Friday, May 28, 2010

Warm Weather & A Full Moon

Time and time again, I hear references in our ER about how our crazy, hectic pace is tied to the cycles of the moon. "It must be a full moon," people say, as if every explanation to being overwhelmed and underappreciated in the ER is somehow aligned to that beautiful bright, glowing circle of wonder that hangs over our heads several evenings a month. I remember driving home many a nights, though, from an ER shift where I've gotten a spanking, only to look up and not find the moon guiding my way.

The other reference? Warm, hot weather. "It is so nice outside today," some staff will say, "it's no wonder we're getting slammed." Again, the thought is that warmer weather promotes more outdoor activities and more buzzing humans which, in turn, promote an increase chance of injury or illness. We do live on a lake, yes, but I can't even remember the last trauma I've had that involved a water-sport activity. I do remember, though, the numerous heart attacks that were a result of patients shoveling three-feet of snow during our cold, windy winters.

After four years of being a resident and thirteen years of being an attending, I have learned that there is only one truth about an emergency room's busiest moments.

Are you holding on to your hats? Ready for the big revelation?

The truth is...there is no rhyme or reason to when the ER might be busy.

Most people assume that Fridays, Saturdays, and Sundays are the worst days to visit an emergency department, that we are at our busiest. Honestly, though, in our ER, Mondays are panning out to be impressive for both the long waiting-times and the quantity of patients coming through. And Tuesdays are coming pretty close to Mondays' craziness. The thought that an ER is less busy in the winter months compared to the summer months is just that--a useless thought. And morning times are supposed to be less congested than evening and night times but, again, I wouldn't hang my hat on that. Many times, I've come in for a morning shift only to find the ER clogged with waiting patients.

So, this is the reality. Every time you go to an ER, you just don't know what you are going to find. It may be slow on a Friday night, and it may be crazy at 3:00 a.m. on a Wednesday morning. But another truth? It is what it is, plain and simple, and a patient yelling and carrying-on about his long wait will not get him seen any sooner. Louder does not make you flow through our system any quicker. Nor does it make you any friends. And calling your family doctor, the one who promised that if you went to the ER 'it will be a quick visit', will not push you further ahead in the waiting line, either. Sorry. That is something you'll need to take up with him.

I'm very matter-of-fact about the whole thing. And I'm certainly not complaining. I signed up for this job, as did the rest of my comrades, and we will all continue to do our best and give 110% of ourselves. We always do. Sometimes, though, on some of the worst days, I wish I had a magic wand to wave over our backed-up ER and start anew.

A few shifts ago, I arrived to work my evening shift (from 6 p.m. to 2 a.m.) only to find that there was a four-hour wait to be seen and approximately twenty-five "angry" patients hanging out in the waiting room. Soon after, unfortunately, we got a motor-vehicle accident with four trauma victims brought to our trauma center for life-saving treatment. As you can imagine, this pushed the number of waiting patients and the waiting-times even further back. Add in the occasional stroke patient and cardiac patient, and you can see where this shift was heading. Despite having 36 treatment rooms and a full staff, we were extremely busy. Organized chaos, I always call it.

By midnight, the wait time was almost six hours. Thirty-five people were still waiting to be brought back to a treatment room. I was told the waiting room was becoming a potpourri of angry incidents. People were starting to lash out. Besides getting our security team and the police in place, what else could we do but keep plugging along.

You know how it feels to return to work after a week or two of vacation and see the pile of work awaiting your return? I think I would liken that feeling to how we all feel during a shift like this. The workload was endless. Despite our best efforts, it was simply one step forward and two steps back.

But, as I knew it would, 2 a.m. did arrive. It was my time to go home. But did I? Hell, no! For the overnight, our ER had one of my partners and one PA scheduled. Hardly enough man-power to provide care. I checked out the patient-waiting list. We were now 38 patients behind. UGH!

I stayed for three extra hours. I could never leave a sinking ship no matter how tired I was or how much I had been kicked around already. By 5 a.m., however, our waiting time was down to three hours and there were only 15 people waiting to be seen. The new, fresh morning team would be in at 6 a.m. And I was at a lull between waiting for results to return on my current patients and for the nursing staff to bring back more new patients.

It was the perfect time to escape.

I found my partner and asked him if he was okay...if he needed any help with anything. He didn't. He graciously took my sign-outs and before I knew it, it was 5:15 a.m. and I was driving home.


I opened up all of my windows and my sun roof and enjoyed the brisk nighttime air as I drove along the lake. Minutes later, I drove by a Tim Hortons and did a u-turn. I parked the car and ran in and got a dozen of my kids' favorite doughnuts for when they woke up in an hour to go to school. If I couldn't be a hero to 38 waiting room patients, I would sure be one for my kids.

As I walked out of the doughnut shop, I looked up. And there it was, glaring right at me--the sky's full monty. Suspended in the clear, dark night among some twinkling stars, the moon and its glow hovered over my every step. I was in a short-sleeve shirt and felt the swirling warm breezes of the night immerse me in their embrace.

That quickly, my center was reset.

Okay, I'll give. Maybe there is something to this full moon and warm weather business after all. Yes, it was warm. Yes, there was a full moon. And, finally, yes--the ER was swamped with patients. That was probably the busiest I've seen our ER in a while.

But, at least it wasn't a Friday, Saturday, or Sunday...

Hey all. I'm working a string of six shifts and it has been crazy-busy, so I'm sorry for skipping Wednesday and today's late posting. I'm whooped and go in for the last one tonight. On a good note, I spotted another double-crack last night! Yes, two in that many months!!! But, no can do...LOL. As always, thanks for reading. I hope your Memorial Day weekend is a safe one spent with those you love. See you next week.

Monday, May 24, 2010

To Feed Or Not To Feed

I walked into Room 22 to find a very interesting patient who presented to our ER with complaints of abdominal pain and associated nausea and vomiting.

The patient sat on her cot with her pant legs rolled up above her knees, refusing, according to her nurse, Gwen, to put on a treatment gown. Her left leg hung in the air, her ankle crossed over the knee of her right leg. Her feet were bare and dirty. Nestled in the crook of her left hip, resting on the cot, was a worn bible, opened to the first page of The Book of Genesis. As Gwen was trying to obtain a better history, the patient was obviously ignoring her, giving all of her attention to the her bible.

Or so I thought. I walked into the room and introduced myself to this patient. She briefly flit her eyes up at me several times. Finally, after gaining her approval, she steadied her gaze on me and extended her hand. We shook. Gwen, meanwhile, seemed to have gotten an even colder-shoulder than before, as the patient turned her back on her to give me her undivided attention.

With her gaze on me, I absorbed this patient's features. She had dirty-blond hair pulled away from her face. Long, thready, frazzled dreadlocks started at the crown of her head and were gathered behind in a bulky ponytail. Her eyes were piercing blue and, quite honestly, unsettling. High cheekbones, clear skin smudged with some dirt, and thin narrow lips accented her prominent nose. Her hemp clothes were worn and faded, tattered almost, and, like her skin and bare feet, smudged with dirt.

She was in her early twenties.

"Hello, Rose," I said with a warm smile, "what brought you to our ER today?"

Her voice was husky yet quiet. "I ate some fish yesterday and I think it was rotten." She went on to explain that she, at the time, wondered if the fish was "not good" because it had "a funny, pink color to it, like salmon. And" she confidently added, "I know my fish--it wasn't salmon."

"Where did you eat this fish?" I asked her. She blatantly ignored my question, which made me wonder if it was from a clean site or a garbage can.

She continued, however, to explain that since eating the fish, she had vomited three times later that evening and once this morning, prior to coming to our ER. "I feel better now, though," she said. She hesitated before continuing. "I'm feeling well enough for a cup of coffee and a sandwich, even."

And there we go--the main reason why Rose was in our ER. She was hungry.

