Monday, June 28, 2010

The Dry Season

I wish it were simply a seasonal variance, the emergency department's environment of dry, humid-less air. A fifth season, of sorts, that would arrive between the last snowfall and the first flowers of spring. We could prepare, in advance, for the pruning process of our bodies, expecting and accepting every minuscule of body hydration to escape us during this period. Then, after a month or two of tolerating mosaic-like skin, we could move on to the next season.

Unfortunately, though, the ER's dry climate is a year-long season. The temperature-controlled, recirculated, skin-cracking air seems to be an everyday affliction. One that most of us have learned to deal with in our own little ways.

The answer could simply be to drink a lot of water. Which isn't easy, since free-time is a luxury in the ER. Remembering to take a drink is usually not a prominent thought during a crazy shift. Maybe the answer is lots of lubrication. Some people need to apply, and reapply, multiple applications of skin and hand lotions before and during a shift. A tube of moisturizing lippage never seems to be far from the typical ER employee. Despite all of these efforts, though, sometimes you simply can't outrun the gusts of stale ER air.

You will crack, my friend, you will crack.

How do I approach this problem? Probably much like most of my co-workers. I try my best to drink a lot of fluids, whether it is plain ice water or with a packet of flavoring mixed in. In the ER, though, sometimes it's just too hard to keep up. At times, even, I have completely forgotten to drink something until I urinate, for the first time, ten hours into my twelve hour shift, and notice my concentrated Sahara urine. Occasionally, we don't have our usual supply of water pitchers to make it easy for us to run to the ice and water machine. During these times, as I learned during residency, I resort to using a clean male urinal bottle to hold my iced water or, better yet, my urine-resembling iced tea. I've made a few people jump (freak-out, actually) from that move. But, hey, at least I am hydrating myself, right?

I also use my Aveeno lotion and my Burt's Beeswax lip balm faithfully and, still, I get dry skin and cracked lips. I have switched brand names to no avail. I have become intimately familiar with every option of every brand of moisturizer in our local pharmacy. I use nasal saline mist spray. And still, I crack. On a side note, I even tried slathering myself with Neutrogena body oil in the shower after I was done washing. Trust me, I didn't like that feeling of being all slicked-up, like a greased pig, for the rest of the day.

It is what it is, I guess, and comes with the territory of our jobs, being cracked and dry and parched. Two-bit impostors of some scaly crocodiles.

Which leads me to today's story.

Recently, while we were out, several of us were sharing some of our more embarrassing work stories with one another. I have enough of these stories to fill a book, actually (do me a favor and act surprised here), and will humbly share several of these stories along this blog's journey. Nothing makes me happier than when we can share and laugh at ourselves, embracing the fact that we too are human. Humble, modest humans. Self-deprecating and all.

Anyway, after the mention of the dry ER climate ("What the heck is up with that?" "Why can't they get a humidifier attached to the furnace?" and "Who gets cotton mouth at work?"), I decided to spill the beans of a time when I was in residency in upstate New York.

I was in my last year and had just finished a grueling twelve-hour shift, working from 8 p.m. to 8 a.m. It was one of those nights where the morning couldn't come quick enough. Lots of traumas, lots of cardiacs, lots of sickness. And lots of coffee. I don't think I had eaten or gone the bathroom the entire shift. It was one of those shifts you leave thinking that "Yeah, I got my ass kicked, but maybe, just maybe, I did make a difference during this one."

At eight, we gathered with the incoming team to sign-out our active patients. I was so dry, cotton-mouth and all, that I could hardly give my report without breaking every five seconds to lick my lips and try to swallow. After report, I went to our locker room and chugged five minutes from the bathroom faucet. Lucky I didn't catch anything. I applied my Chapstick and was on my way.

The drive home consisted of me taking two major highways, about five minutes on each, before exiting onto a country road and finishing the peaceful thirty minute drive. As I started out on the first major highway, I glanced at myself in the rearview mirror and noticed the big bags under my eyes. And then I gasped. Right there, dangling from my nose, was a cruddy, dried-out booger.

Or maybe it was the crumb-topping from a piece of apple pie. Oh, that's right, I didn't have a piece of apple pie with crumb-topping.

Well, I was mortified. Was that dangler there during sign-out? Or had it just been born minutes before while I was changing out of my scrubs? I felt like I should have given it a name.

Well, of course I couldn't let it just sit there. I had to get rid of it. Not an extra-napkin carrying kind of guy, I knew I wouldn't have any tissue in the car. So I just knocked it off, onto my car's floor. But did I stop there? Noooooo, not moi. I had to make sure there weren't any more. So, unfortunately, I did a very slight, superficial dig. Or maybe it was a quick side-swipe.

And that's when I got busted. As I was scratching and not picking, looking in my rearview mirror, I suddenly heard some relentless horn-honking. I looked to my left, out of my driver's window, and there were three college kids passing me in the left lane, all pointing at me and mimicking picking their nose. They were laughing quite hard, I must admit. And who could blame them? I would be, too, if I were passing a nose-picker in another car and was with two college buddies.

Well, of course, I had to laugh along, but not until after I cursed the dry ER. If only I had one of those misting fans attached to my neck ID tag, this might not have happened. And to add insult to injury, the back seat kid mooned me as they sped by. Can you believe that? The bastard! I'm okay with getting mocked, but I didn't like an unknown bare-ass giving me an 8:30 a.m. wake-up call.

I turned off the major highway onto the next one and, surprised not to have any cars in either lane, finished the swipe job. Took a big drink of my bottled water. Applied my chapstick. Laughed at myself. And hurried home to the welcoming arms of my wife, she who married a booger picker...

I don't think so.

And all because of the eternal ER dry season.

As always, huge thanks for reading. I hope you all had a great weekend. See you Wednesday, June 30...

Wednesday, June 23, 2010

The Unexpected Change Of Life

Imagine being in your early seventies, cruising through your golden years, content with knowing that you've lived a pretty blessed life. The kids have turned out well, you are still married to the spouse you fell in love with fifty years prior, and you end each day with a smile and a good book.

A well-deserved twilight in a much-appreciated life.

Unfortunately, though, life can be cruel. And being in your seventies doesn't guarantee you a trauma-free life. Or the use of your legs.

I walked into Room 17 to meet my next patient, a woman in her mid-seventies who was wheelchair-bound. As I walked into the room, I was graciously greeted by a smiling woman who sat upright in her treatment cot, her hand warmly outstretched, her straight legs extending limply in front of her. Her soft brown hair and matching eyes exuded good energy, matching the room's atmosphere. I immediately liked her. This patient's husband sat in a hospital chair under the room's cardiac monitor. His face, unlike his wife's, was etched with hesitation and concern.

Sitting in the room's far corner, tucked neatly away from both the patient and our medical team, sat a mechanical wheelchair, all black and high-backed, its leg-support frames jutting forward from the seat. A black shiny direction ball sat on the right armrest. Despite it's obscure location, the wheelchair was an elephant in the room.

