Wednesday, July 28, 2010

The Friendly Head-butter

The ambulance call came in shortly after 2 a.m. "We're bringing you a 27 y.o. unresponsive male with a head injury and alcohol on board." Despite the patient's unresponsive state, the prehospital team's vitals for this patient were stable.

We prepared a trauma room for this patient, unsure if we would need to intubate the patient to protect his airway and get an appropriate work-up. Alcohol ingestion with unresponsiveness can mean something very serious and, until we had a chance to thoroughly examine this patient, we would provide him with every cautionary medical measure available. Of course, flipping the coin, alcohol ingestion with unresponsiveness can also simply mean "passing out." And as anyone who has worked in an ER setting can tell you, the majority of patients who come in with these similar symptoms are usually just of the "passing out" variety.

Soon enough, the prehospital crew wheeled this patient through our ambulance bay doors and rushed him to Room 18, where we were waiting to greet them. The patient was disheveled, laying on his back, his head turned over his right shoulder. The smell of vomitus was overwhelming, a mixture of bile, soured alcohol, and undigested food. On closer inspection, that was not a designer graphic t-shirt he was wearing but rather a run-of-the-mill Hanes t-shirt sprinkled with the remnants of his puking. Corn kernals included. His cargo shorts were hanging halfway down his pelvis.

As we moved this patient from the transport cot to our hospital bed, the paramedics filled me in with a little history. "Einstein, here," the one paramedic started, "was out tonight with a bunch of buddies drinking and having a grand ol' time." He paused for a minute, chuckling to himself, before continuing. "Somewhere around his tenth drink, his buddies said he started head-butting anyone who would let him."

"You mean people actually let this guy come up to them and head-butt a 'hello' to them?" I asked, incredulous at the thought.

"They probably didn't see it coming," the paramedic answered. "Supposedly, he's real quick with the gesture," he continued, "like a head-butting champ or something."

How's that title for making your parents proud? "Champion Head-butter, 2010." I don't think I would have a prouder moment than if one of my children came home with that award. Especially if it came with some cash. Throw in a tiara and a sash, too.

"Anyway," the paramedic finished as we began hooking the patient up to our monitors, "he head-butted one too many people. He walked up to another drunk buddy of his, slammed heads with him, and literally dropped. Before he hit the floor, though, somebody standing next to him was able to catch him and ease him down. Witnesses said he was out like a light."

I yelled in this patient's ear and was happy to see him stir. I rubbed his chest and pinched his toes to make sure he was appropriately responsive, and he was, trying to swat away annoying me. I listened to this patient's heart and lungs. All clear. I reviewed his vitals. All stable. I looked closely at his pupils, happy to find them appropriately reactive. I was reassured that he was in no grave danger.

Now I had time to do a closer, more focused exam, starting with his head. Hardly surprising, this patient had a large, erythematous abrasion on his forehead, the skin tense from some localized swelling. I pushed on it to make sure his skull bones were stable underneath, expecting nothing less than a hard-head from this patient. He didn't disappoint. I looked in his ears and nose. No blood. I pushed on his facial bones and found no other abnormalities. The rest of his exam was also unremarkable.

In essence, this patient was a drunk with a big "goomba" on his forehead.

Prior to leaving his room and ordering his CT scans, the patient began stirring. His nurse, fresh out of nursing school, greeted him. "Hello, Mr. Sanders," she said, "I'm Chrissie and this here is Dr. Jim. We'll be taking care of you tonight." I said "hello" to him while I nodded my acknowledgement.

The patient must have liked what he saw in Nurse Chrissie, turning his attention back to her. In an artificially deep voice, slurred slightly, and with a lopsided grin, he said, "How you doin', Chrissie? You can call me Larry." He pulled his hands through his hair, trying to straighten-up a little. Unfortunate for him, though, there is a limit to how appealing you can make yourself when you are drunk, sitting in a hospital cot, covered in a gray, threadbare hospital gown. Oh, with a big "goomba" on your forehead.