It turned out that she had already asked Gwen for some food and coffee and Gwen had put her on hold. "Rose," Gwen had explained, "we need the doctor to see you and get some of your blood results back before we can give you anything to eat." That explained the snubbing of Gwen. I had to smile, since Gwen was an extremely compassionate, cognizant nurse.

"Rose," I said, looking her in the eyes, "is this the real reason you came to our ER? Are you hungry?"

Rose stared at me as I visualized the cog wheels in her brain churning. Finally, she spoke. "Um," she started, "I came here because I ate some bad fish. But now I feel better. So yeah, I guess so. I was hoping, I guess, that you guys would be able to give me something to eat." As she spoke, she held my gaze. I appreciated her efforts at honesty.

Gwen looked at me with her knowing smile. I looked back to Rose. "Rose," I said, "I need to perform an exam and, since the triage nurse ordered some blood work, I need to review your results and make sure they are all good before we can let you eat. You understand this, right?"

Rose nodded her approval. With Gwen at bedside, I performed a thorough exam of Rose. Everything checked out well. Specifically, she had no abdominal pain on exam. I walked out of Rose's room and reviewed her stable vital signs and her stable blood work on my computer station.

As far as I was concerned, we could now feed Rose.

Which presents the dilemma we sometimes face in the ER. Frequently, we get unfortunate patients that present for reasons other than emergent medical care. It might be a drunk, homeless person, refused for the night by the homeless shelter for his alcohol abuse, who is looking for a place to sleep. It could be a patient who is looking for free prescription vouchers to get his medications renewed. And, in Rose's case, it could be a person simply looking for a meal, a cup of coffee, a warm blanket, or some companionship.

As far as I am concerned, we should extend ourselves, as long as it doesn't take away from providing emergency care to those in dire need. And, as long as our efforts are appreciated. Is a bed free? Go ahead and lie down for a short while. You're hungry? Let's see if we have any pudding or turkey sandwiches for you. Your cold? Here is an extra blanket for you from our trauma blanket warmer. Free vouchers? Well, I see those cigarettes and iPhone poking from your pocket, so we're not going to be able to help you with that tonight. Sorry, but I can only go so far.

With these acts of kindnesses, though, I understand the flip of this coin. You set yourself, your ER, and your staff up for repeat visits by these patients who come to expect these kindnesses every time. And, as a result, they keep coming back and coming back and coming back. Sometimes clogging the system. Eventually, these kind acts are no longer appreciated but, rather, demanded. We've all seen this happen. And it's at this moment when our thought process changes.

With Rose, she had only been to our ER once before so, after Gwen and I agreed, she received a full meal, some warm coffee, some foot slip-ons, and a social service consult prior to being discharged. She was gracious for everything, which helps the cause. And it was our pleasure, really.

However, there are repeat offenders whose visits to our ER number in the fifties and hundreds. Seriously. And, unfortunately, these handfuls of patients are the ones who can ruin it for the others.

The ER presents many moments of internal struggle where, as an individual working there, you have to review and examine your moral fiber and essence. This is one of those struggles for me. I wish we could accommodate every single person's needs, but that is unrealistic. So, I'll just continue to provide on an individual basis. And, hopefully, these kind acts will be appreciated and not abused and demanded.

To feed or not to feed...that is the question.

Happy Monday. I'm eager to hear your thoughts on this post... As always, big thanks for reading. Next post will be Wednesday, May 26th. See you then...

Friday, May 21, 2010

The Lonely Walker

They made a regal couple, the elderly man and woman sitting in Room 19. She was the patient, he the supportive husband. She sat in the treatment cot while he sat in a chair pulled near her bedside. Together, they greeted me with their warm smiles as I walked into their room.

They both had full heads of healthy, silvery hair that shimmered from the overhead fluorescent bulbs. Their eyes were intense and watchful, and their crescent lips, framing big, teethy welcoming smiles, stretched like thick, pink rubberbands across their lower faces. He was impeccably dressed in conservative, mid-season wear, including a green layering-sweater. She was in a threadbare hospital gown, clearly confident and stylish despite her outfit.

After introductions and the shake of our hands, I learned that they were both in their early eighties and had been married all of sixty years. Sixty years! Can you believe that? How amazing. I congratulated both of them on achieving such a milestone.

"I know where I'm going," she laughed, looking heavenward, "for putting up with him all of these years." He laughed harder at her words than she did.

This, ultimately, explained the matching walkers that were parked against the counter in Room 19. Who needed matching rings for a 60th anniversary present, anyway? I would think that I, too, would be more practical on my 60th anniversary. I noticed these walkers immediately upon entering the room. His and hers. Identical. Front wheels, back posts with thick rubber stoppers, and a right-sided hand brake on each. Greenish-blue in color. Her's had feminine clothing casually strewn over the front bar.

She was 82, to be exact. "He's a few years older than me," she jokingly added, dismissively nodding toward her husband, "I'll always be his spring chicken." By triage notes, she had presented with a two-week history of worsening abdominal pain "that came in waves," mainly to the right upper quadrant. "But right now," she told me, "it isn't so bad." It seemed to be associated with any intake of food.

She still had her gallbladder and my first three thoughts of the cause of her pain were gallbladder, gallbladder, and gallbladder. Of course, elderly women thoroughly enjoy stumping us in the medical field, so I also entertained other suspected reasons for her pain--an ileus (where the bowels are less efficient in moving air or material forward), a bowel obstruction (where the bowels kink on themselves and prevent any forward passage), referred pain from the heart or lungs, an atypical urine infection, or some form of peptic ulcer disease.

I questioned her further. She had no fever. No change in bowel movements. Some occasional nausea and bloating. Then, I asked her one last question, whose answer raised my suspicions beyond the normal concerns.

"Do you have a cancer history, Mrs. Brown?"

"Actually," she answered reflectively, "I do. I had breast cancer about a year ago." She looked over at her husband and smiled. "Remember those days, dear?" She explained that she had undergone chemotherapy following a right mastectomy.

Oh no, I thought to myself. Add metastatic cancer to that list. Unfortunately, I have seen several cases of elderly patients with a remote history of cancer who had presented with a recurrence of their cancer, abdominal pain being their only complaint. I could only hope Mrs. Brown wouldn't be in that category.

I did my exam on Mrs. Brown. Sure enough, she had significant abdominal pain to her right upper quadrant, but only if I was palpating deep in that area.

I explained my suspicions to her. We would need to test her urine, her blood, perform a chest x-ray, and finally, the most important of all the tests, perform a CT scan of her abdomen. That would effectively rule-out or rule-in my biggest concerns. Because we had just had a stroke patient and a trauma patient before her, I explained her workup may take a few hours time.

"Honey," she said to her husband, "go ahead out to the car and take a nap. I'll be all right in here. Dr. Jim," she added, winking at me, "will take good care of me."

Any other night, I would have worked hard to find an extra cot for Mr. Brown, but this night in the ER was crazy. I knew there were no available beds. "Go on, Mr. Brown," I said, "you have a few hours nap time ahead of you. I'll take good care of your wife."

I left the room and let Mr. and Mrs. Brown have a private moment. Minutes later, I saw Mr. Brown shuffling down our hallway toward the exit sign, guiding his lonely walker along the way.

Slowly, Mrs. Brown's results started to return. Her urine was clean. Her chest x-ray was unremarkable. Her blood work, however, returned with two concerns-a mild drop in her red blood cell and platelet counts and an elevation in three of her liver enzymes.

I entered her room to explain her results to her. And also to share that she was now second in line to go over for her CT scan. She was, however, napping. I softly strolled up to her lone walker to check it out more closely. It was spiffy. I've only seen aluminum and black walkers before, and was wondering if this was a custom paint job.

"I never wanted that thing," Mrs. Brown said, my back to her, startling me. I turned around. She had awakened. "Edgar needed one. I was afraid he was going to fall. But you know men...he insisted that he didn't need one. The only way I got him to finally accept using one was if I got one, too."