"Hello, Mrs. Wilson," I said, walking up to this patient and grasping her extended hand, "I'm Doctor Jim. It's a pleasure to meet you." I turned to her husband, offering my hand, and we shook as well. He eyed me warily, his expression one of a fierce protectiveness that I have appreciated on a spouse's face of previous sick patients. I recognize it for what it is--a simple expression of deep love.

"Mrs. Wilson," I continued, turning back to the patient, "what can we do to help you today?" I sat down on the physician stool by the side of her bed.

"I'm worried I might have another blood clot in my leg," she said, eyeing her own left calf.

As explained by Mrs. Wilson, she had had a blood clot in her left leg several years prior. As a result, she had been placed on the blood-thinner coumadin, mainly to prevent any further blood clots from forming. In January of this year, she added, the coumadin had been stopped under her doctor's guidance. "And let me tell you," she said, sweeping her arms for emphasis, "I don't miss that medicine at all. Making adjustments with the daily dosages, getting endless blood draws to check the levels, and worrying about bleeding and bruising all the time. Who needs that?"

I laughed at her spirited animation. "I'm here today, though, doctor," she continued, "because my left calf is swollen and I am worried I may have developed another clot." With this, her husband spoke up, his husky voice contrasting his thin, wiry frame. "I hope not, honey. I know how much taking that medication bothered you."

I approached the difficult subject--her being wheelchair-bound. Wheelchair dependence equates to some degree of immobilization. Immobilization equates to a higher risk of blood clot formation, since the lack of contracting calf and thigh muscles decreases the vigor of the venous blood returning to the heart from the lower body.

"Mrs. Wilson," I asked gently, quietly, "do you mind me asking why you are dependent on a wheelchair. What happened?"

As she spoke, her husband looked down at his restless hands folded in his lap. Mrs. Wilson took a deep breath before starting. "It was a few years ago. I was driving alone in my car on a rainy day when, unfortunately, I had an accident. A horrible one at that. As soon as it happened, I couldn't move my legs. I thought that maybe I had broken them both. Or maybe they were pinned under my dashboard. As hard as I tried, though, I was stuck, trapped in my car." As she had approached these last spoken words, her voice had subconsciously lowered.

Her smile belied her anguish and I remained silent, patiently waiting for her to finish. "It turns out," she softly whispered, "that I was wrong. I didn't break both of my legs. And my legs weren't trapped under my dashboard. I had broken my lower back and this resulted in a spinal cord injury." An injury that changed her life forever.

Her husband contributed. "She had real bad arthritis and, because of this, her lower back vertebrae were brittle and couldn't tolerate the awful force of the accident. Her broken back pushed into her spinal cord and paralyzed her legs."

Imagine the wide circle of hurt that her injury had created. Her children, her grandchildren, her husband, her friends--the pebble of her injury must have rippled through too many unimaginable facets of the life that she knew.

I shook my head. "How awful," I muttered, immensely sad for her. I tried to imagine my mother or father in such a predicament, the changes in their life that would be necessary after so many complacent years without tragedy. Going from the general aches and pains that come with age to simply not having the use of their legs.

Mrs. Wilson placed her hand on top of mine, which was resting on her side rail. "Dr. Jim, I look at this injury as a blessing. Sure, there are inconveniences that come with each day, but I'm lucky to be alive." She paused, resting her eyes on my own. "I still get to wake up each day. I get to talk to my children, my husband, my grandchildren, and my friends. There is still a lot I can do." Her eyes lit up and her smile broadened as she talked. I had no doubt that this resilient woman had acquired a deeper understanding of the important things in life. "Don't get me wrong," she continued, "it's been hard, sometimes really hard," she said, nodding to her husband, "but I'm here and I'm alive. And I feel the love of my family."

Her perspective was inspiring and well-timed. I had been having one of those "poor me" days. Just the previous night, one of my favorite aunts, my Godmother, had died. I was struggling to wade through my next few shifts before heading home to be with my family throughout the visitations and funeral. For various reasons, my aunt's death had reminded me that I am entering another phase of life, where the people I respect and look up to for spiritual guidance were gradually leaving this world for greater things. I was sad for her children, my cousins.

Thanks to Mrs. Wilson, though, I lost my "poor me" attitude pretty quickly. I changed around my thinking, too. I pictured my aunt being reunited with my uncle, her husband. I pictured her being greeted by previously deceased family (including my mother) and friends. I pictured her smiling and pain-free. I pictured her as a protective angel who, undoubtedly, would watch over all of us. I would miss her, yes, but she was not suffering anymore.

Looking back at Mrs. Wilson, I saw nothing but smiling and warmth, an infinite aura of graciousness. Her appreciation for life was evident and dazzling. Her subtle lessons about life and loss and positively readjusting under difficult times were not lost on me.

Thank you, Mrs. Wilson.

I am happy to report that Mrs. Wilson didn't have a blood clot in her leg, after all. In other words, all that blood was returning to her heart just the way it should. With energy and vigor.

I wouldn't have expected anything less from this amazing lady.

As always, big thanks for reading. Have any of you sustained a tragedy that you've had to overcome? Next post will be Friday or, at the latest, Monday. See you then...

Monday, June 21, 2010

The Hawk And The Sparrow

Recently, at one of my kid's sporting events, an amazing, awe-inspiring event took place in the skies above, encouraging all of us spectators, family and friends alike, to abandon watching the actual game in favor of the unfolding scene.

I present to you, the hawk and the sparrow.

It was early evening, that pivotal time when the sun begins its slow descent, signaling the insects of dusk to come out and partake in their human feasting. Clouds were sparse and lazy, the few present hovering protectively over the field. The baseball game, exuding palpable excitement, was extremely close, tied after three full innings. The kids, playing for sole possession of first place in their league, were treating us to a great game.

They had earned our attention. As any parent knows, some of these sporting events are downright dull and painful to sit through (what we don't do for love), but this baseball game, thankfully, was not one of those times. We fans, spread out over two stands of bleachers, were rooting our teams on, excited for the great heart our kids were showing.

So, to draw our attention away from the game, something very unusual, very unique, would have had to occur.

And it did.

I had heard the sparrow and the hawk before I had seen them. It was a distant screech, presumably from the hawk, mingled with several chirping squawks from the sparrow. Intrigued, I looked up to find the small lone sparrow flying in hot pursuit of the hawk. Yes, I got the order right. The sparrow was chasing the hawk.

Now, I have seen smaller birds chase after bigger birds before, most likely to protect their nests and the contents. But those interactions, although entertaining, were extremely brief. Either the smaller bird succeeded in driving off the predator or else the bigger bird ignored the vain attempts of bamboozlement and continued with the planned attack.

But this sparrow, well, was the underdog--the "little engine that could." It tailed the hawk for a good twenty seconds, its incessant chirping interrupted only by the occasional screech from the fleeing hawk, before suddenly gaining on the hawk, swooping in, and pecking at the hawk's back and head. It then swooped away as the hawk circled in the air.

I was entranced. The hawk circled around and, much to my chagrin, the little sparrow did not take leave. Rather, it seemed to do its own little dance before circling and flying head-on toward the hawk. It looked to be on attack again. "Uh, oh," I thought to myself, " here we go. It's snack time for the hawk."

