station nurses. Despite her room being located about fifteen away, Tiffany still managed to make quite an impression on all of them.

Because it was a quiet night, we were able to keep Tiffany in her ER room and observe her frequently. Well, the nurses did. After reviewing her normal CT, I was content in just getting updated reports about her from Laurie. Who am I to come between Laurie and her excellent patient care?

Finally, after about three or so hours, Tiffany sobered up enough to walk our hallways and go to the bathroom on her own accord. She walked out of the bathroom shaking her head. "I look like shit."

I think we all bit our tongues over that easy set-up.

Prior to being discharged, I checked on Tiffany for one last, final exam. She checked out well.

"I'm sorry about bothering you last night, sir," she said, chalking up a point for her apology but losing it just as fast by calling me sir. "Sir" equals "old man" when I hear it spoken to me. "I hope I didn't do anything to embarrass myself," she added.

"Oh, no," I assured her, lying through my teeth, "you were perfectly behaved. Not a problem at all." I wanted to be honest with her, but I knew that the truth would have completely embarrassed her. What purpose would that have served? She had been the guiding foghorn on our dark, murky, overnight shift and would never know.

She smiled then, completely unaware of how awe-inspiring her performance had been. I wished I could have given her a standing ovation. Instead, I extended my hand to her and we shook. "Good luck to you, Tiffany." Yeah, I thought to myself, good luck in your pursuit of the 2010 Miss Flatulence title. You're a shoe-in. "Thank you, sir," she responded, gathering her possessions and folding her discharge instructions into her jean pocket.

Pretty and gassy. Pretty gassy.

A pretty vulgar combination, if you ask me.

Isn't a little Monday morning bathroom humor better than a strong cup of coffee? LOL As always, big thanks for reading. See you mid-week...

Friday, April 16, 2010

This Father's Daughter

She was 50. Prior to being transported to our ER, her only complaint had been for non-traumatic elbow pain over the past two weeks. She was on no medications and had no significant medical history.

She was at home, preparing to visit her doctor for a scheduled visit, when she collapsed. Because she didn't drive, her elderly father had planned on swinging by to pick her up. He had just called and spoken to her minutes earlier to let her know he would be there shortly.

He arrived at her front door and knocked. No answer. He rang the doorbell. Again, no answer. Panic set in. This was not like his daughter to not greet him when she was expecting him. He knocked again, harder. Nothing. He kept his finger pressed to the doorbell, hoping his daughter would hear its continuous ringing and come to the door. She didn't. He tried turning the doorknob, but it was locked. He banged his aging shoulder against the door. It didn't budge.

He remembered the spare key she had given him months ago. "I'll never need this," he had said, trying to give it back, but his daughter had insisted he put it in his glove compartment. He stepped off the concrete porch pad and ran down the sidewalk, back to his pickup truck to retrieve the key. He found it, hidden under a pile of napkins.

Returning to the door, he struggled to fit the key into the lock. As a father, he knew something was wrong, very wrong. With trembling fingers, he finally succeeded in properly jamming the key into the door's lock. He turned the doorknob, barely breathing now, his mind racing of the possibilities he would encounter.

The door opened. He stepped into the small kitchen and yelled his daughter's name. No response. He listened to hear if the shower was running, but it wasn't. He strained his ears for anything, any sound of activity that would reassure him he was overreacting.

That's when he heard the moan. It was garbled and low, guttural almost. He followed the sound into his daughter's bedroom. That's where he found her, lying on the floor, beside the telephone nightstand.

He tried to rouse her, but he couldn't. Knowing something was terribly wrong, he dialed 911. Waiting for the prehospital team to arrive, he sat down on the floor beside her, caressing her head. Talking quietly to his daughter, he filled her ear with the promises that everything would be okay. It had to be, since they were all each other had.

The ambulance team arrived. After briefly interviewing her father and performing an exam, they prepared the daughter for transport to our emergency department. They were concerned that this patient may have had a stroke. They offered the elderly father a ride in the ambulance, with his daughter, but he decided to follow them in his pickup.

In the ER, the prehospital radio went off. They reported that a 50 year-old woman with a sudden onset of right-sided weakness and garbled speech was being transported to our facility. There had been no signs of trauma. Confirming that the time frame was adequate, a stroke alert was called in preparation of this patient's arrival. She would be a perfect candidate for tPA therapy if she did indeed suffer a stroke that was not hemorrhagic.