I nodded. "They sure look nice," I said. "Thank you," she said, "they are identical. We call them "the twins." If I had to use a walker I didn't really need, then at least I was going to pick out a color that suited me."

I smiled before remembering the business at hand. Slowly, I explained to Mrs. Brown what I had meant to explain when I first revisited her room. After finishing, I assured her that I would be back the minute her CT results returned.

An hour later, I walked, heavy-hearted, back into Mrs. Brown's room, accompanied by her nurse. Mr. Brown had returned, his silvery hair now somewhat mussed up from his successful nap. The greenish-blue walkers, side by side again, seemed to present a fortified protective wall. I held her CT report in my hand.

"Good news or bad news?" she asked, as Mr. Brown leaned forward from his seat and grabbed her hand. I looked them both in their eyes.

"Not good," I said. I went on to explain that Mrs. Brown's liver, via CT, appeared abnormal. Not only did she have multiple liver lesions suspicious for metastatic disease, but she also had a solid liver mass that was partially obstructing her small bowels. As I spoke, I appreciated the tightening grip Mr. Brown's hand took to Mrs. Brown's.

We all took a deep exhalation when I finished my explanation. "Well," Mrs. Brown said, "I guess that how she goes, then." She looked over at the two walkers, side-by-side. "I guess I won't be needing that thing much longer, Edgar." Her eyes grew glassy, and I was surprised that she had focused her attention, after such devastating news, on the walker. After spending a few more minutes with them, I stepped out to arrange for Mrs. Brown's admission.

Rare or not, I still strongly believe in the power of prayer, sometimes if even to make me feel a little better about things. I'll admit, though, that there are times when my prayers take on a very different, even bizarre, angle. The night I treated Mrs. Brown, I'm sure, my prayers were along that path. Although, to me, they were quite simple and clear.

I prayed that those walkers would sit side-by-side for another 60 years.

As always, big thanks for reading. To the amazing commenters from my Wednesday post, thank you, thank you. Too kind. Next post will be Monday, May 24. See you then...

Wednesday, May 19, 2010

The Quivering Finger

It is hard to believe, but today marks the six-month anniversary of my blog, StorytellERdoc. Including today's, I have posted 72 short-stories since November 19th, 2009. I look at my archive, the comment sections, and the number of cool visitors that have visited "my baby" and simply shake my head at how things transpired to get to this point.

Thank you, everybody.

I remember the first time my writing group mentioned the possibility of me starting a blog. We were sitting in Marcy and Christine's living room, getting ready to critique our submissions for the week, when I shared a funny work story. "You need to start writing these down, Jim," they said. "Yeah, right," I thought to myself. I am not a blogger. I had visited multiple sites, both medical and generic, and, although some were brilliant, I simply didn't see myself fitting into this world.

My wife loved my writing group's idea. "Jim," she said, "you haven't seen a blog that you would mimic because either you haven't found it or, more realistically, it doesn't exist. Make your blog by your own rules."

Hmmm. That seed of an idea slowly took. I started thinking of stories that affected me during my medical career, and it wasn't long before I realized the common denominators of those stories most important to me.

Number one. Compassion. Or lack thereof. In today's medical world, I sometimes get frustrated at the lack of compassion and awarenss in regards to both the medical and non-medical issues. It seems that we must move patients, at times, like cattle. See more, bill more, don't spend as much time in each room. Bullshit to that, I say. Behind every face is a story, and shame on all of us if we don't take the time to recognize those stories. Why must we avoid humanizing a patient who is already human? I wanted to bring some heartfelt emotions back to each patient's case.

Secondly, the power of some of my patient stories are simply that I strongly associate their perspective with my own life. A Mother's Cry? I have three kids. Grandpa's Grandkids? I loved my grandmother greatly and couldn't imagine seeing her die in this manner. The Complacent Eyes? My son spent two years of his young life on chemotherapy--I know those eyes well. Heroes Among Us--both Gigi and Linda? How amazing to look at someone and their approach at life only to realize that, at some point, I may have taken a misstep or two down the "for granted" pathway. These stories hit their mark on my heart.

Thirdly, the underlying humor of some patient scenarios just, plain and simple, crack me up. I love a good laugh as much as the next person. If I can't laugh at the ridiculousness of some of these work encounters and life experiences, I am in for a long, boring haul. And a short career, actually. Among others, Double Crack, The Thong Expert, Meeting Candy, The Half-Load Predicament and It Wasn't Me! can take me immediately back to that moment where I find myself cracking up all over again.

Finally, what I am most proud of, are my stories of the ordinary. Sometimes, these remarkable stories sit among the muck of normalcy and boredom and, when I finally dig them out, make me want to jump up and down and share them with the world. An example? A Love Story. When I saw that son helping his father down our ER hallway to the bathroom, I wanted everyone to stop what they were doing in our ER and look at what I was witnessing. Instead, at the time, I only shared it with Weezie, one of my favorite secretaries, before writing the words to give this scenario a life. Big Stuff, Big Words, The Fringe Benefits, and This Father's Daughter walk along the same lines.

After deciding what perspective I wanted my blog to take, I put my fiction novel on hold and attempted several short stories. I submitted them to my writing group, appreciating their honest feedback. My biggest critic, though? Easy. My wife. My awesome, incredible typically-normal every-reader wife. I would hand her a story and nervously watch her read it from the corner of my eye. Her tears, her laughter, and the "yes" and "no" nods of her head told me all I needed to know about a piece.

Armed with about twenty stories and a committment to try to post three days a week, I finally decided to give this a go. The name was settled upon and, after a breakfast date with Christine, a design to my blog was decided. She graciously and unselfishly set the blog up for me, including the incredible banner. Big kudos to her. I joke with her that she missed her calling.

Finally, I had to write a profile about myself. Have you ever done this? After confusing myself more and more, I finally just sat at the computer and ripped it out in five minutes. What you see is the unedited version. After the final sentence, "I am a writer," I was tempted to include "I am not liking this self-profiling bit at all."

After my writing group and wife gave a thumb's up to my first, introductory story, the day finally arrived for posting it. I was filled with self-doubt. What was I thinking? Why was I wasting my time? And who would want to read my words, anyway? If I could only get twenty people to read my stories, I figured, this might all be worth it.

I walked up to my computer and sat down, hovering my right index finger over the left-sided mouse button. The computer arrow sat over the "Publish Post" button on my blogspot page. A simple click and I would be officially entered into the blogging world.

I couldn't do it. I wasn't sure if I was ready to "put myself out there." I looked down at my quivering finger. I took a deep breath. I reread my first post, desperately trying to find any grammatical errors or content problems. Trying to find any problems that would warrant stalling the process. I reread the post, again.

Finally, I looked at my trembling right hand and decided to quit being a wimp about it.


And from that quivering finger and subsequent click, here I am.

A few changes have come over the past six months. Now, I write most of my stories the day before they are posted. And no critiques to them (well, occasionally my wife will still get first dibs). They are, for the most part, in their rawest, unedited form. I no longer check comments and my email every hour the first day of a posting. I don't follow my visitor numbers and stat counter nearly as often as I used to. A naturalness and inherent comfort has begun to settle in.

I want each of you to know that it has been my privilege to write this blog. Seriously. It has been incredibly humbling to think that someone would actually take time from their busy day to search out my site and read my words. If there were an award for the coolest, most honest, intelligent, and faithful readership, you, my friends, would get it. To those of you who have blogrolled me (including my very first ones, Blisschick and Seaspray) and reposted my works on your own site, a special thank-you.

Finally, as I have said before, the friendships are easily my biggest gain from this whole experience. You all hold incredible, memorable stories, and I appreciate you giving me a glimpse into your lives and bringing your kindnesses into mine.