The sparrow and the hawk flew directly toward one another, a daring game of chicken now playing-out. Despite both birds gaining speed, the moment slowed, and I held my breath, anticipating the hawk's snatch of the little bird. Although I didn't want to see the sparrow meet its untimely death, of course, my morbid fascination pictured the scene quite clearly. My eyes, unblinking, were fixed upward.

Surprisingly, it was the hawk that balked. Chicken-shit, I thought. Fifteen or so feet away, the hawk had veered upward, out of the sparrow's direct line-of-fire. The sparrow stayed on course, though, hardly intimidated by the hawk's half-circle. And before I could blink my eyes, the sparrow was in hot pursuit again, matching the hawk's screech with its own chirps. There's no way, I thought to myself, that this sparrow would repeat his brave pecking attack like before.

I was wrong. Within seconds, the sparrow swooped in from behind the hawk, looking as if it had landed on the hawk's back. It hovered there, in full flight, before beginning to peck at the hawk again. The hawk's squawking assured us that it was as confused as we were by how this was playing out. The sparrow, after several seconds, lifted off the hawk, forfeiting a little distance, before continuing to tail the bigger bird.

I paused from the scene, realizing that I had missed the first player batting in the new inning. I looked around me, at my fellow spectators, amazed to see that half of them were, like me, also watching the scene in the sky unfold. And missing the game, too.

Well, the sparrow's attacks didn't stop. Soon, after some spreading of words and pointing of fingers, all of the spectators were looking up, completely mesmerized by the little bird's attacks, which kept coming every thirty seconds of so. As you probably guessed, it didn't take long before the baseball players joined in, pausing between plays and pitches, to look up at the sky and point.

The sparrow, incredibly, kept its attack on the hawk going for ten minutes, easy. By this time, we, the crowd, were "oohing" and "aahing," even going so far, on several occasions, to cheer for the underdog sparrow as it ducked from the hawk, redoubling its efforts to maneuver itself behind the hawk before going in for another round of aggressive pecking.

Finally, the scene stopped. Both birds must have been exhausted, if not hoarse. The hawk headed south while the sparrow turned northbound, toward the thicket of tall maple trees, finally abandoning its pursuit of the hawk. There seemed to be a unified cheer and a collective sigh of relief, from the fans, that the chase was over.

I have to be honest. It was hard to focus on the baseball game after this unplanned entertainment. Baseball game--boring. Little bird chasing big bird--exciting. For the next half hour, conversations were ceaseless about the bold, daring sparrow and "that wimpy hawk." Me, the one who practically grew up in the woods among my forestry family, was simply enthralled with the unfamiliar scene I had witnessed. I have no idea what brought on the sparrow's aggression but, nonetheless, appreciated the piss-and-vinegar that little shit of a bird had shown all of us.

Plus, this story packed more ammo than if the hawk had simply snatched the sparrow from midair during the earlier scuffling.

I always root for the underdog. I don't know why, although it seems that I inherited this trait from my mother. Watching the nature shows as a child, I remember her always rooting for the unfortunate animal being chased by the lionesses or the cheetahs. Really, who roots for a warthog?

But this little sparrow? I'll tell you what--that little bird single-handedly stirred up a whole baseball season worth of excitement. It was that cool. I love these little life moments that turn your thought process upside-down. I mean, really, I doubt I will ever see a sparrow kick a hawk's ass again. Ever.

Oh, and just in case you were wondering who won the game, I'll tell you. The underdog team did.

Go figure.

As always, big thanks for reading. I hope you all had a great weekend. A belated "Happy Father's Day" to all of you real men who step up to the plate every day, trying your best to be a good father-figure in someone's life. Well done. See you all Wednesday, June 23...

Wednesday, June 16, 2010

Two-fers And More

Anyone who has worked in an emergency department is well aware of the term "two-fer." It is a term that seems to be accompanied by dread and a discouraging shake of the head. Unfortunately, though, it is a reality that comes with our jobs. And as much as we'd like to run from a two-fer, we have all learned that it is better to just suck-it-up and deal with the situation.

Two-fer. See, just thinking about it, I can feel my heart rate picking up.

So, as the name implies, we are not dealing with a single patient. Nope. A two-fer typically means that there are at least two patients from one family that wish to be seen. For example, a mother with some URI symptoms may decide to be seen by a physician as long as she is checking-in her sick toddler, he with a fever and some ear tugging. Maybe it's the elderly couple who have both decided that their diarrhea is from eating out at a local buffet house. "I knew I shouldn't have eaten the rice, Edgar. It didn't look right." Maybe, even, it's twin pelvic exams for the college roommates who do everything together.

Surprisingly, though, I think patient number two does not typically plan on being seen but, instead, makes the split-decision to be treated once they arrive at the ER. And why not, really? They are already here. If their family or friend is going to be treated, they may as well get "checked-out, too."

If it were only two patients, maybe it still wouldn't be such a big deal. But guess what? Yep, you guessed it. Sometimes there is a "three-fer" signed in. Sometimes, even, a "four-fer" and a "five-fer." A general rule is that the more people that sign in from the same family, the less sick they really are. And because of that, they usually get sent to our express track. Don't you think, for one minute even, that I don't appreciate immensely that provider taking one for the team.

A few years back, one of my favorite physician assistants, a compassionate free-spirit named Patty (imagine Carole King dancing wildly at Woodstock), was assigned to my supervision. And it was during this shift that Patty set a new record. In my book, anyway.

Guess how many she saw from one family? Five? Nope. Six? Nope. Drum roll, please...Patty saw seven patients from the same family. Is "seven-fer" the right term here? I don't honestly know.

Can you even imagine walking into one treatment room and finding seven patients, though, waiting to be seen? I can't, although Patty seemed to take it all with a grain of salt. "I may as well just buckle-up and get this family taken care of, Jim," she replied when I called her to ask if she needed any help. And tell her that I thought she was a god. "They all seem to have the sniffles," she added, "I'll be okay."

It turns out that two adult-cousins, mothers in their twenties, each brought in two of their kids to be seen for cough and cold symptoms of a day's duration. While checking in their kids, the two adults decided that they, too, wanted to be "checked out." Heck yeah, why not? So let's count. One mommy plus two kids equals three. Plus, one mommy and two more kids. Three plus three equals six. Not seven.

Oh, but while this family was in triage, one of the young mother's decided to run back home and get her third child, an infant, who "was just starting to get a runny nose, too." So, while she was away, the other mother took charge of four unruly, poorly-behaved kids. We could hear them, three halls over in our acute ER, causing a ruckus. Wouldn't you think that if they were sick enough to come to the ER, they would be somewhat fatigued or a little wiped-out?

This, my friend, is how Patty ended up with seven patients in one room. While mom number two was away, mom number one was placed in one treatment room with the four waiting kids. The door was shut after a few minutes, by nursing, because of their disrupting behavior, until Patty went in to perform her exam. Pardon me, I mean exams.

Happily, Patty reported that there was no significant concerns or illnesses in the room. An ear infection here. A strep throat there. Otherwise, normal cough and cold symptoms presumed to be viral.