I, with the rest of our ER team, waited for this patient's arrival in Room 26. In three short minutes, she was being wheeled through our ambulance bay doors and down our hallway. Quickly, we were able to slide the patient from the prehospital stretcher to our hospital cot, all the while listening to the medical report given by one of the paramedics.

Her vital signs revealed that her blood pressure was quite high. She had no fever, her respirations were slow and erratic, and her pulse was normal. On exam, she had a flaccid right side, was nonverbal except for her occasional moaning, and teetered between some minimal form of consciousness and being unresponsive. It appeared that this patient had suffered some catastrophic brain event.

We emergently intubated this patient, both to protect her airway as well as ensure adequate oxygenation to her ill body. After a repeated exam by the neurology team, the patient was hurried to the CT scanner to determine the extent of her stroke.

While she was out of our department, escorted to CT by our nurse, the respiratory therapist, and a neurology resident, I went to the family room to speak to this patient's father. I was accompanied by our social worker and nursing supervisor.

I knocked on the door, opening it slowly to reveal a gentleman in his mid-seventies, tearful and distraught, running his hands through thin wisps of graying hair as he sat in the corner wing-backed chair. He had the look of a hard-working, honest man, dressed in a pressed flannel shirt and brown Dickie pants. He was alone.

"Sir," I said quietly, after introducing myself and my team, "I'm so sorry about what you are going through. Can you tell me what happened or anything that might help us with your daughter's care?"

With great detail, he told me about their plans to visit her family doctor that morning regarding her elbow. He was not aware that she had any medical problems. "She's a hard worker, that one. Never had time to be sick, really." He shared how he went to pick her up, only to find her collapsed beside her bed prior to his calling the ambulance. I listened intently, watching this father struggle to be stoic in his misery.

After maybe five minutes, a faint knock on the family room door preceded one of our nurses stepping in and interrupting our conversation. "Dr. Jim," she said, "can you come here, please."

I excused myself, leaving the father with our social worker and nursing supervisor. I stepped into the hall. "What is it?" I asked the nurse, herself wearing a worried look on her face.

"The CT scan, it's bad. The radiologist wanted me to get you."

I rushed to our physician work space, pulling up the patient's head CT images on the computer panel while I dialed the radiologist's number. What I saw saddened me. This patient had a significant brain hemorrhage, one that was shifting her brain from its midline and filling her ventricles with blood. The radiologist confirmed what I was looking at--that this patient most likely had a ruptured brain aneurysm. I called neurosurgery and the OR stat, since this patient needed emergent decompression of her brain's swelling and bleeding. Her problems were life-threatening.

I went back to the family room, where I sat down opposite the father. His expectant eyes bore into me. Slowly and deliberately, I explained all of the results to him. He unabashedly cried, his shoulder's shaking. "She's all I have left," he muttered. I was affected by his emotions and, looking at the tearful social worker and nursing supervisor, I knew that I wasn't alone.

We escorted the patient's father back to Room 26, where he was able to sit with his daughter as we awaited the go-ahead from the OR. I hovered in the room with several techs, the patient's primary nurse, and a respiratory therapist, overseeing the quick preparations of getting his daughter ready for surgery. I continued to watch the father, unable to turn away from the deep grief and ache that enveloped him.

This patient was taken to the OR. Thankfully, she made it through her emergent neurosurgery. She remained far from a successful outcome, however, since her following few days after surgery would be fragile and tenuous.

Usually, I follow-up with these types of emergent cases, the types that pull at my heartstrings. But, for this case, I didn't. I couldn't. I thought of this patient and her father frequently, yes, but I couldn't bear to think of this father losing his adult-daughter. I was willing to risk not learning of a possible successful outcome if it meant I also didn't learn of a sad, heartbreaking one.

I recognize what I am doing. I am protecting myself, adding another cement block to that protective shell that surrounds my heart. Building it up. Tearing it down. It is a constant but necessary struggle for each of us in the medical field.

I hope and pray, though, that this patient did well. After all, this father's daughter was all he had left.

As always, big thanks for reading. Next post will be Monday, April 19. I hope you have a great weekend...

Wednesday, April 14, 2010

Making Me Proud

My wife and our thirteen year-old daughter went on a girls' date this past summer. Just the two of them. Shopping, shopping, and more shopping. And. More. Shopping.

The rest of us gladly gave them this time, happy to avoid our busy mall area.

Karen and Emma had a wonderful day of togetherness. They had gone to stores they normally wouldn't shop at, trying on different-styled clothes and shoes, and just enjoying their "girly" afternoon immensely. Fashion shows left and right, I'm sure. And at Emma's age, nothing is better than a private day with Mom, right?