Funny how things work out. I have always loved to write and, until a few months ago, never pictured my outlet to be in this shape and form. Thankfully, others saw this as the perfect avenue for my words. You're involvement is making this a worthwhile journey in my life.

Thank you.

As always, big thanks for reading. And bigger thanks for helping me reach this milestone. Much appreciated. Next post will be Friday, May 21. See you then...

Monday, May 17, 2010

Being Regular

One of the more frequent topics of complaint in the ER setting, unfortunately, regards bowel movements. Too many. Too few. Too hard. Too soft. Too watery. The wrong color. The right color but the wrong time of day. No flatus. Too much flatus. Associated cramping. The list goes on and on. And on. And...on.

Anyone who works in medicine and, specifically, patient-care knows exactly what I'm talking about.

When a patient starts going down this road, I am pretty skillful with diversion conversation. Imagine Mrs. Smith, an elderly woman who "just so happens" to have brought me a list of all of her bowel movements during the past two weeks. Lucky me, right? A third of the way in, when she starts to talk about her love of corn and her subsequent change in bowel habits, I have to stop her. I have no other options, really. Well, unless you count plunging a syringe of epinephrine into my heart an option.

"Mrs. Smith," I say, a warm smile on my face, "I don't mean to interrupt you, but you look an awful lot like Betty White. Isn't she so pretty?" When Mrs. Smith blushes and starts talking of her love of "The Golden Girls," I feel victory. I taste victory. I smell victory. But, sadly, it is short-lived. "I wouldn't be surprised," Mrs. Smith says, outsmarting me, "if Betty White loved corn, too." And back to the list she goes.

With all of these conversations and complaints of what could go wrong with bowel movements, I have a big fear that when I become an elder myself, I might obsess about my own BMs. I would hope I wouldn't, but one never really knows. Metamucil? Check. Fibercon? Check. Prunes? Check. Chex cereal? Check. Fleet's Enemas? Check. I can only hope that I'll have my bases covered.

Plus, I love corn. And corn-on-the-cob.

A few years back, I took care of an elderly gentleman, bushy eyebrows and all, who had presented to our ER because he had not had a bowel movement for three mornings.

"I always have a bowel movement after I wake up," he explained staunchly, trying to give some formality to such a subject. "I haven't changed anything, either. I still eat a bowl of Chex in the morning and take my fiber pills at night. I even tried Metamucil last night and still, nothing." After speaking, he gave an exacerbated exhalation for good measure, just to make sure I understood his predicament.

I looked at this gentleman sitting in his gown on the treatment cot. He looked very comfortable despite his lack of recent bowel evacuations. Concern, though, was etched on his face.

"Are you having any abdominal pain, sir?" I asked. "No," he answered. "Any fever? Any blood in your stools?" No and no. "Did you try an enema or do anything different to see if it would help you with your bowel movement?" Most people have some sort of back-up plan (pun intended) for when they are constipated. For me, a strong cup of black coffee does nicely (well, unless I just ate forty pieces of banana laffy taffy).

The gentleman hesitated before finally speaking. "I, um, well," he stuttered, before finally deciding to just spill, "I tried to dig myself out."

Ugh. My eyes instinctively went to this patient's hands. They appeared to be clean. I struggled to spot anything under his nails, but failed. Thank God. I looked down at my own hands, grateful for my subconscious habit of always putting on gloves before shaking a patient's hands.

Now it was my time to stutter. "Um, well," I said, "when did you try to 'dig' yourself out?" Did I really want to know? Just asking, even, made me shudder.

"Last night," the man answered. He paused, and I knew what he was going to say next. Please don't say it, please don't say it, please don't say it, I chanted to myself.

"And this morning, too." Ugh, he said it.

Well, as I said before, I like corn as much as the next person. And, also, consider me a good Boy Scout. I want to be prepared. Always. You're never too old to learn, right?

"Sir," I asked, "can you tell me how you tried to dig yourself out?"

He raised his bushy eyebrows and looked me in the eyes, realizing that I was being serious. And honestly, although I joke, I was being serious, since I would need to check to make sure he wasn't bleeding or had injured himself. "Well," he said, "I got me some petroleum jelly and coated this finger with it (he held up his right index finger) and... ."

You get the idea, I'm sure.

The idea of digitally disimpacting a backed-up patient is not new to me. I've done plenty of them. Most everyone in the medical field can attest to trying to shirk this part of our job, though. It is truly a procedure that rolls downhill. Starting with the lowly medical student. If one isn't available, call the freshest intern on the block. No intern? That's okay, find me a mid-level or senior resident. It's a really bad day in the ER, though, when the attending has to double-glove-up and do it himself. You earn your money that day, for sure.

But to do that to yourself? I wouldn't even consider it. If I hadn't considered self-disimpaction during my laffy taffy crisis, I think it's safe to say that I will never consider it.

Even during corn season.

This elderly patient, he with the clean hands and fingernails, did beautifully. Rarely will I order a soap-suds enema (since this is the nursing equivalent of a disimpaction and gains me no points in popularity), but I did on this patient, since he did have some minor rectal impactions on x-ray and exam.

The nurse schooled me, though. "Doctor Jim," she said, smiling even after giving the enema, "I did the enema but he still needs some help." That explained her smile. "I think with your help," she added, enunciating a bit too much, "we might have some success."

I tried using my charms of conversation. "Have I ever told you, Nurse Bonnie, that you look just like Angelina Jolie?" Maybe, I had thought foolishly, I could work my way out of this one.

"Nice try, Doc," Nurse Bonnie said, now laughing along with me, "but you could look like Brad Pitt (which, I might add, I do) and I'm still going to need you to disimpact my patient."

Humbly, I earned my money that day.

Do me a favor, okay? The next time you are in the ER as a patient and you skillfully bring up your bowel movements (whether they are your primary or secondary complaint), remember that we, in the health field, are people too. We feel your pain. We want you to be regular, trust me, we do. And we want the best for you.

Which is why, in my opinion (and humble charming way), you should see your family doctor for any bowel complaints. Any at all. Trust me, they do a much better job of disimpaction and managing the bowels than any ER doctor I know.

Maybe that's the line I should have used on Mrs. Smith.

As always, big thanks for reading. It seems that we in the medical field have no fear talking about this subject. I can only hope I didn't scare you. Next post will be Wednesday, May 19. See you then...

Friday, May 14, 2010

Speaking For Mom

I walked into Room 28 to examine a woman who had presented to our emergency department with complaints of abdominal pain. She had initially been examined by our chief resident, who was under my supervision for this particular shift.

Unfortunately, this patient was a "frequent-flier," presenting to our ER multiple times in the past few years. Complicating the matter, she spoke no English. Despite our offers to provide a translator during her visits, she refused. Every time. Instead, she placed that responsibility on her ten year-old daughter's shoulders.

My resident was somewhat flustered by this patient. For one, her multiple visits to our ER were always for chronic issues that, despite significant past work-ups, never amounted to any significant findings. Secondly, the language barrier. When a patient and a physician do not share a common language, there is always a concern that some important fact or angle may be overlooked. In addition, this patient had now been in our country for a few years. During that time, wouldn't you expect her English skills to advance a little bit? I can't picture myself living in France for two years and not learning some French. Yes, no, wine. Those words would roll off my tongue in the first week. This patient, for whatever reasons, seemed to have not made much effort in learning even basic English words.

Which leads us to my resident's biggest frustration. The daughter. And the burden placed on her to translate for her mother. If the patient had come to our ER over thirty times in the past few years, how many times do you think the daughter had been with her? Even conservatively, if the daughter had accompanied her mother on half of those visits, it's still too much. In addition, most of her mother's visits were regarding abdominal pain. Some of the questions asked during history-taking can be very sensitive and specific with this complaint and, yet, the mother wouldn't answer a question unless it was through her daughter.