"I'm good, Larry," Chrissie answered, enunciating 'Larry', "and how are you doing?" "I got a massive headache," he answered her. Then, turning to look at me, he said, "Hey dude, how about some medicine for this headache. Jesus H. Christ, already." I felt like head-butting him. In a nice, friendly way, of course.

A few minutes later, after this patient returned from the CT scanner and was waiting for his results, a call came back from the waiting room concierge. "Is it okay if Mr. Sanders has a few friends come back and wait with him?" "Are they sober or drunk?" the secretary rightfully asked before giving her permission. "They might have had a few drinks," the concierge said, "but they are really respectful and concerned."

I was walking down the hall, coming back from seeing another patient, when I saw Larry's friends coming from the opposite way. I wasn't aware of the concierge call, but none of that mattered. I knew who these two guys were the minute I saw them. I slowed my walking pace, wishing that the fluorescent hallway lights were just a little more brighter so I could better appreciate their appearances.

Both of the guys were wearing fashionable jeans with flip-flops that clucked with every step, graphic-Ts, and, barring the sprinkles of vomit that covered both of their fronts, looked quite hip. But these weren't the signs of their brotherhood, of best buddies out on a late Friday night having a great time, now bonding in our ER.

No, that sign would be the matching "goombas" they both wore on their foreheads. Bright pink, two inches in diameter, and glaringly obvious under their shaved heads, their warwounds looked almost identical to the injury of our patient, Larry. Their friend.

I stopped them as they walked by. "Hey guys," I said, having a little fun, "what happened to your heads?" The one remained silent, intently watching his pacing feet, while the other spoke. "You don't even want to know," he said, shaking his head in disappointment. "Well," I said, "if you guys want to be seen or get a bad headache, let us know, okay?"

Soon after, Larry's CT reports came back negative for any injury. Outside of a bad headache and a nice-sized contusion/abrasion, he was getting off quite nicely. I went to the room to explain his results to him, and caught my breath as I walked into Room 18. With these three buddies sitting close together with their matching injuries, how could I not think of The Three Muskateers?

Larry, thankful for not having any significant injuries, started crying (the gut-wrenching bawling brought on by a stiff drink) and throwing around his apologies to anyone who would accept one. A tech walking by his room even got one. "I'm so sorry, buddy," Larry said. "For what?" the tech asked. "I just am," he replied. The tech kindly went and got Larry a box of tissues.

Finally, a sober friend came to drive them home. A female. Long brown hair, very sophisticated-appearing, wearing a warm smile. Evidently, she also had a great sense of humor. She exhibited a hearty, genuine, gutteral laugh, I'm told, when she walked into Room 18 to gather her friends. And had a hard time stopping.

At least the patient was a gentleman. She wasn't sporting a matching forehead "goomba"...

As always, big thanks for reading. Trying to keep things light this week. See you Friday...

Monday, July 26, 2010

It's Not Working

She was the wife of the patient in Room 24, a gentleman in his early sixties seeking treatment for his abdominal pain. She was of slight stature, barely over five feet tall. Her hair, straight and gray and hanging to her shoulders, was tucked behind her ears. The lenses of her glasses were thick, the type that disproportionately magnify the eyes and give them a non-human appearance. Her thin, gold-wired frames seemed to sag from their weight. Between the constant retucking of her hair behind her ears and the adjusting of her glasses, with her right index finger, on her nasal bridge, this woman came across as quite fidgety.

Although I wasn't treating her husband, I was sitting in my hallway seat just between Room 24 and the nurses' station and had heard the nurse mention the "nervous Nellie" wife of the patient in Room 24.

That was the understatement of the year.

I had first noticed her as she walked out of her husband's treatment room and approached the station. "Excuse me," she said to the unit secretary in a soft, feebly voice, "but can someone help me?" "Sure, maam," the secretary answered, "what can we do for you?"

As she spoke, the wife picked some lint off her craft-store sweater, doctored up with sewn-on pom-poms. "Well," she said, "the monitor keeps beeping in my husband's room."