At one point in their day, unfortunately, they had experienced a little "encounter."

Last year, we purchased a VW Beetle Convertible to run around town in during the brief but beautiful summers we have here along our great lake. It's not a big car and certainly doesn't need a lot of room to be parked comfortably in a spot. What it lacks for in size, though, "Bumble" makes up for in fun. Can you imagine the added pleasure that driving this car during a girls' afternoon out brought to my family?

So, during their excursion, my wife and daughter decided to stop at Marshall's. My wife, as she tells the story, drove down the main parking aisle near the store and found two spots alongside each other. She put on her signal and turned into the one empty spot. There were no cars behind her while she was turning in, and no cars approaching from the opposite direction, either.

She and my daughter gathered their things, purses and what not, and, as they were each exiting the car, their doors open, my wife said another car zipped out of nowhere, trying to pull into the adjacent empty spot beside her driver's side.

As she was stepping out, my wife said this car kept impatiently inching forward, into the vacant spot, barely leaving room for her. "He even parked outside of his lines, Jim," she said, adding worth to her story. Sadly, as the car got closer and closer, my wife noticed an offensive man, 50-ish maybe, yelling obscenities and flailing his arms at her. She said it was obvious that he was in a rush and was frustrated with giving her the ten seconds time she needed to get out of our vehicle. A car that you can fit three in one spot, no less.

My wife was incredulous at this gentleman's behavior. Behavior that our daughter was witnessing.

"What's wrong with that guy, Mom?" Emma asked.

"I don't know, honey. Stay here for a minute, though, would you?"

My wife was going to have a talk with this gentleman.

She walked up to this gentleman's car door and waited for him to get out. She mimicked for me the look of surprise on his face when he glanced up through the window to find her standing there. I wish I had been there.

He opened his door and got out, cleaning up his behavior and no longer swearing.

"Is there a problem, sir?"

Clearly, she had embarrassed him. He didn't respond and struggled to keep eye contact with her. She just kept staring.

Isn't it funny how a lack of a windshield can turn a lion into a mouse?

"Did I do something wrong to offend you," my wife continued, "because if I did, tell me so I can apologize to you for it."

She paused, giving him a chance to explain himself. He didn't grasp the chance. I can only imagine what being called-out felt like.

My wife continued. "And if I didn't do anything wrong and you were just yelling and waving your arms at me because you were impatient, then I don't appreciate your behavior at all. In fact, you should be ashamed of yourself."

She pointed to my daughter. "That's my thirteen year-old daughter over there. We're trying to raise her to be a good citizen and person. Today, she witnessed your rude behavior and asked me why you were acting this way. What should I tell her?"

The man was frozen to his spot, speechless. Again, he offered no excuse for his behavior.

"I guess I'll just tell her that you're having a bad day and leave it at that. I'm sure you wouldn't want us to think you act like this every day."

My wife, realizing her point was made, turned back to our daughter. "Come on, honey," she said, walking back and holding out her hand to Emma, "let's go do some shopping."

Together, hand-in-hand, they walked into the store.

Hurray! My wife, although steady in her beliefs and convictions, rarely sees the need to be confrontational. To her, that is wasted energy. She has that rare ability to see the best in everyone, often dismissing their ugly side to "They must be having a bad day." Clearly, though, this man's swearing and carrying-on must have affected her to some unfamiliar level.

If you ask me, mama bear was just protecting her cub.

From every perspective, my daughter was fortunate to have learned such a lesson from her mother. Importantly, Emma learned that one can stand up for themselves and do it in a respectable and dignified manner. Sadly, though, not every person is going to have the courteous manners and exemplary behavior that we try to instill in our kids, and we just need to accept the good with the bad. Actually, embrace the good. And, before moving on, learn something from the bad. In the right doses, actually, the lessons learned from these negative encounters may hold more benefit for our children than we realize.

The best thing about this encounter, though, from my view? My daughter was able to see that she has one heck of a cool Mom.

Something she probably already knew.

As always, big thanks for reading. Next post will be Friday, April 16. See you then...

Sunday, April 11, 2010

A Couple Days

I walked into Room 17 to see a sixty-ish woman who, by the nurse's triage note, had come to our ER for shortness of breath. A smoker, with a history of chronic obstructive pulmonary disease (COPD). The nurse's note reflected her suspicions that this patient may have pneumonia.