I walked into the room to find a laughing patient sitting upright in her cot, watching TV. Despite her loose hospital gown, I could appreciate this woman's large size. She appeared very comfortable, though, and in no acute distress. Her daughter sat in a corner chair, also smiling as she looked upward at the TV. She was beautiful. Dark hair, dark eyes, long lashes, and dangling pink gemstone earrings that swayed with her laughter. She wore a pink Hannah Montana sweatshirt. Looking up at the TV, I was not surprised to see the channel was set to The Hannah Montana Show on the Disney channel.

"Hello," I said, holding out my hand to the patient and shaking hers, "I'm Dr. Jim, and I'll be treating you today with Dr. Mary, whom you just met. How are you?"

The patient looked from me to her daughter, who translated everything I had just said. When her daughter was done, the patient turned back to me and silently nodded. I continued focusing on the daughter, holding out my hand and walking around to the other side of the cot where she sat. "You are her daughter?" I asked. She nodded. "What is your name, honey?" "Annabelle," she answered, shyly.

"Annabelle," I said, "we appreciate you being here today to help us with your mother's care. Would your mother want us to call a translator instead, though?" Annabelle translated my words for her mother and returned her mother's response to me. "Absolutely not," Annabelle said.

"Okay, then, Annabelle," I said, "I will ask you all my questions and you can, in turn, ask your mother, okay? If there are any questions you don't feel comfortable with, just tell me and I will call in a translator."

Even this, Annabelle translated for her mother, who's return response, through Annabelle, was "There is no question that my daughter has not already heard."

So, I asked away. Fever? Nausea? Vomiting? Diarrhea? Where is the belly pain? Similar to past episodes? Chest pain? Trauma? I kept it short and sweet. Finally, I briefly asked about any urinary problems or vaginal problems. Annabelle didn't even flinch, asking her mother my questions and relaying her mother's answers. She was a translating pro, albeit at the age of ten. Practice makes perfect, I guess.

After the questions, I performed a physical exam that was stable and unremarkable for any abnormalities. I reviewed a new set of vital signs, also normal. This was all similar to what my chief had found. This patient's blood and urine work had returned prior to my exam, even, and I was armed with the knowledge that all of those results were normal as well.

I explained the results of my exam and the testing to Annabelle, who in turned spoke to her mother about it. The mother seemed genuinely happy. I explained that I was going to call her family doctor and review the results of our exam and testing and would expect her to follow-up for her chronic abdominal complaints in the morning with him. She agreed.

Before leaving, I focused on Annabelle. "You were so helpful today. Did anybody give you any stickers yet? Or a popsicle?" Annabelle didn't answer me but, instead, turned her face from me and toward her mother and started talking in their native language. It took me a minute to realize that she had thought those last questions were directed toward her mother.

"No, no, no, honey," I said, interrupting her and laughing. "Annabelle, I was asking you those questions. Did you get any stickers or a popsicle for being such a big help with your mother's care today?"

"No, Doctor Jim, I didn't," she replied, shyly gazing to the floor with her eyes. Her voice, in English, was quiet and faint; in her native language, fluent and guttural and husky.

"Well, Annabelle, your mother and we are sure lucky to have you translate for us. Thank you very much. Let me go get you some thank-you stickers, okay?" She nodded yes to my words, smiling now, her secondary teeth perfectly white and evenly lined. Her smile lit up the room.

I left the room, hearing Annabelle's explanations to her mother grow faint as I walked down the hallway. While my chief called the mother's doctor, I perused through our sticker collection and picked out about fifteen or so for Annabelle, including some new kitty-cat ones that I couldn't wait to get rid of (sorry, just not a cat fan here). I went to our employee lunch room, where we keep our popsicles, and grabbed Annabelle a bright blue Italian ice. Who doesn't like blue popsicles, right?

As I walked back into their treatment room, my chief resident was just leaving. "Everything all right?" I asked her. "Everything's good," she assured me, "Dr. Smith is going to see Mrs. Demshonova tomorrow at 9 a.m.

Perfect. I walked in and handed Annabelle her well-earned stickers. "Do you like cats, Annabelle? " She answered with a nod, hurriedly scanning through each of the stickers. "And here," I said, pulling the popsicle out from behind my back, "here is a blue popsicle for all your hard work." She looked at her mother who nodded to her, and Annabelle shyly took the popsicle from my hand. I finished. "It sure was nice meeting you, today. Thanks again for all of your help."

As I began retracing my steps out of the room, Annabelle's mother spoke up. "Excuse me, sir," she said, in broken English. I stepped back in and walked towards her cot, surprised to hear her speaking English. "Yes?" I asked. The patient looked from me to Annabelle, who was devouring the popsicle while rechecking the stickers, and back to me again. "Thank you," she said, grabbing my hand and squeezing it. "Thank you," she repeated again, more softly, for good measure.

"You're welcome," I said, returning her transcending smile with my own simple one.

I walked out of that room and realized that this was a good mother. And Annabelle, of course, a good child. Although I wouldn't expect my ten-year old to translate for me, this patient did. Whether is was cultural or not, I don't know. I do feel confident, though, that this mother wasn't being abusive of Annabelle, she just expected a family member to translate for her. A family member who just happened to be ten-year old Annabelle. Nor do I think the mother deliberately abused our ER with so many visits. Again, I simply think she didn't understand the process of following through with her chronic complaints with her family doctor. What do you think?

The patient and her daughter, after being discharged, walked down the hallway toward the exit door. Holding hands.

I walked back to my chief resident. "They turned out to be quite nice in there, didn't they?" I asked. "Yes, they were," the chief said, happy with the outcome.

Hopefully, she learned a little something besides clinical medicine from this case.

I know I did.

As always, big thanks for reading. I hope you all have a nice weekend. Next post will be Monday, May 17. See you then...

Wednesday, May 12, 2010

Against The Norm

I grew up in a small town. One of seven kids. Raised by parents who represented the expected, traditional roles. Dad worked hard and, with his brothers, became extremely successful in the forestry industry. Heck, he even cut down the presidential Christmas tree one year. Mom kept house and raised us kids quite nicely. The family glue, she was. A sit-down, multi-course meal was enjoyed by the nine of us every night. Roast beef and potatoes, steaks with home-fries and corn, breaded pork chops with green beans and cinnamon applesauce. Who eats like this anymore?

My family was conservative and Catholic. Through and through.

To my parents' credit, expectations were placed on us. Expectations that prepared us for life's many angles and unexpected surprises. Expectations that taught us that life's blanket has many different colored threads interwoven throughout it.

For one, we had to excel in at least one sport. Mine, you ask? Easy. Tennis, which I actually played through college on scholarship. I also loved basketball and baseball. My sister Rosie, although she won tennis districts in doubles a few times, claims to have been the best cheerleader in the family. A sport now, yes, but in her day, a few stomps of the feet and claps of the hands really didn't impress the rest of us. A "stomper," I called her, instigated by the fact that my parents actually accepted this activity as her official sport.

We also had to maintain an A or high B average. My parents batted seven for seven with this expectation. We were taught that discipline and hard work reaps many benefits, especially good grades. And, as expected, we all attended college and graduated. For some of us, books became our very close friends.

We had to be kind and compassionate, to one another and to our fellow-mankind. Mom would perpetually have us kids deliver meals to many of our elderly neighbors. In the winter, we shoveled our neighbors' walks. In the summer, we cut their grass. Without pay. And, more importantly, without complaining. My dad, after hooking up his snow-plow to his pick-up, would plow any driveway in three counties.

Probably the most interesting expectation placed by my parents, though, was that each of us had to excel at playing a musical instrument. Mine? Classical piano. How's that for you. Ten years to boot. I initially loved playing the piano in elementary school. Around 10th grade, however, I was starting to enjoy it significantly less. Imagine being a teen-ager and having to leave basketball practice early for an hour piano lesson with Sister Mary Catherine, who happened to be the spitting younger version of Sophia from "The Golden Girls." She was tough, but I learned well. Besides other pianists, among us we have an accordian player, a french horn expert, and a clarinet virtuoso.