"Patty," I had to ask, "is this a record for you?"

She didn't even flinch. "Hell, yeah, Jim," she said, chuckling, "and I hope I never have to top it."

I was eager to see how she approached so many patients. Maybe she saw one or two patients at a time and then stepped out to fill out the medical charts. That's how I would do it, I think. To avoid all that confusion.

"Nope," Patty said, shaking her head and pulling out a ratty 8 1/2" x 11" paper, "all of my notes are right here." As the mothers had talked, she had taken notes on each patient and then immediately performed their exam. "If I had stepped out of that room, even one time," she added, "I don't think I would have ever gone back in." When she was done, she stepped out of the room and formally filled out each patient chart, their discharge instructions, and their prescriptions, if needed.

Time spent? One hour. Which, when you think about it, is a good average. Seven patients an hour. Us ER docs typically average two to three patients an hour, although our patients may be a bit sicker. Nonetheless, Patty kicked ass. And I told her so.

"Yeah, well thanks, I guess," Patty said, wondering if I was teasing her or being serious. Maybe a bit of both, actually.

News of Patty's heroics travelled fast through our ER and, for the next week, she was looked at with nothing less that pure adoration. Honestly, I think she soaked all the glory and attention right-up. Who wouldn't. Some even nicknamed her "Seven."

As much as a team player that I am, though, I was very glad that it was Patty who stepped up to the plate to see this family. And not me. I think Patty single-handedly saved me from becoming a befuddled bobble-head.

Suddenly, a two-fer doesn't sound all that bad anymore...

As always, big thanks for reading. I hope everyone is having a great week. See you Friday, June 18.

Monday, June 14, 2010

Who Am I Treating?

Occasionally, as difficult as some patients may be to treat in the ER, for whatever reasons, that difficulty may be nothing compared to the stress and negativity brought to the encounter by their accompanying family members or friends. People who "know the patient more than they know themselves" and don't hesitate to try to dictate the course of therapy for the patient.

Don't get me wrong, I appreciate a family's or friend's input greatly. In fact, I welcome it. Sometimes, even, they can be a greater source of the patient's history than the patient himself.

But...sometimes the support person can be totally and completely obnoxious and abrupt in how they choose to communicate with our staff. "Demanding" is a word I hear often. They just know that the patient needs two pillows. Three warm blankets. A new pair of footies. A turkey sandwich. Some ginger ale, not orange juice. The patient likes to lay on their left side, not their right. They need this and this and this test, but not that one. Oh, and by the way, where do they go to get their parking ticket reimbursed for free parking?

I recognize that sometimes this is simply a vain attempt by the visitor to have some sort of control over an uncontrollable situation, sure. A spouse trying to make her sick husband comfortable. A parent trying to ease their child's pain. A best friend trying to step-up to ensure proper treatment. I fully understand all the reasoning behind these situations. More importantly, though, I respect and applaud their advocacy.

Unfortunately, though, sometimes a visitor's intentions can be detrimental to the patient, if the patient is an adult, is coherent, and can easily verbalize their problems and symptoms by themselves.

I was sitting in my hallway seat, several months ago, when I observed the triage nurse escort two women to Room 27. One woman appeared to be in her sixties, the other in her thirties. The older woman appeared irritated, grumpy almost, while the younger woman was smiling and walking alongside the older woman. Neither appeared in any distress.

Within minutes, the patient's name appeared on our computerized list of waiting patients, so I clicked on it. Surprisingly, it was the younger woman who had checked in as the patient.

I walked into the room to find the younger woman sitting comfortably in the treatment cot, a gown draping her thin frame, a smile still on her face. The older woman, who by now I assumed was the patient's mother, sat in a chair under the corner TV. She was still scowling.

I approached the patient first, my hand extended. "Hello, Ms. Brown, I'm Dr. Jim. Nice to meet you, maam." She extended her hand and we shook. "Hello," she returned, meekly. From the corner of the room I heard the other woman speak. "And I'm her mother." I left the patient's side and walked up to the mother, my hand still extended. The mother eyed my hand for several long uncomfortable seconds before finally extending her own. "Nice to meet you, maam," I added after our handshake.

I went back to the patient's bedside. "Ms. Brown," I started, "what can we do to help you today in the emergency room?"

And before Ms. Brown could even begin to answer, her mother started in. "Kathy has a seizure problem and we are due for our yearly neurology appointment and thought we would come here to get everything done."

"In the ER?" I asked. "Yes," said the mother, continuing. "She needs an EEG, an MRI, and you may as well just call the neurologist down to see Kathy as long as we are here. That way, we won't have to waste a day going to their office."

I turned back to Kathy. "Kathy," I said, "how long have you had a seizure disorder?" From the corner of the room, I heard her mother answer. "Since she was seven." I continued focusing my full attention on Kathy. "And Kathy," I said, "have you been having an increase in seizure activity?" Kathy nodded her her head "no" while, again, from the corner of the room, her mother piped-in. "No, it's just time for her annual check-up." Again, I kept my focus on the patient. "Kathy, has there been any changes recently to your anti-seizure medications?" Again, as Kathy nodded "no," I heard the familiar, interrupting voice. "Eight months ago, the doctors increased her dilantin, but otherwise she has been on the same medicines as always."

I had finally had enough. "Kathy," I asked, holding my index finger up to the mother, requesting her to wait, "are you okay to answer my questions? Or is there a reason your mother keeps answering for you?" Kathy looked at her mother to me. "No," she said, "I guess my mother just always likes to be in charge." From the corner of the room, the mother yelled out, "I do not, Kathy."

I looked at the mother and cocked my eyebrow. "What?" she asked, "I haven't been answering all of your questions." "Yes, maam," I assured her, "you have." Her scowl deepened. "I appreciate you trying to help, maam," I said, continuing, "but this is what we are going to do. I am going to ask Kathy all of my questions and then, when I finish, I will give you a chance to add whatever you want, okay?" She dismissed me with a roll of her eyes and a shrug of her shoulders.

So, I had two problems on my hand. A mother who wanted to interrupt my history-taking with every question addressed to her daughter. And, a mother who wanted an extensive work-up and consult that, unfortunately, wasn't going to happen the way she had hoped for her daughter.

Well, I guess it was just one problem, really. A vocal, demanding mother.

After I finished my interview with Kathy, who did a fine job of telling me about her history, I looked toward her mother. "Do you have anything you'd like to add, maam?" She just "humphed" at me and remained quiet. I proceeded with a physical exam that was completely unremarkable.

The triage team had ordered some baseline blood work and some medication levels on Kathy and, after those results were posted, I went in to speak to the women.

"Well," I said, "I have good news. All of your blood work has returned satisfactory. Including your anti-seizure medication levels."

Kathy gave me a grateful smile as her mother spoke up. "But what about her EEG and MRI and neurology consult? Aren't you going to get those done now?" I explained to the mother that those tests, as well as Kathy's neurology appointment, had already been scheduled and that I wouldn't be able to provide those tests through the ER. Not without an emergency concern. And, trust me, there was no emergency concern.