I walked into the room to find a woman who appeared much older than her stated age. Her thin, gray hair hung lifelessly along her face to her shoulders, a needed washing evident. Her face was pale. Thick, crevassed wrinkles hovered at the corners of both her eyes and lips. Clear plastic tubing ran along the front of her emaciated, gowned torso, only to wrap around her ears, swing back, and sit comfortably within the patient's nose. Necessary oxygen, since her levels had been below normal upon her arrival.

The most spelling observation, however, was the smell of the room. Overpowering. A stale, cigarette-scented heaviness combined with a musty, ill-human smell. The smell of a neglected, mistreated body.

Except for her nurse standing at the room's corner counter, this patient was alone. And as we awaited the arrival of a respiratory therapist and a radiology tech to take a portable chest x-ray, I had my chance to interview this patient.

"Hello, maam," I approached, my gloved-hand extended. "I'm Dr. Jim and I'll be working with Nurse Denise to take care of you today."

She nodded her acknowledgement, took a deep breath through her nose, and mumbled a return greeting.

"What can we do to help you today?" Although she was in some degree of respiratory distress, I didn't know how far she was from her baseline. Something told me, though, that this woman lived every day with some respiratory struggle.

"Well," she started, her voice dry, "I've had a wicked cough for a couple days and now I'm having trouble breathing." She spoke fragmented sentences, squeezing out four or five words at a time before pausing to drag in a hit of oxygenated air through her flaring nares.

I asked my usual questions. Fever? "Yes, a couple days." Sputum? "Yes, a couple days." Achy? "Yes, a couple days." Are you eating okay? "No." For how long? You guessed it--"A couple days." Have you been using your nebulizer? "Yes, a couple days."

It became a game between us. This patient, despite her distress, was having some fun with me. She was able to successfully twist almost each of my questions around until her answer, "a couple days," seemed an appropriate response. Every question, no matter how I phrased it, was artfully turned on itself. Nurse Denise, now starting the patient's IV, kept glancing at me, loving the mind-play that she no longer had to endure.

I liked this patient.

Finally, I knew I had her. "Maam," I asked with sincerity, "do you smoke?" From the smell of the room and her body, from her wrinkles and parched, scratchy voice, I knew the obvious answer. Like any other patient, though, I needed her to share the specifics of her smoking habit with me.

She took another deep inhalation before answering. "No." Her answer surprised me.

"Excuse me, maam," I said, arching my brows, "you don't smoke?"

Again, emphatically even, with a defiant glint to her eyes, she answered me. "No, I don't smoke."

Hmmm, I questioned myself, how could I have been off-base on this one? I decided to take the round-about way. "Have you ever smoked, maam?" Her answer was short and sweet. "Yes." Now I figured it out, cracking her. "And when did you quit smoking, maam?"

Although her answer was somewhat expected, even I was surprised by it. "Three hours ago."

Seriously? Are you kidding me here? As much as her answer annoyed me, though, I had to appreciate this woman's gumption. "So you quit three hours ago?" I confirmed with her. She nodded her head. "Yes. I decided to just throw those nasty things out."

"Congratulations to you," I said, smiling, "but do you think that qualifies you as a non-smoker now?"

"Well, why wouldn't it?" she asked, sincerely. "I don't plan on smoking ever again."

That's a story I've heard time and time again, unfortunately, and this patient had a long medical history of coming to our ER for similar complaints. She would be a non-smoker only until she got back home and pulled those "nasty things" back out from her garbage can. Unless she stopped at a convenience store first, after her discharge.

This patient did well for us, turning around much better than I had expected. She received IV steroids, several breathing treatments, antibiotic coverage, and some cough syrup. Soon, she was speaking full sentences again.

After fine-tuning her, I discussed with her my wish to admit her and make sure she continued to improve. She flatly refused. "I've got cats to feed at home," she said, "they're my babies." And although I believed her, I think the stronger reason was that her cigarettes were getting quite lonely without her attention. And she for them, too.

She signed out against medical advice. I called her family doctor, who assured me that he would follow up with this patient the next day. He seemed frustrated by this woman's self-negligence, as we all were, failing to persuade her to give up her addiction. Nurse Denise even gave her a smoking cessation talk, but it fell on deaf ears.

With this patient's lack of desire to help herself and her cause, I knew that our ER team would be seeing her again. Years of smoking one to two packs of cigarettes a day had taken an irreversible toll on her body. She was approaching the phase where soon, she would be requiring supplemental oxygen at home. And more and more medical attention.