"Okay, maam," the secretary said, "I'll send someone right in." As the woman turned and walked back into the room, the secretary paged Liz, the nurse for Room 24, who, after examining the monitor, found it to be working just fine.

A few minutes later, as I was hunched over a chart while writing on it, I heard someone clear their throat. I looked up to find the patient's wife, moving in to take ownership of my personal space. "Can I help you, maam?" I asked, amused. "Well, yes," she said, again with a crackling, muted voice, "my husband's phone in his room isn't working."

"Oh," I explained, "you just need to dial "9" first and that will give you an outside line." She nodded as I continued. "Do you need to make a call, maam?" "Well, actually, no," she said, hesitantly, "I just want to make sure it's working in case there is an emergency with my husband. You can never be too prepared."

She didn't strike me as the boy scout type.

I gave her a smile before standing to go meet my next patient. She turned and walked away from me, heading back into Room 24. After finishing with the new patient several minutes later, I returned to sit at my computer, only to find Liz shaking her head in frustration. "What's the matter, Liz?" I asked, quite sure that I would know the answer. "Are you having one of those days?"

"That wife is going to be the death of me," she chuckled, good-naturedly. "She just came out and said our counter drawers are broken because when she opened them to see what was inside, they wouldn't 'close right'." It turns out that a safety-latch had caught that prevented the drawers from closing. "What's she doing going through our drawers, anyway?" Liz added.

Well, unfortunate for us, this woman was just getting warmed up. Soon, and in no particular order, she came out to request an extra pillow for her husband (an impossible task in our ER). "Oh," she added a minute later when she came back out, "and another warm blanket, too." She requested coffee for herself. "And a more comfortable chair if you have one." A few minutes later and she was back. "Do you know that the waste basket is almost full and will probably need emptied? Oh, and that red container on the wall looks like it's filled with needles."

Seriously, she had an endless list of issues that soon became quite comical to us, the staff.

"Shouldn't my husband's IV be dripping faster?"
"Do you have an extra pair of those slippers that I can take home?"
"When's the last time someone washed the room's curtain?"
"Can someone look at the mole on my husband's back as long as he's here?"
"Was that a helicopter I heard outside?"
"Do you think we'll be home before Jeopardy starts at 7:30?"
"Are you sure you set the wheel-brakes on the cot (they were)?"
"I think one of the fluorescent bulbs is burned out in the ceiling (it wasn't)."
"The blood pressure cuff is broken, I can't get it to inflate on my arm."

"Your ER still validates parking vouchers, right?"

I found her initiative and gumption to be refreshing. And funny. It was easy for me to be amused by the ongoing antics since I wasn't the one in this woman's line of fire. That would be Liz, who appeared less and less amused with each new request or complaint.

Although this woman consumed much of our energy, we recognized that she was harmless. At one point, the staff pulled the curtains shut and slid the glass doors to the room closed, trying in vain to contain this woman and her nervousness. But slowly, as we all watched closely, she eased the curtain open about two feet, with the utmost caution and silence, before she slid the glass doors open enough for her to poke her head out, looking up the hallway and looking down the hallway, making sure she wasn't missing anything.

Finally, with about twenty minutes left to my shift, this woman approached the nurses' station yet again. "She's coming, she's coming," I heard the secretary hiss to everyone. Suddenly, everyone gave the appearance they were deeply immersed in charting about the many patients they had single-handedly saved that day in the ER. All but me, that is. I wasn't lucky to be holding a chart at the time.

The woman cleared her throat. "Hmmm, hmmm." "Yes, maam," I asked, "may I help you?"

"Yes, you can. I just used that bathroom right there (she pointed to one of our public restrooms just three doors down from her husband's room) and I don't think the motion-control sensor on the paper towel dispenser is working--it only gave me one piece of paper to dry off with."

"Well," I said, the others glancing at us from their eyes' corners to see if I would address this woman's issues or turf them, "how about we go take a look." She couldn't hurt me now that I only had 15 or so minutes left to my shift.