"But," the mother said again, speaking up, "Kathy hasn't been feeling well recently. I want all of those tests done now. We'll wait for the appointment, if that helps."

I assured the mother, again, that Kathy had a great exam, great blood work results, and would need to move forward as planned by her neurology team. In all honesty, I told her, I wouldn't even be able to get this requested workup for one of my family members, unless it was a new-onset seizure or the patient was in status (a seizure that won't stop).

"Kathy," I asked the patient, "are you okay with everything?" "Of course," she answered, sincerely, "I didn't want to come today. Mom thought we could get everything done early so we wouldn't have to waste a couple days next week."

Out of courtesy, I did call the resident on the neurology team to make them aware of this patient's treatment in the ER. They whole-heartedly agreed with our ER approach, reiterating that this patient would need to keep her outpatient appointments.

I discharged this patient to home, knowing that there was no way I was going to make this mother happy. As they walked out of Kathy's treatment room and down the hallway, I noticed that Kathy still was smiling, while her mother maintained the scowl that prevailed during her time with us.

I had to wonder to myself how Kathy maintained such a happy state. I hope her smile was genuine.

The best I could hope for, I guess, was that Kathy, and not her mother, would get the hospital questionnaire. And that she would get some good results from her non-emergent, outpatient-testing, too.

If only we could just make everyone happy...

As always, big thanks for reading. I hope you all had a great weekend. Although I'm traveling for work the next few days, the next post should be on Wednesday, June 16. See you then...anyone with similar stories to share?

Wednesday, June 9, 2010

A Snapshot Of Sad

A few weeks back, both of my girls had late-afternoon soccer practices and, since my wife was an excellent soccer player in her day, she welcomed the opportunity to go with both of them to their practices. Afterwards, their "girls-only" plans were to continue, including pursuits of some dinner, some ice cream and a little shopping. Of course.

Since Cole had his own soccer practice after school and was off from baseball for the night, this also afforded us the opportunity to have our own bonding time. After talking about it, I gave him the option of picking out a restaurant where he and I could grab a bite before going to a local golf driving range and hitting a bucket of balls.

"Should we go to Hoss's or Bob Evan's, Dad?" he asked, a big smile spreading across his face. In our family, it is a running joke about our kids always picking either Bob Evans or Hoss's to eat. Since I don't eat greasy breakfast food often, Bob Evans is my guaranteed ticket for getting an upset stomach. Worth it, though, since I can never say "no" to their big breakfast meal for dinner. Hoss's, on the other hand, is a buffet that is famous for its unlimited salad bar, which includes its choice of four soups (I'm a soup guy here) and, most importantly, a huge dessert line, complete with their own self-serving soft ice cream machine. Twists included. An obvious plus for any kid, probably.

Cole hmm'd and haa'd for a few minutes before deciding. "Hoss's it is, then," he said, adding, "unless you would rather have Bob Evans, Dad." Nope, I assured him, any decision he made would be a good one.

So off we went to Hoss's. Little did I know, though, that this visit would open up an opportunity to talk to Cole about a serious issue.

After driving the ten minutes, we arrived at Hoss's and parked our car in the lot. We hurried to the entrance, eager to dive into the salads, the soups, and the desserts.

We opened the outside double doors to enter the welcoming foyer of the restaurant, only to be greeted by three young kids creating havoc while arguing over the gumball machines. The youngest, about five or so, was on his knees trying to wedge his hand up into the exit slot of one machine. The middle child was at another machine, fumbling to put some coins in and turn the handle. The oldest child, a girl, probably around Cole's age of ten or eleven, stood in front of the second set of entrance doors, blocking our way. She was waiting to step up to the machine the middle child was at. There were no adults around.

Strikingly, and sadly, all three kids were very obese. Most remarkable, though, was the oldest child, the girl, who was around Cole's age. Easily, she must have weighed over two-hundred pounds. She had light brown hair, straight, cut in a bob, which seemed to accentuate her full cheeks and chin. She wore a fashionable short-sleeve t-shirt with a graphic logo on front. Unfortunately, though, it was several sizes too small, revealing her protruding belly from below. Her arms and legs seemed inflated and over-sized, poking out of her summer clothes. She wore thin flip-flops that did little to support her weight or fallen arches. As I took her in, she continued to block the doorway while trying to tug her middle brother away from the gumball machine so she could access it.

Cole looked up at me as if to ask what to do. I winked at him, willing to patiently wait out the arguing.

After thirty seconds or so, the other door that led to the welcoming foyer, an exit door from the inside cashier, opened up and a very obese woman in a flowing, floral-print dress walked out. She was accompanied by an equally obese elderly woman. I assumed it was the children's mother and grandmother.

The mother yelled at her kids. "Hey, you three," she said with a sharp, grating voice, "move and get out of the way. Can't you see you are blocking the door for these people." She lifted up her arm and waved her finger at her kids, who looked up to finally notice us waiting. "It's quite alright, maam," I assured her, "we are in no hurry." She gave me a brief smile. "I don't know where their manners are these days."

The girl my son's age moved to the right of our entrance door and we were able to continue on our way. I noticed my son smile at the girl as we passed. "Have a nice night," I added to the family.

After sitting down and grabbing our plates of food, I decided to question Cole about what we just saw. "Cole," I said, "what did you think of those kids at the gumball machines?"

"What do you mean, Dad?" he asked, pausing with his spoonful of chicken noodle soup in mid-air. "You mean how crazy they were trying to get the gumballs?"

"Yes," I said, "and..." He interrupted me. "And," he continued, "how big they were?" I winced a little, although I was glad he didn't use the other "f" word.

"Yes, that too." I paused to let him talk. "Well," he said, "I think they were acting crazy because their mother wasn't with them. They straightened right up, though, when she came out." He took his spoonful of soup to his mouth and swallowed it before continuing. "And they probably eat too much candy and soda or else don't exercise enough, I guess. Maybe they watch too much TV or play a lot of video games."

He was probably right. "But Cole, why do you think they eat too much candy? Because they are sad? Or bored? Or just like it?"

"Probably bored and they like it, Dad," he said, "but do people really eat because they are sad?" I assured him that they do, sometimes. "Cole, what if she (now focusing on the girl his age to make it personal) doesn't have a father in her life? Or maybe she has a father that yells at her all the time? Or what if the kids at school are mean to her? Maybe she eats candy to feel better about all of it."

"But where would she get all that candy, Dad, or the money to buy it? Do you think her mom buys it for her?" He was thinking hard now, placing his spoon on the table. Again, he hit on something big, as I thought back again to the mother and grandmother as they walked out of the exit door.

"I'm not sure," I told him, trying to lighten it up, "maybe, though, she saves all her Halloween candy through the year like you do!" We both laughed, thinking back to this past Halloween when Cole set a new house-record, bringing in over seven pounds of candy (yes, now the kids weigh it, not count it, it seems).

"Cole," I added, "do you have any classmates like this girl?" He nodded no, continuing to eat his soup. "But if you did," I continued, "you would be nice to her, right? Give her a smile? Say "hello" as you passed her in the hallway?"

"Of course, Dad," he said, not even pausing, as I remembered him smiling at this girl as we walked through the entrance way, "why wouldn't I?"