A part of me feels bad for the older folks who began smoking years ago, when the ill-effects were not as clearly defined. This habit breeds itself into so many aspects of a person's life, and I can't imagine the effort it would take to pull that yellowing thread from one's life quilt. I have a harder time, though, understanding the younger population who imbibe in smoking. Haven't they seen the aging effects? The portable oxygen tanks that their predecessors rely on? The escalating cost of their habit? From a medical standpoint, treating asthmatics and COPDers who smoke remains a staggering portion of our patient load within our department.

After a social service consult, this patient was discharged to home and encouraged to follow up with her doctor in the morning, as we had scheduled, or return if her symptoms worsened or changed in any concerning way.

As much as we tried to help this patient, I knew she would be back. Eventually.

I just hope not in a couple days.

Sorry this posted late. As always, though, big thanks for reading. Next post will be on Wednesday, April 14. I hope your day goes well...

Friday, April 9, 2010

The Witness

The patient arrived in cardiac arrest. He had been brought to our emergency department in the middle of the night. Although he had a significant cardiac history, he was only in his late-forties. His transport from his house to our department had been less than ten minutes and, along the way, the pre-hospital team had done an excellent job of intubating this patient and establishing an IV.

His wife was with him. Less than fifteen short minutes before their arrival, her life had been altered forever when her husband had woken her, from a deep sleep, to complain that he had intense chest pain. Seconds after, she witnessed him become unresponsive.

On arrival to our ER, we found this patient to be in pulseless ventricular tachycardia, a malignant, life-threatening electrical rhythm of the heart. Following ACLS protocol, we shocked this patient several times while performing CPR and administering multiple doses of medications to combat this rhythm.

After several very intense minutes, we were able to regain a sinus rhythm and a pulse on this patient. Despite this, he remained unresponsive and his blood pressure was minimal. We continued our efforts to stabilize this patient as we awaited cardiology's arrival.

Despite our aggressive medications and interventions, this patient returned to a pulseless ventricular tachycardia. More shocks followed. More medications were given. And, once again, we were able to break the bad rhythm. But, not for long.

Cardiology arrived and together, we continued to fight for this man's life. His rhythms were very fragile, and it seemed that he alternated between a normal rhythm and these continued life-threatening ones, now including asystole (a flat-line, so to speak). Asystole is bad, very bad, and is rarely survivable.

We were running out of options. If we were going to be able to intervene any further, we needed this patient to remain in a more stable rhythm. Getting him into a sinus rhythm had been hard enough, but nothing we seemed to do would keep him there. His heart, from previous infarctions and damage, was resistant and stubborn to our best efforts.

As the cardiologist and our ER team continued with resuscitation efforts, I went to the family room to speak to his wife. She was obviously upset, and I explained her husband's dire situation. Our reality was that time was not our friend, that the longer he continued in asystole and ventricular tachycardia, the less chance of his survival. She understood my words. "I always knew it would end this way," she said, her honest words reflecting her inherent sense of the situation.

I invited her back to be with her husband, to witness the momentous efforts we were all giving him. She wholeheartedly agreed, embracing my invitation.

Returning to the oversized room, filled with people and shiny medical equipment, I looked at the resuscitation through her eyes. Three nurses, each scurrying with a focused determination, documenting our efforts and pushing IV medications. Two techs, one actively performing CPR while the other was readjusting the patient's blood pressure cuff. Two respiratory therapists, standing at the head of the bed, one using an oxygenated bag to ventilate this patient via his airway tube while the other prepared a mechanical ventilator, ready to be used in the event of our resuscitation succeeding. The cardiologist, standing at the patient's open side, dictating the next course of medications. The pharmacist, standing with the crash cart outside of the patient's door, repeatedly handing in the next dose of ordered medication. The patient's wife. Me.

And the patient. Lying on the hospital cot. Unresponsive. In asystole. Again.

I guided her to his side, where she grabbed his hand.

Despite this many people in our big resuscitation room, the air seemed open, the frantic energy palpable. The team moved purposefully and in sync. Their caring, their vigor, their sadness, their intensity was obvious, witnessed by the patient's wife.

Unfortunately, the patient's heart became refractory to all of our best efforts and our medications no longer had any effect. I had the tech hold CPR and we confirmed asystole on several cardiac monitor leads. The portable ultrasound was brought to this patient's bedside. It confirmed our worst fears, that his heart had no squeeze, no motion, no life. His wife saw the stillness of his heart on our black-and-white screen.