By appearances, my family looks like the typical, if blessed, American family. Some of us are conservative in our thinking, some of us liberal. Each of us is quick to admit that we had something special and lucky with the childhood cards we were dealt.

Within my siblings, I am probably the most liberal. Does that mean I am Obamafied? Hardly. I'm still a physician working hard in the American system. But I love diversity. I crave diversity. Part of my job's enticement, besides the rewards of helping a patient through an emergent illness or injury, is the social interactions I have with so many different people from so many walks of life. It's a very cool place for me to sit--an appreciation of diversity perched on my left shoulder and my traditional upbringing on my right.

Recently, I wrote a tongue-in-cheek post about men being wimps. It was a spirited and laughable post, although I stand by the elemental truths that us men, with exceptions (of course), are not the stronger of the two sexes when it comes to facing illnesses. Some of the comments from that post questioned if I were stereotyping and, if so, why?

I took a few comments and let them brew in my mind, gathering wisdom with a few passing days. And you know what I realized? I learned that, if anything, I am quite far from the typical, stereotyping person. I don't judge but, rather, observe. Sometimes my observations may not sit well with someone, but that's okay. They are my observations. My experiences.

Flipping that coin, I would be a hard person to stereotype, too. And I like it that way.

I made a mental checklist to prove it. I work out at a gym four days a week while listening to acoustic Sarah McLachlan on my mp3 player. If you looked at me, you would probably think I read history or murder mysteries. Wrong. I just finished two incredibly-written "chick books"--The Help and Saving Ceecee Honeycutt (both of which I would highly recommend). By ninth grade, even, I had read all of Shakespeare's works. Not to say that I don't like a good Patterson book once in a while (all hail Alex Cross). I am both big city and small town. I am both country and a little bit rock-and-roll. Come June, my wife and I will be seeing both Ingrid Michaelson and Cyndi Lauper in concert (I'm a sucker for a strong female voice). I can cut a tree down on a peg fifty feet away and, yet, can successfully pick a perfect room paint color in an instant. I get angry at seeing healthy people my age abuse our country's fine intentions of financial assistance but will fight to have every child, every handicapped person, and every elder adult benefit from my taxes. I am compassionate most always. I will avoid flushing the toilet after one of my prouder productions (if that isn't something to beat on your chest about, what is?). I like a beer but, once in a while, I might have a glass of wine, a vodka tonic, or (gasp) a martini. I enjoy landscaping and washing and waxing cars, playing sports, and teasing the shit out of my family and friends. I can iron and press a dress shirt with the best of them (a necessary talent during the medical school years).

You get the gist. Essentially, I don't want to be pigeon-holed. Ever. Who among us does? Most of us are not a box with four sides. My interests are scattered all over.

Today, at work in the ER, I met an amazing couple. Women who were life-partners. Women whom I initially thought were best friends. After spending several of my rare down-time minutes with them, just talking, it became very evident that they were committed to one another. And they couldn't have been any more fun, this couple, laughing and finishing one another's sentences. As I walked out of their room, I smiled. Big time. I appreciated their diversity and I appreciated my privilege to meet them and learn a little more about the big picture of life from their perspective.

As I sat at my work desk afterwards, I thought about how each of us has an unexpected something about us that, if isolated, could be judged as peculiar or "not normal" by our fellow man. Me included. But what is normal and what isn't? And who made those rules? What people expect from me and what people ultimately find out about me sometimes sit on opposite ends of the spectrum. How cool is that? This very thought is the thing that drives me, inspires me even, to learn more about the people in my life, the patients and families in my ER, and a stranger I may pass in the street.

I observe people and appreciate their differences.

My parents' rules and expectations went with the norm of what I knew life to be. And yet, because of those norms and guidelines, I have interests that extend way beyond the stereotyping and norms as defined by our society. Just what, I'm sure, my parents were hoping to instill with their expectations. If so, they succeeded. And I thank them.

Do any of you have an unexpected something about yourself that goes against the norm? I'll bet each of you have an answer that is three letters, starting with "y" and ending in "s." And Pat and Vanna, I'll take a vowel--"e"--right there in the middle. Am I right? Do I win a prize?

My kids face the same expectations as I did as a child--they all play the baby grand that sits off our foyer, they get great grades, and they play two or more sports. They are good kids who love music and books and are kind to other people.

Hopefully, that's not against the norm. But if it is, I'll gladly keep things the way they are.

It worked for me.

As always, big thanks for reading. Especially this one. A change of pace in sharing some of myself. Next post will be Friday, May 14. See you then.

Monday, May 10, 2010

I'm Going To Die!

Occasionally, a patient will come into the ER with a profound sense of foreseeing their immediate death. A foreboding that, despite their complaints and physical findings not matching up, death might be knocking on their door.

I'm not talking about how some people think they may die young. Or that they may die a tragic or traumatic untimely death. Haven't we all had that thought at one time or another? Rather, I'm talking about that patient who is lying in their cot, looking somewhat stable, piercing into your eyes with their frantic own. "Please don't let me die," they say, before you can even begin to sort out their history and perform a physical exam.

This kind of talk and behavior, as you can imagine, may be quite unsettling, both for the patient and the providing medical team. In most circumstances, that dramatic foreshadowing deserves some attention.

Recently, an elderly male had been rushed to our emergency department from the radiology department, where he had been undergoing an outpatient, IV contrast-enhanced MRI. After the MRI nurse had pushed his contrast into his IV catheter, the patient began flailing and screaming.

"I can't breathe!" Help me!" "I'm going to die!"

The MRI nurses looked for a rash. They found none. They listened to his heart and lungs. They sounded good. They reviewed his extensive MRI checklist but found no documented allergies of suspicion.

"I'm going to die!" the patient yelled again. His frantic nature became contagious and, within a few minutes, the patient was being wheeled into our department. Room 21.

I remember hearing the concerning page overhead. "We need a doctor in Room 21, stat." As luck would have it, I was just walking out of Room 22, the next-door room, after explaining some results to that patient. I hurried into Room 21 before the page was even finished.

Entering, I found an elderly male, 75 maybe, in a loosely-tied hospital gown, sitting upright in his cot. "Are you the doctor?" he asked, focusing his worrisome eyes on me. As I nodded yes, I glanced up at his cardiac monitor, which was showing a stable cardiac rhythm, good oxygenation on room air, and a slightly elevated respiratory rate. As I was looking, an automatic blood pressure reading had cycled and that, too, was normal.

"Help me, doctor," he exclaimed, his eyes remaining fixed on mine, his voice cracking, "I'm going to die!" To add a dramatic flair, one of the overhead fluorescent bulbs began flickering its last hurrah, casting intermittent shadows on the patient's face. An interrogation room atmosphere.

I quickly introduced myself, shaking this patient's hand, as I listened to a brief overview given by one of the two nurses. As she finished, I still hadn't heard what I wanted to hear--a solid reason for this patient's words and behavior.

It was time to interrogate. "Sir," I said, "has anything like this ever happened to you before?" No, he replied. "Are you having chest pain or calf pain with this shortness of breath?" No. "Have you had any recent cough or cold symptoms?" Again, no. "Any trauma or falls?" Nope. "Have you ever had any allergic reactions that may have caused a similar reaction?" You guessed it, no.

I was told this patient's brother, whom he lived with, was going to be escorted to Room 21 shortly. I looked forward to talking to him. In the meantime, I did a thorough exam on this patient and found nothing remotely concerning. He had no rash. He had no wheezing or stridor. He had normal heart sounds.

"Sir," I asked him point-blank, "do you have a history of anxiety or nervousness?" He shook his head "no." "On any new medicines?" Another nod "no."

Even though we approached this patient as a possible allergic or anxiety reaction, based solely on his MRI-department history, he still warranted a thorough work-up, because of his age and several cardiac risk factors.