And that's where our conversation ended about this topic. My son smiling, and me looking at him with some major pride in my eyes. Although he had noticed the children, he didn't judge them or seem affected by them.

After this experience, I did a little research on childhood obesity. The most surprising thing I learned was that I overestimated the number of children who are obese, by definition, because of medical or genetic reasons. It seems that the majority of childhood obesity cases are due to social causes, a reflection of poor choices from the adult-figures in their lives. Poor exercise habits, poor dietary choices, poor discretion of computer and TV use, and the poor decision to use food as a reward or comfort can add up to some very serious issues for children. Even life-threatening. Sometimes, of course, there are some very worthwhile reasons, medical or otherwise, as to why a child is overweight.

It sure doesn't help, though, to live in a society where extreme thinness and waif-skinniness is embraced more than a healthy lifestyle is.

Which leads me to my point. Let's either start, or continue, to make our kids the number one priority in our lives. They are our legacy. They are our future. They are our treasures. Treat them as such. Eat together at meal time. Cook together. Shop together. Pursue fun physical activities as a family. Go for a walk, a hike, or play Frisbee in the yard. Play kickball. Turn off the computers and TVs and video games. Get involved in school and community functions. Read, especially before bedtime. Talk. Be fully aware of your child's life. Don't make excuses. Don't put them on your back burner. Love them.

And teach acceptance, not judgment. Especially when you don't know another's story.

Love. Peace. Harmony.

It was probably another typical evening in Cole's eyes, dinner and some fun afterwards. For me, though, it was a huge reminder of just how many times through a typical day my kids will be bombarded with "life" happenings.

I can only hope that someday our kids will walk confidently into this big, big world of ours. My bigger hope, though, is that every child out there has an adult in their life who also wishes the same for them.

As always, big thanks for reading. I see much of the above at work in the ER, but seeing it through my son's eyes gave me a new, fresh perspective. See you either Friday or Monday. Until then...

Monday, June 7, 2010

The Coumadin Goose-Egg

Despite the light drizzle of rainfall, she pushed the grocery cart filled with her unwashed clothes to the local laundromat. It was Tuesday and, like any other Tuesday, it was laundry day. Despite her dislike of rain, habit and her dirty clothes dictated that she make this journey.

Her apartment was just a few short blocks from the laundromat. Being elderly and recently widowed, a local laundromat, a supermarket, and a bus stop were on her short list of requirements for her new apartment's location. She had never taken the time to learn how to drive when her husband was alive. On hindsight, though, she should have insisted that he teach her. Now, she relied on public transportation and her steadfast grocery cart, given to her from the local grocer's manager when she had asked him about buying one.

She smiled to herself as she remembered that recent day. "This ones' an old one," the manager had said as he patted the cart's handlebar, refusing her money, "just take ol' Bessie and get some good use out of her, okay?" She blushed before taking Bessie, not quite sure how to deal with the random kindness of a stranger.

As she pushed her cart slowly along the sidewalk, she came to a slight decline just a half-block from her destination. Even in dry weather, she had fretted about guiding her cart down this gentle-sloping hill. Now, with the rain-slicked walks, she stopped at the top and appreciated the wet sheen of the approaching pathway. She briefly contemplated turning around and returning another day to wash her clothes.

She should have.

Slowly, after deciding to proceed to the laundromat, she guided her filled-cart down the sloping walk. One step. Another. And another. Her hands tightly gripped the cart's handlebar, her elderly, frail forearms beginning to burn from the effort it took to maintain her sliding cart.

Another step. And another. The muscles of her arms tremored. Her calves tightened. She leaned her body back, struggling to keep the cart from careening out of her control.

It was all in vain. Just a few short yards into this declining slope, she lost control of her cart. It began to slip and slide over the sidewalk, pulling her resisting body along, her hands still death-gripping the handlebar. It veered towards the left, almost jumping the curb and joining the local traffic, before she was able to over-correct the cart and steer it right.

The cart jumped the sidewalk and smacked right into a telephone pole. And, unfortunately, so did she.

I walked into Room 22 to find a very sweet-appearing elderly woman in her late seventies. She was sitting upright in her treatment cot, a hospital gown loosely draping her frail body, answering her nurse's interview questions with her matching frail, high-pitched voice. One that crackled with nervousness. On her room's counter, I noticed a pair of comfortable leather beige shoes, old and well-worn. Beside her shoes, a pair of pastel-blue pants. Polyester, of course. And on top of the pants, a blood-soaked floral shirt.

"Mrs. Taylor," I said, extending my hand as I entered, "I'm Dr. Jim. Nice to meet you, maam." She looked up at me and gave me a feeble smile, extending her hand, cold and covered in paper-tissue skin and blue-ribbon, spidery veins. I took it between both of my gloved ones.

"Maam," I continued, "what happened that brought you by ambulance to our ER, today?" Despite asking, I already knew the answer. Whether it was my nearness or the brightness of the overhead fluorescent lighting, I could now appreciate the significant cephalohematoma of her right frontal region. Othewise known as a contusion. Or, for those of you in my age group, a "goose-egg" or "goose-bump." You know, those big swollen bumps that our mothers used to hold the flat edge of a table-knife against to reduce the swelling when we were young and had just fallen off our bikes.

Anyway, Mrs. Taylor's goose-egg was quite impressive, covering most of her right forehead with the lower border extending into her upper brow and eyelid on the same side. Even her nasal bridge was swollen. Overlying the goose-bump, a superficial abrasion seeped a touch of thin, watery blood. The overall injury gave this kind woman a lopsided, deformed appearance suggesting that she just went ten rounds with Rocky.

Mrs. Taylor, in-depth, told me what happened. It was important to her that I understood two things. One, that she was a recent widow and missed her husband terribly. And two, that she had tried everything in her power to stop her cart from going out-of-control.

I patted her shoulder. "I understand, Mrs. Taylor. Thank you for sharing that with me."

What complicated Mrs. Taylor's history, besides Mrs. Taylor being elderly, was the fact that she was on coumadin, a blood-thinning medication that is used in the treatment and prevention of clots and, in Mrs. Taylor's case, for an irregular heart rhythm that otherwise increases the likelihood of stroke. I knew this, from the sheer size of her injury as well as the thin, watery blood oozing from the site.

I asked her a few more questions. Had she lost consciousness? No. Did her neck hurt? No. Did she have numbness or tingling or weakness in any of her extremities? No. Any chest pain, shortness of breath, or abdominal pain? Again, no. No arm, leg, or pelvis pain, either. On exam, outside of her impressive contusion, she didn't have any other significant findings. Well, unless you count her damaged pride.

I sent her, frail smile and all, to the CT scanner, where we imaged her head, her neck, and her facial bones. We were overly-cautious in her testing as her injury was considered a "distracting injury," meaning that with all of her attention focused on her goose-egg, she might not realize if she had neck pain. Thankfully, though, her reports came back well. No skull fractures or intracranial bleeding, just the large collection of swelling and bleeding outside of her skull cap in the frontal region. Her neck CT? Negative. Her facial bones CT? A questionable non-displaced distal tip nasal fracture. Her coumadin level had been in therapeutic range.