Forty or so minutes had passed since the patient arrived and, as I had explained to the wife in the family room, time was not our friend. We had no other options of treatment to save this patient.

"Please, stop," the wife said. "Please, just let him go in peace."

A powerful moment.

With no objections, we ceased resuscitation efforts. Time of death was proclaimed. I thanked my team. I crossed myself. I conveyed my sympathies to the wife. The crowd of people slowly withdrew from the room. The lights were dimmed. The patient was covered in nice, clean blankets. The patient's wife was brought a chair, along bedside, where she sat, continuing to hold her husband's lifeless hand within her trembling own. A box of Kleenex somehow found her lap.

The family doctor was called. The coroner was notified. I dictated my note.

All methodical parts of my job. When I was done dictating, I went back into the room. As I expected, his wife was still there.

"I'm so sorry for your loss," I repeated.

She nodded. "I know you tried your best." She paused, taking a deep breath, before continuing. "Thank you for letting me be with him in the end. I needed to be here."

I walked back out of the room, thinking about how much medicine has changed. Not only with newer drugs and newer procedures, but newer thinking. A few short years prior to this patient's arrest, it would have been unthinkable to invite a family member to bear witness to resuscitation efforts. Some literature has evolved since, strongly in favor of presenting this as an option. Clearly, this wife was empowered, her view clarified, by being with her husband at the end. It was necessary for her closure, to witness our heroic attempts.

What would you do?

Me? I'm not so sure. I don't know if I would want to bear witness to such an event of a loved one. I probably would. I have to wonder, though, if my indecision or hesitation is, in part, from doing this job for a living or just my inherent spiritual make-up. Obviously, witnessing such a dreadful event may not be for everyone.

Let's just hope that we never have to make this decision.

As always, big thanks for reading. Next post will be Monday, April 12. I hope your weekend is a good one...

Wednesday, April 7, 2010

No Nadia

Remember Nadia Comaneci? Montreal Olympics, 1976? At age 14, she won three gold Olympic medals, receiving several perfect scores of 10 along the way. I was nine, five years her junior, and I remember being completely enthralled with both the Olympics and Nadia. Especially Nadia. When she looked into those Olympic cameras after finishing a routine, I just knew her big smile was meant for me. Yes, even at 9, I had a little bit of a pathetic yearning to me.

Unfortunately, my next patient in Room 33 was no Nadia. Not even close.

I walked into the room to find a 52 y.o. male lying in the hospital cot, writhing in pain. He looked older than his stated age, was short in stature, and chunky. His wrinkled forehead merged fluently into his bald scalp, framed by a skillful comb-over. His wife, wrapped tightly in her overcoat, had pulled up the corner chair to sit alongside her husband's cot. As she nervously tucked wisps of gray hair behind her ears, the concerned look on her face tightened.

"Sir," I asked, after my brief introduction, "what happened?" I wasn't going to pussyfoot around when he appeared to be in so much pain.

"Ohh, ohh," he moaned, "I slipped in the shower." With those words, both of his hands instinctively went under his sheet to his groin area.

"What did you hurt? Your hip? Your head?" I asked, looking from him to his wife.

"No," his wife jumped in, "he did a split. Like a cheerleader. He hurt his groin."

"A split? Like a cheerleader?" I asked, my mind immediately picturing Nadia and her floor routine. "You mean as in a full split to the ground?"

The middle-aged man nodded "yes" as his wife spoke again. "Yes, that's what we mean."

I could hardly picture this patient bending over to tie his shoes, let alone having one foot slide north while the other headed south. It sounded like a true, black-and-blue ball-smacker. And at his age, no less! My thoughts of Nadia, unfortunately, were replaced with images of this patient in his shower. Naked. Dripping wet. Finishing up his wash cycle. And slipping. Laying on the bathtub floor, under the hot streaming water, yelling for help. Ouch. Dreadful.

Suddenly, my groin hurt, too.

"I'll be right back, sir," I assured him. "I'm going to go find your nurse and order some pain medication for you." Male groin pain is a true emergency in my book, any day. After all, you know how wimpy us men can be. Women, on the other hand, are tough as nails. They laugh at pain like this.

I found his nurse, who promptly brought this patient some injectable relief. After that, I was able to get a better history and perform my physical exam.

This patient had had a long, exhausting work-day and, short of a drink, all he had wanted was to have a nice, relaxing shower to wash away his stress and burn down his tension-candle. As he was finishing, ready to turn off the shower nozzle, the freak accident happened. His forefoot slid forward, along the length of the slippery bathtub basin, while his back foot slid in the opposite direction, towards the drain. All the while, his groin ligaments tautly stretched to their limit. When they would give no more, he felt the horrendous pain from the strain.