We ordered a stat EKG, a portable chest x-ray, blood work, including some screening cardiac enzymes that would elevate if there were any concurring ischemia to the heart, and a d-dimer, a blood marker that, if positive, raises one's suspicion for a blood clot.

The patient's brother still hadn't arrived by the time I reviewed the patient's EKG and chest x-ray, both normal. I had someone go look for him as I reviewed the patient's blood work results, hot off the presses. Surprisingly, normal.

I was in Room 21, explaining all the good results to the patient, when a smiling, elderly man was escorted into the room by one of our techs. If you took away the patient's nervousness and sense of dread, this arriving man would have been what I imagine this patient to look like. Obviously, it was the patient's brother.

Being told that his brother had finished in MRI, this man had gone to the cafeteria to grab a bite while waiting for an official discharge. The brother had not been told of the situation in the MRI suite.

"So Frank," the brother spoke, shaking his disapproving head, exasperated, "you did it again, huh?"

"Did what?" Frank asked, now glancing sideways out of his eyes at me.

"Have another nervous attack," the brother said. "I told you to make sure you told everybody you have anxiety and are on medication for it. You didn't, did you?"

I looked incredulously at Frank, who now fully avoided eye-contact with me. I looked at the brother. "I point-blank asked your brother if he had anxiety or nervousness and he told me 'no.'"

"Of course," the brother said, "he always denies it. But he has about five or so attacks a day. He seems to be more and more preoccupied with dying these days. " He looked at his brother, the patient, before turning back to me and continuing. "Did he tell you he was going to die?"

I shook my head "yes." The nurse shook her head "yes." Frank, even, shook his head "yes." "Well," Frank's brother continued, "I hear that about five times in a day. Frank gets all worked-up, insisting that I will be living alone by the end of the day." The brother hesitated, as if he was going to add a quirky little comment to that last statement, but bit his tongue.

"How does Frank look to you now?" I asked the brother.

"Like he always does," the brother replied. That reply was music to my ears. Frank looked at his brother, piercing eyes and all, and spoke quite dramatically. "That's enough, Elmer."

Elmer wasn't intimidated. "You're right, this is enough." I stepped out of the room only after refereeing the minor argument that ensued. And ordering some Vitamin "V" for Frank.

It turns out that Frank had held his morning medications, including his valium and anti-depressant, in preparation of his MRI. Unfortunate, since some people without anxiety still require an anxiolytic to get through MRI testing. After a social service consult, I called Frank's family doctor with a report of what happened and, more importantly, to get a follow-up appointment for the next day.

The family doctor was surprised that, somehow, Frank's medications and history of anxiety were not conveyed to the MRI staff, which could have preempted an ER visit. It made me think, though, that if you point a finger, four are still pointing back at you. The family doctor had ordered the test and knew this patient better than anyone else. I would have assumed he would have alerted the MRI team to Frank's recent bouts of anxiety.

"May I ask," I questioned, still a little perplexed, "what was the reason for Frank's MRI?"

"Oh, sure," his doctor replied, "it was a brain MRI to rule out any recent or remote stroke activity. He's been getting real forgetful lately."

So, as it turns out, the forgetful patient forgot to share his anxiety issues.

I walked back into Frank's room to explain his follow-up plan, only to find Frank and Elmer both calmed down, watching a baseball game on TV. "So I'm not going to die, Doctor Jim?" Frank asked one last time.

I shook my head no. "Sorry, Frank, not today you aren't."

Not on my shift, anyway...

As always, big thanks for reading...I hope everyone had a great weekend. Next post will be Wednesday, May 12. See you then...

Friday, May 7, 2010

A Mother's Cry

Every day is a gift...

Initially, this was posted February 17th, and your overwhelming response and compassion astounded me. Thank you. May it remind everyone of the tremendous treasures we have been entrusted with when we become parents.

It happened again last week. Among the hustle and bustle of a crazy shift. A pre-hospital radio call from an ambulance team that nobody ever wants to receive.

"We're bringing you a child in cardiac arrest."

Noooooooo. Word traveled quickly through our staff, and the mood immediately got very somber as everyone prepared the resuscitation room for this child. We could only pray that the child being brought to us would respond to our life-saving measures.

Nurses ran to get the intubation and IV trays, pharmacists ran to get the resuscitation cart with all the emergent medications, techs ran to get the EKG and ultrasound machines, and respiratory therapists ran to get a ventilator. Two of us physicians were working with a slew of residents, and we all reviewed our mental checklists and tried to enter our objective frames of mind. Organized frenzy.

My partner requested to be the lead physician during the resuscitation. Being young and recently-trained, he wants to save the world. We all want to save the world, I guess, but for now we'd focus our energy on saving this child. I assured him that I would stay in the room and help with the resuscitation efforts.

The ambulance arrived. With a sad nod of his head, a trusted paramedic gave answer to our searching faces. No response. Yet. We all caught our breath as our hearts plummeted.

We transferred this child to our hospital cot. We emergently intubated this child, checked for any pulses, and continued CPR when we found none. IVs were hard to establish, so I started an intraosseous line by sticking a needle into this child's left tibia. Aggressive fluids were given. Medications were administered. Ventilations were forced into uncooperative lungs.

Efforts continued. My partner followed the life-saving protocols but didn't get any response from this child. Prayers were whispered. Seconds were watched as they ticked on the clock. Slowly, as slow as any time had ever passed, a heartbreaking realization permeated the room. We might not succeed.

My partner ran to the family room to discuss options with this child's parents, while I continued to follow all the resuscitation protocols. We had nearly maximized all of our medications. And still...nothing. CPR was continued, ventilations were continued, more medications and hydration were given.

My partner returned to the treatment room. He looked at me expectantly, and I shook my head "no." My partner shared his conversation with me. Dad was still at work, and Mom was in the family room with our social workers, waiting for family to arrive. She had been invited back to watch the resuscitation efforts, but declined. Her child had been through this once before, because of chronic, ongoing medical problems, and had survived. Surely, she thought, her child could survive again.

After almost an hour of failed heroics, with absolutely no response to any of our interventions, we confirmed what we were most afraid of. There were no palpable pulses. There was no cardiac activity, confirmed on monitor and with our bedside ultrasound. There were no spontaneous respirations. There were no signs of life from this child.

There would be no miracle.

My partner asked if anyone in the room objected to his pronouncing this child's death. Nobody objected, since we had all been involved in trying to save this child's life. We knew the efforts that had been put forth were monumental. No attempt had been spared by our team to bring this child back. Unfortunately, and for unexplained reasons, the fates held different plans. My partner announced the time of death.

I requested a nurse to clip some of this patient's hair for the family. I crossed myself after my silent prayer. I fought my tears. Hell, we all fought our tears. I consoled my partner, who, like me, has three young kids of his own. Slowly, a wave of profound sadness and nothingness swept across us. What good are any of us if we can't save a child's life? My partner went out to the family room to deliver the awful news.

Then, time stood still. From two hallways away, I heard the haunting sound. A sound that I knew was coming. A sound that is played over and over in my mind for days after an event like this. A sound of profound anguish. A sound of utter disbelief. A sound of infinite pain.

A mother's cry.

Slowly, as we all knew would happen, the mournful wails of crying crescendoed, and our emergency department came to a stand-still as Mom was escorted through our halls into her little child's room.

Despite our best attempts at maintaining our objectivity, and despite the fact that there were many more patients waiting to be treated, our ER staff cried collectively and gave consoling hugs to one another. We are mothers. We are fathers. We are brothers and sisters. We are sons and daughters. We are friends. We are human. And, we were broken.

Dad arrived just minutes after Mom was escorted to the room, and the cries of desperation were repeated. This time, husky and deep. Slowly, though, his cries softened and dissipated, until there was but one lone cry that began again. Higher-pitched. Guttural. Primitive. Emanating from the womb. A cry that conveyed the raw anguish and helplessness that only such a profound loss as losing your child could bring.