I discussed all of Mrs. Taylor's results with her. "Thank you, dear," she said, after I explained her next course of action. Since she was on coumadin, despite not having any significant bleeding within her intracranial space, we were going to admit her to the medical service for overnight observation. This is our hospital's protocol. Had she had a significant brain bleed, she would have been admitted to trauma and neurosurgery services and had her coumadin's effects reversed.

I never saw family or friends during the time Mrs. Taylor spent with us in our ER. Despite her frailty, though, she demonstrated a piss-and-vinegar attitude and resilience that assured our nurses and myself that she would be okay. She was one neat lady.

My one wish, though, for Mrs. Taylor? Well two, actually. One, I wished she had learned to drive at some point in her life. I meet too many elderly women who's husbands did all the driving so "I never had to learn." Of course, though, that would probably be me stuck behind her driving 15 mph in a 45 mph speed-zone. And two, I wished her husband had still been alive to hold a table-knife against her big ol' goose-egg.

Just like my mom used to do.

As always, big thanks for reading. I hope you had a great weekend. Next post will be Wednesday, June 9. See you then...

Friday, June 4, 2010

The Wonder Of It All

Have you ever looked at a child only to find yourself staring in awe and amazement at the wonder of it all. I look at my three kids and am simply astounded that we did something so very right, my wife and I. The infinite smiles, the high-pitched laughter, the innocent and untampered views of life through their eyes, the heartfelt hugs--the list is endless as to the joys and delights they bring to our lives.

Even during my son's illness, when he spent several years on chemotherapy, I was awed at the resilience and beautiful spirit of not only him, but of my two young girls, his sisters, who also bravely walked the path of his illness with us. With heads held up, I might add. They wanted matching mediports so that their brother would not feel isolated with the "bumpy" on his chest. Pure and magical love.

As much as a setback as his illness was for our family, though, we survived that life trial and, in fact, emerged so much more stronger and appreciative of the offerings of this life. We were taught life-lessons that some people never learn. We reaped the benefits of compassion, both receiving and giving in ample, unselfish amounts. The small shit took a back seat to the more important "stuff" that life had to offer.

One of our amazing ER nurses, Kathy, the mother of a son with cystic fibrosis, said it best when Cole was first diagnosed. "Welcome to the 'Parents-Of-A-Sick-Child Club'," she whispered in my ear while hugging me. "It's a club that no parent would ever want to belong to," she continued, "but one that will change your life forever." No wiser words were said to me during that period of my life. Several times, I have reminded Kathy, who continues to struggle daily with her son's life, that the snapshot of her hug and her words will linger forever with me.

Mostly, I am thankful that my son's illness was a temporary, albeit two long years, and not a permanent fixture in our lives. We know we have been blessed. That our family is one of the lucky ones.

In the ER, when I meet the parents of an ill child, especially a prolonged, chronic illness, my utmost respect and compassion flows outward in tidal waves. I can only imagine the heartbreak and the struggles they have known in dealing with the fight for their child's life, trying to obtain just a wee bit of normalcy. Struggles that may never cease, that may continue to ebb away at the glimmers of hope and happiness that are too infrequent in their lives. Struggles that weigh down the shoulders and plummet the heart, time and time again.

A few years back, during the middle of a night shift, I walked into Room 22 to see CeCe, an unfortunate five-year old child born with microcephaly, a neurologic developmental disorder. There is a disturbance in the rapid growing of nerve cells, which results in a variety of symptoms, including striking neurological defects (such as mental retardation, severe intellectual and developmental delays, and seizures), a deformed, dwarfed body, and a shortened life span. Treatment for this illness is symptomatic and supportive. There is no cure.

As I walked into the room, diminutive CeCe was lying on her back in her treatment cot, her mother bent over her, stroking her braided and beaded hair while whispering into her ear. Her father stood along the other cot's side, stroking CeCe's hand. She was, despite her age, about the size of a two-year old toddler. She was nonverbal, and all four of her extremities were contracted and spastic. Her head, as expected, was quite small. It was a heartbreakingly, beautiful scene. CeCe was obviously loved.

CeCe had been brought in by her parents because her "trach" had fallen out in the middle of the night. She was in no respiratory distress, but it had been placed a year prior in the event she would develop any breathing difficulties. Her parents wanted to replace it themselves, but under a controlled environment ("just in case something goes wrong when we put it back in"). In essence, our medical team was just going to hang out and watch CeCe closely, on monitor and clinically, to make sure that everything went as planned.

After meeting the parents and saying a few words to CeCe, who had no response, I assured the parents that we were ready for them to replace the trach. "Who's going to do it?" I asked.

"I will," CeCe's father said, turning the new trach over in his hands, examining it closely.

"Are you sure you don't want me to do it or call in an ENT specialist?" I asked, feeling a little of his nervousness. "It's no problem for us, really," I assured him.

"No, but thank you. I would rather replace it in case it hurts my little girl."

Before starting, Mom crossed herself while Dad bent over to whisper his assurances to CeCe in her ear. "I don't mean to hurt you, baby," he said. CeCe had no response.

"I'm ready, honey," CeCe's mother said to her father, giving the go-ahead. Slowly, he bent over CeCe's throat, inserting the tip of the curved, plastic tubing of the trach into the small open hole of her anterior neck. It didn't go far, though. He was meeting some resistance.

"Are you okay?" I asked, watching CeCe closely through this. I had noticed CeCe squirming as he struggled with the resistance. "I think so," he replied, adding a little more strength to his attempts.

And then it happened. A small miracle of sorts. As Mom was bent over, whispering love to her daughter while Dad struggled to place the new trach, a sudden, brief smile passed over CeCe's face. I had seen it. I know I did.

With a little more effort, Dad finally was able to insert the trach to his liking. We secured its placement before obtaining a CXR to make sure it was placed appropriately and that we didn't collapse a lung or disrupt the trachea's integrity.

All turned out well. CeCe remained very stable, her vital signs normal and her clinical exam unchanged. The CXR confirmed a job well-done by Dad.

"I have to say," I told CeCe's parents before discharge, "that you have one lucky little girl. The way you both approach her, whispering in her ear and caressing her, is quite beautiful. Your love for her is very evident." I looked at the nurse, who nodded her agreement. "In fact," I added, looking at Mom, "I think I saw CeCe smile when you were talking to her."

"She did?" Mom asked, before continuing. "I live for those moments."

"Does she do it often?" I asked, wanting to hear more.

"Not often enough," Dad spoke, "maybe every few days at the most. We wish CeCe smiled more but, honestly, we'll take what we can get."

They were packing up, getting ready to leave, but I had one more question that I needed answered. "CeCe's hair," I asked both of them, "who braided it and put all those beads in?" Her hair was a sight to behold--numerous, small, loose braids that were delicately woven and tied with multi-colored beads at each end. Not an easy feat, I'm sure. "Oh, that," CeCe's mother said, blushing slightly, "I did that a few days back. I love doing it, actually. And CeCe seems to enjoy when I do it. In fact, her most recent smile was when I was tying those braids."