Did I say "ouch" yet? I did? Okay, then how about "Oh, shit!"

So, there he laid, in a split position, the warm water continuing to rain down from the shower-head onto his naked body, his groin aching and throbbing. Luckily, he didn't strike his head or hurt any other part of his body. Just his groin. Not to say that his split was graceful, mind you, but at least he kept the injuries to one area.

"Help me," he yelled, praying his wife would hear him.

She did. Not knowing what had happened, she called 911. Promptly, our prehospital emergency crews arrived, untwisting this patient's legs before drying him off (I don't think that was in the job description). They helped him into a robe before transporting him to our ER.

His physical exam? Well, it probably goes without saying, but this patient smelled clean, in an Irish-Springy kind of way. I wish all my patients could smell this good. Otherwise, his vital signs were stable. He had no neck pain. No head pain. No chest or abdominal pain. No extremity pain. Again, just pain in the groin. Pain that made this patient twist his unsettled body back and forth in his cot, probably aggravating his pain more. On testicular and scrotal exam, he had only some minor tenderness, which told me that his ball-smacker was no perfect 10. No swelling or abrasions. His hips and pelvis seemed stable, and I couldn't reproduce the pain by rocking his pelvis or rotating his hips. All good. The only thing I could really find, sadly for him, was significant inguinal ligament pain, made worse with his own torso-twisting.

We x-rayed his hips and pelvis to confirm that there was no fracture. And there wasn't. Sometimes, a ligament can avulse a small section of bone from where it is attached, but, luckily, I didn't see any avulsion fractures, either. We also performed an ultrasound on his testes, and, I'm glad to report, his jewels were without any significant trauma. Mild swelling at best. Nope, despite this fall, I don't think the patient would be packing much heat in his Levi 501 Button-flys.

It looked like he had a pure and painful ligament strain.

After controlling his pain and reviewing his tests, our ER team was able to get this gentleman up from his bed and have him walk in our hallways. Despite a little wider and inhibited gait, he did much better than I had anticipated. With every step he took, though, I found myself thinking "ouch," "ouch," "ouch." We offered him crutches in the event he got too sore to walk, but encouraged him to walk as much as possible without them. We advised him that if he wasn't significantly improved after a few weeks of conservative therapy, his family doctor may need to pursue a CT scan or MRI of his pelvis. Finally, I gave him icing instructions ("Yes," I assured him, "you do need to pack your groin with some frozen vegetable bags.") and some prescriptions for pain control. "Oh yeah," I thought to myself, "and don't attempt to run a marathon in the next few weeks."

The patient seemed to appreciate all of our efforts. I hope as much as I appreciated his flexibility.

Even though I work out frequently, including some intense stretching, I could never imagine doing a full split. Never, ever. I'm still cringing thinking about this poor guy and his accomplishment. Between discovering me and the laughing spell that would follow, I don't think my wife would have been able to call 911. She's the type that needs to see blood if you want to call yourself injured.

How this guy was able to walk after his fall was beyond my comprehension. I actually thought of including him in my "Heroes Among Us" column, but realized that half of my readers, the ones with two XX chromosomes, probably wouldn't find him so heroic. But when I think of a patient and hear Rocky's theme song playing in my mind, it's at least worth the consideration, right?

As I stood in the hallway and watched our tech transport this patient, via wheelchair, from his room to the ER pick-up bay, where his wife was waiting, I couldn't help but let my mind wander back to amazing Nadia again. A perfect 10. Can you imagine? The first gymnast ever to achieve such an honor. Heck, she was probably doing a split as her mother birthed her. I just don't know how the human body can do such things, though.

As for this patient, I thought back to the details of his slip and fall. I ran and got a sheet of paper, wrote on it, and held it up for the ER team to see. They all chuckled.

3.5. Because I was not the Russian judge, I was very generous with my score.

Although this patient was a long way from a perfect 10, in my book, he still deserved a gold medal. Or, at the very least, a pair of dangling bronze trophy balls.

And a bag of frozen peas.

As always, huge thanks for reading. Next post will be Friday, April 9th. I want to sincerely thank those of you who wished me a Happy Birthday and a Happy Easter in your kind comments. It was a great, memorable weekend. Especially, I thank those of you who shared a piece of your life story with us...very cool.