God Bless this mother. God Bless this father. God Bless this child. And may God Bless and watch over this family. And all of us.

My most heartfelt wishes for every mother, and mother-figure, for a blessed Mother's Day weekend. May your presence in the lives of those you love be cherished. And may unbridled love be returned to you in deserving, infinite amounts. New posts next week...

Sunday, May 2, 2010

Man Up, You Wimp!

As a typical guy, there are several painful illnesses that can hit our brotherhood in an instant. No warning given. No "Get out of jail free" pass, either. Just cruising along, having another fine, healthy day and baam!--suddenly you are lying on the floor in severe distress.

The most feared? A testicular torsion. It can happen spontaneously. It can happen suddenly. And if you are the owner of a testicle or two, it can happen to you. Simply put, the testicle can twist on its supporting ligaments and vessels, in essence cutting off the blood supply while stretching and irritating the supplying nerves. Sounds painful, yes? Excuse me for a second while I wipe my eyes--they're welling up just from talking about this one.

Or better yet? Taking a direct traumatic hit to the groin area. We've all seen the funniest home video shows where Dad takes one to his manhood, only to buckle over and writhe in pain. It's funny, sure, as long as it's not one of us that took the shot. And usually, the laughing female voice we hear is the guy's loving wife or girlfriend, still recording. Explain that one to me! Whatever you do, maam, don't put the camera down to help out your man!

At least with these afflictions, though, we can't be compared to a woman dealing with the same illness, shaming us with their inner strength. We can carry on and on and never have to explain ourselves and our pain. Or worry about comparisons.

However, the illnesses we do share with the more stoic and stellar species--you know, the ones with two xx chromosomes--are numerous. Chest pain. Abdominal pain of a million etiologies. Migraines. Broken bones. An asthma attack. The list is long. If you came and worked one shift with me, you would find it very evident that a woman is so much more tolerable and less whiny than a man with a similar problem. Almost always. Us guys? Yeah, for the most part, we are big wimps.

A few months back, I had two patients, a man and a woman, present to our emergency department, within an hour of one another, with the same illness. Unrelated, they were both suffering with kidney stone pain. Pain that was sudden. Pain that radiated from the flanks toward their groins. Pain that they both graded a ten out of ten.

Walking into the woman's treatment room, I found a patient with her eyes closed, breathing deeply in and out. Her tight grips on her cot's side rails were her only clue to being uncomfortable. Calmness permeated her room.

After a brief review of her history, which included a previous history of kidney stones, and a primary exam, I offered her some pain medications, in addition to some IV hydration and nausea medicines.

She smiled, taking me up on my offer. "Thank you, Doctor," she quietly said, "that would be wonderful."

After ordering her CT scan, urinalysis, and baseline blood work, I continued into another treatment room, just two doors down from her, to see the male patient.

I heard him before I even walked into his room. Between the cursing, the moaning, and the angry words directed at his wife, I knew he was going to be a difficult patient to manage.

I walked into the room, ready to briefly introduce myself and obtain a bare-bones history and physical, before offering some similar pain relief. I didn't get the chance to do either.

"God-damn it," the patient said, sarcastically, greeting me, "are you the doctor? I'm in pain here." He, by the way, arrived after the previous patient. The drama in the room was suffocating, to say the least.

I assured him that yes, I was the doctor. After a few more obnoxious words, and some dramatic flailing, he refused to tell me anything about what brought him to our ER. Now, I'm all for giving someone a break when they aren't feeling well, but his actions and words were bordering on ridiculous. "I'm not telling you anything more until I get some God-damn pain medicines," he said, crossing his arms over his chest. If he hadn't been lying in a cot, I know he would have been stomping his feet.

I know that kidney stones can be painful. I've seen enough patients with them to get that. I also know that I never want to have one. But, I also know that pain does not give one an excuse to be as blatantly rude and disrespectful, with the medical team providing care, as this patient was. Sometimes, a patient may forget that we are on their side. At any rate, it's hard to get under my skin and, after walking out of the previous stoic patient's room, this gentleman succeeded in doing just that.

"Sir," I said, "I understand you are in pain, but I won't let you talk to me or anyone else in my presence in that manner. Do you understand?" He eyed me while receiving my direct stare. "Do you understand me, sir?" I repeated. He nodded yes. "If you cooperate, I will be more than glad to help you after I learn what brought you here and perform a brief exam. I'm sorry if you don't understand this process, but that's how it's going to be done." His nurse, standing by his cot, nodded her agreeement.

Translation: Man up, you wimp!

With a little coaxing from his wife, we arrived at an understanding. As I requested, he provided me with the details of his sudden onset of pain. He was home lying on his couch when he suddenly had been overcome with pain in his right flank area. "I know it's my kidney stones again," he said. "It's just like my last one."

After cooperating, he also received pain medications with some IV fluids and nausea medicines. "Finally," he complained to the nurse, "that took forever." Yes, sir. Twelve minutes to be exact, from the time he was placed in his room until the time we pushed his medications.

Ultimately, both patients had results conclusive of a kidney stone via CT scanning. His, three millimeters. Hers, four millimeters. Both stones were in the UVJ, or the uretero-vesicular junction, the distal part of the ureter, the tube that connects the kidney to the bladder. Both stones were near their journey's end. There was no hydronephrosis, or backed-up fluid, to either's kidney.

I walked into the woman's room and explained her results. She looked more at ease, greeting me with a smile as I entered. "Thank you," she said, continuing to be stoic and kind, her grips lessened on the side rails, "for all you did. This was a wonderful experience." She had refused any further offers of IV pain medications. "I'll be fine," she had assured us. I wished her the best, advised her to return to our ER if she had uncontrolled pain or fever, and sent her home with a prescription for pain medication. She would follow with her urologist in a few days.

She had been an absolute pleasure.

Next, I walked into the man's room and to explain his results. He had received several additional doses of pain medication and appeared much more comfortable, although his complaining nature was still evident. "God-damn it," he said, now rating his pain a one out of ten, "why do I have to suffer with these god-damn stones. Why couldn't someone else get them, instead?" I explained to him that his stone was small, was near the end of passage, and that we would be sending him with a script for pain medications. On review of his previous records, he had always passed his stones without complications. I suspected that this would be no different. I referred him back to his urologist for a follow-up appointment in a few days. Yes, I was sharing the love.

I know this is an extreme example of comparing a man to a woman, with many variables to consider (a family history of stones, the size of the stone, an individual's response to pain, age, etc.). Consistently, though, through my career, women have demonstrated to be much more stoic, mature, and admirable in dealing with illnesses than men. You can't change my mind of that. It could be something as simple as the flu, or something as complex as a myocardial infarction. It doesn't matter, really.

My one buddy has a theory--the more screaming and carrying-on from a patient, the less the likelihood of that patient being seriously ill. Likewise, the more stoic a patient, the more serious the illness. At first, I laughed at him and his observation, thinking he was just joking around. "Seriously, Jim," he said, "just think of all the guys we've treated who were crying when we walked into the room." Unfortunately, after this many years spent in the ER, I've seen his theory prove itself true.

What do you think?

I think us men need to toughen up and start spitting out some nails. Or eating black licorice to grow some hair on our chest. Even throw away that certificate for a pedicure and an hour massage. Hide the cologne. Quit watching "Dancing with the Stars." Maybe, just maybe, we should step up and offer to deliver a ten-pound baby, au natural. That might put our pain in perspective.

On second thought, though, maybe I should hope to get a kick in the balls or a spontaneous testicular torsion instead of any other painful illness...that way, I won't be embarrassed or shamed by my fellow womankind when I start my high-pitched screaming in the ER. Or flailing my arms. Or crying...

As always, thanks for reading. Hope your weekend was a good one. See you next time...