I pictured Mom at home, sitting behind CeCe, propping her up into her own lap, fluffy pillows surrounding them, and lovingly, with the utmost tenderness, combing out and braiding each little twine of hair, before beading its end.

Waiting for a glimpse of CeCe's brief smile. Living for it, actually.

Meeting CeCe and her parents reminded me of just how lucky a man I am.

If you are the parent of a chronically-ill child, I dedicate this post to you. Don't forget, for one minute even, that there are many of us out there who see you, who send you our prayers and good energy, and who recognize the love and effort you give to your child. Despite your struggles, at some point in your life journey, the reasons you were blessed with your child will become evident to you and will hopefully enrich your life and the lives of those around you. If they haven't already, that is.

The wonder of it all...

As always, big thanks for reading. I hope your weekend is a great one. Next post will be Monday, June 7. See you then...

Wednesday, June 2, 2010

The Stressful Life

So you think you have a stressful life?

I walked into Room 14 and introduced myself to my next patient--a peroxide-blonde, twenty-something female anxiously sitting in her cot, her tattoos peeking out from both the collar area and the short-sleeves of her hospital gown.

"Hello, Marissa," I said, "I'm Dr. Jim and I'll be taking care of you today. What happened that brought you to our ER?"

Her answer was brief and, quite honestly, unexpected. "My boyfriend and my husband are both being jerks to me." It turned out that she had been "completely stressed out lately" from the shabby treatment from the men in her life. As a result, she was having episodes of heart palpitations, episodic runs of shallow, rapid breathing, and being "jittery all the time."

"In fact," she said, interrupting my history-taking, "I need a cigarette real bad. Like, right now."

I shook my head "no" to her request, explaining that my ER patients are not allowed to leave our department to go outside and smoke. "If you really need to, though," I said, "you are free to sign out against medical advice, go out and smoke all you want, and then sign back in to be seen. Unfortunately, you might be waiting a while."

As I expected, she decided not to sign out AMA and go have a smoke, but not before rolling her eyes at me. That's okay, though. Little did Marissa know, but I got an A+ in "Rebuffing Eye Rolls, 101." Hell, I could teach that class, even.

We continued on with our discussion. "I think I might be having a heart-attack from the stress," she said, sincerely trying to explain the full scope of her symptoms. "I never was like this until my husband threatened to leave me, and now I am stressing-out all the time. Even my boyfriend notices it." There was no flicker of self-awareness, although I was expecting at any time for her to jump up and down and recognize the root of her problems. Without my help. I was hopeful that saying the words out loud might make the obvious evident to her.

No such luck. Marissa needed to hear her it spelled out from her friendly ER doctor.

"Well, Marissa," I asked, "do you think that maybe you are creating a lot of your stress by trying to have a relationship with two men at the same time? Emotionally, that is a lot of energy you are giving away." My shoulders shuddered as I had a sudden thought of just how much physical energy Marissa might be giving away, too.

"Um," she said, "I don't think so. I think most of the stress is coming from trying to get pregnant." She looked at me to gauge my response.

I took the bait. "You're trying to get pregnant?" I asked, trying to mask my surprise. "By which guy--your husband or your boyfriend?"

"Well," Marissa said, "that's part of the problem. I don't know who I want to have a baby with yet. My husband is good-looking, but my boyfriend is a little smarter, I think." She took a slight pause before continuing. "Do you think I should go for some good-looking kids or some smart ones?"

I looked around her treatment room closely, straining my eyes to find the hidden camera that was obviously recording my reaction for one of those candid camera shows. I couldn't find a little peep hole, though. Unfortunately, this was a real patient-physician encounter.

"And," Marissa continued, "it's not just who should I have a baby with that is stressing me out. My boss just increased my hours to thirty-five a week. I used to do twenty-five hours before. I don't know if I can handle ten more hours a week."

Again, I took the bait. "What do you do that is so stressful, Marissa?" "I'm a bartender," she said, puffing out her chest with pride. "Do you have any idea how stressful a job that is?" I assured her that I didn't. "Yeah, well, it's not only about mixing and serving drinks. I have to listen to people go on and on and on about all their problems. Like their problems are more important than mine. Most of the time, I just smile and nod my head while I'm tuning them out."

I smiled at Marissa and nodded my head.

I had had enough of Marissa's complaining for this visit. It was time to move on to her physical exam and testing. And, hopefully, figure out what we could do to help her.

"Marissa," I said, after completing a stone-cold normal exam and reviewing her normal EKG, "I have several worries about you, the most important being that you are carrying on relationships with two men. I worry for your safety right there. Are you protecting yourself?" She looked at me funny. "Are you sexually active with both of them?" I asked her more plainly. "Well, yeah," she said, like the answer should have been obvious to me. I, however, didn't want to assume anything.

"Then you need to make sure you take care of yourself and protect yourself, okay?" She nodded yes. "Otherwise, I'm afraid, your symptoms all seem to be related to stress. The treatment for that," I continued, "is simple--reduce the stress. I don't know how you are going to go about this, but you need to simplify your life, make some decisions about work and your relationships, and start carrying those decisions through."

"But," she said, "I don't know if I should stick with my husband or my boyfriend. What would you do?" I looked at her, at the sincere plea from her confused eyes, and realized that she was not going to be able to make the decision on her own.

In my mind, I knew exactly what I would do. First and foremost, I would have Marissa throw out her cigarettes. Then, I would have her avoid both men for a month and see where that would leave her. Finally, I would have her immerse herself in her work, since her pride was quite evident when she spoke about her bartending work. Unless, of course, the bartending environment was contributing to her problems (which, I suspect, it probably was).

As gently as I could, I shared some of my thoughts with her. I explained to her that she was exhibiting "psychosomatic symptoms," where her body was physically exhibiting symptoms from her mental stress. Pure, unadulterated anxiety. Marissa, I thought, could benefit from a professional counselor to guide her through some of her decisions. And by staying in close contact with her family doctor, too.

"I'll tell you what, Marissa," I said, "I'm going to have one of our case managers come talk to you. They'll review your counseling options with you and, hopefully, a counselor will be able to help you make some decisions that will be in your best interests. Does that sound okay?"

She nodded her head "yes." "And," she added, "can I have something to help with my nerves over the next few days?" It was my turn to nod my head "yes." What I was providing was, really, only a band-aid to her problems, though. With her unique complaints, she needed to sort her head out.

I wonder if Marissa ever pursued counseling or not. Part of me suspects that she probably blew it off, thinking her time was more valuable than driving somewhere for an hour appointment. But a small part of me still wants to keep the faith in her...that, with a little guidance, she would begin to make more responsible decisions.

Sometimes, the stories and complaints we hear in the medical field are nothing short of mind-boggling. We only wish we were making some of this stuff up. Imagine, being torn between having a baby with your husband or your boyfriend. Makes me wonder if the baby turned out cute or smart.

Maybe both.

In the meantime, I'll just keep things low-stress on my end, plugging away as a father, as a husband, and as an ER about you?

As always, big thanks for reading. I hope you all had a great holiday weekend. See you on Friday, June 4. Until then...