Friday, April 2, 2010

Yin & Yang Weekend

I just got home from an incredibly hectic shift. Arriving at 6:00 a.m., there were eight people waiting to be treated from the overnight, several waiting for over three hours. When I left at 2:30 p.m., there were, again, eight people waiting to be seen, the wait still over two hours. Not the same people, of course. But still, the feeling of accomplishment was a little lacking.

Chalk it up to the yin and yang of the ER.

This weekend holds more of the same. Much to be happy about, with a touch of sadness mixed in. The yin and yang of my life.

I'm off from work the next four days. As I type, perfect weather hovers outside my office window, an unexpected embrace of warm sunshine befriended by a slight breeze and an endless blue sky. A long-lost hug that will linger for four days, if the weather-lady is right. Just in time to welcome Easter weekend, one of my favorite holidays. Peanut butter eggs, marshmallow chicks, fruit-flavored jellybeans, big chunks of chocolate--by noon Sunday, if my family isn't on a sugar high, then shame on us. If you see my family in church, I will be the one with peanut butter breath. My wife? She'll be the one with fluorescent pink, yellow, and blue sprinkles, remnants from the marshmallow chicks, clinging to her chin.

What makes this a most happy weekend, though, would be that it's...(drum roll, please) my birthday. Yep. Easter Sunday will be my 43rd birthday. I'm surprised, really, that I am entering my mid-40s. I remember very well when 40 seemed ancient to me, and I've surpassed that. Although my mind, spirit, and body are, for the most part, preserved, I sometimes look in the mirror and wonder who the person looking back is. According to my wife, it's my father's son.

Honestly, though, I couldn't really care that it's my birthday, except for the excitement it brings to our home, to my family. For the past week, I've caught my kids and wife whispering to one another, multiple times, only to stop as I approach. "Hmmm," I'd ask, faking bamboozlement, "what are you guys talking about?" My kids, especially my youngest, can't lie to save themselves, and yet they are able to play along remarkably with this.

Our family's birthday tradition? Started by my mother and successfully passed on, I, Mr. Birthday Boy, get to pick out dinner, which this year will be perogies and fresh sausage from the local Polish market. God Bless the Polish. And my birthday cake? Like every year past, Mom's Famous Chocolate Cake, made from scratch (including one cup of brewed coffee), topped with creamy, whipped, melt-in-your-mouth peanut butter frosting.

Doesn't life sound good? And taste good? Believe me, it is all good. Especially the cake.

So for all of my yang, what is the yin? The most simple way to explain it, I guess, is with two words--Mom's cake. Now baked by "my girls," my wife and daughters, and not by Mom.

Four years ago, on April 6th, Mom died. Two days after my 39th birthday.

My memories of Mom are almost all good, barring the last few weeks of her life, when AML ravaged her beaten body. I remember my 39th birthday very well, the feelings of helplessness that day. Trying to smile on the outside while the inside was desperate to change fate. The yin and yang of my young kids trying to celebrate my birthday while Mom lay ill in her own bed, breathing her last few breaths. After years of Mom breathing her beautiful spirit into us seven kids, it was her time to exhale her last breath. And time for us to breathe her spirit into our own families, without her.

After four years, it's easier to celebrate again. Time is the great healer. Thanks to my thoughtful sister, Rosie, who photocopied each of us a copy of Mom's hand-written and manually-typed recipes (refined tips included), chocolate cake with peanut butter frosting is not the only recipe of Mom's that my family enjoys. You should taste her Apple Jewish Coffee Cake. Laminated and bound, these recipes are truly gifts that keep on giving.

This is not depression, trust me. Simply, the memories and reflections of my mother's life are quite strong during this time of year, walking hand-in-hand with the introspection of my own life. As human beings, we have the privilege to experience some of life's lows, embrace them, grow stronger and wiser from them, and use these experiences to better ourselves. An ever evolving task. From this rubble, an appreciation of life's finer moments is gained.

Do any of you know where I am coming from? Any stories to share?

A memorable holiday weekend, filled with fun and laughter, good food, and celebrations of our religious beliefs, awaits my family. I know that. And I look forward to it. Plus, don't forget about the birthday presents I'll need to unwrap! I'm easy that way--give me a good book and a great musical CD, and I'm happy. At points, though, I know my mind will wander to thoughts of my mother.

It will be okay.

After all, I know where all this sunshine came from.

As always, big thanks for reading. A Happy Easter to all of you who celebrate this holiday. Enjoy your weekend. See you next week...