"And you are sure it didn't work?" I asked her as we walked the short distance to the bathroom. "Nope, I'm sure." "And you just used the bathroom right now? Or earlier today?" I asked her, trying to keep her talking and not complaining. "Oh," she answered, "just right now. I came straight to the station to tell you all about it."

We came to the bathroom door, which was loosely shut. We knocked to make sure it was empty. It was. I went in first, opening the door while I flicked on the lights. I took two steps into the bathroom before it hit me.

The smell, that is. It smacked me right in the face. The bathroom utterly stunk in the most primitive, disgusting, and vile way possible. And trust me, those of us who work in the ER are intimately familiar with stink. It has to be something impressive to rile us up.

While I was trying not to vomit in my mouth, the woman spoke. "See, right there," she said, pointing to the motion-controlled paper-towel dispenser, "I couldn't get more than one piece out of that thing." How, I had wondered to myself, was she even able to take a breath in while this fog of stink gripped my neck, suffocating me?

I moved quickly now, my life goal dramatically reduced to making sure the motion-sensor worked before I dropped to the floor and seized, my body's attempt at violently shaking any trace of this stench from my being. At the paper-towel dispenser, I waved my hand three different times in front of the sensor and, each time, a healthy piece of paper towel came out. "Well," said the woman, "I'll be. It does work!" Like a fireman leading a victim from a burning building, I grabbed this woman's hand and pulled her from the bathroom into the hallway, pulling the door closed behind us.

"Are you okay, sir?" she asked me as I bent over to take a deep breath. "I will be," I said dramatically, which was lost on her. I continued. "You said you just used that room, as in just right now." She nodded yes. Why on earth couldn't she have waited ten minutes before coming to us with this complaint?

"Okay, maam," I said, escorting her back to Room 24, "I know you have come out to the nurses' station several times for help, but go ahead and relax in the room a bit with your husband. I'm sure he will be going home shortly."

This was the last I saw of that woman before I left my ER shift (running out the door), eager to get home to change my clothes. I had told Liz exactly what had gone on in that bathroom. "I swear, that woman must have dropped a deuce to shame all deuces," I said. "That little, frail woman?" Liz asked in disbelief. "And she didn't smell it?" "Not once," I said, incredulous, "did she act like she smelled it or was embarrassed by the stench." "Amazing," Liz muttered, stifling her laughter, "she complained this entire visit and then led you to a bathroom she was responsible for smelling up. She had to have known..."

I drove home in my car thinking about this wife. I had, at one point wanted to meet the husband, to see what kind of guy this woman was married to. But, in my haste to leave the ER, I had abandoned that venture.

Since this wife had been very critical of our ER, though, I think it's only fair that I give a little critique of my own.

1. This wife's olfactory senses, well, they ain't workin'.
2. This wife's bowels, well, they are working just fine. Trust me.
3. And finally, if you ever need a bathroom's motion-sensor checked, do not, and I repeat, do not come looking for me. I'm retired.

As always, big thanks for reading. I hope everyone had a great weekend. To the commenters on Bald Is Beautiful, thank you for sharing your stories. I'll see you Wednesday, July 28th. Emma update--she is home and safe and slept 16 straight hours, a house record! Our circle is complete again. Thank you all for your prayers and well-wishes!

Tuesday, July 20, 2010

Bald Is Beautiful

She was sitting up and resting comfortably in her hospital cot, her home-made mauve and black afghan tucked comfortably under her arms. A pale yellow handkerchief was lumped on the bedside table beside the phone. She looked up at me as I walked into the room, greeting me with her big smile and sparkling hazel eyes. Except for a few patches of sparse, fuzzy auburn hair, she was bald.

"Hi, Mom," I said, walking up to her and pulling my mask down to gently kiss her cheek, "how are you today?" Despite the heart-breaking circumstances which lead to her being a patient lying in a hospital bed, I had never seen Mom look so beautifully breath-taking. And under normal, healthy circumstances, she was already quite a beautiful person, inside and out.

Mom ran her hands over her scalp, weakly smiling. "Well, honey," she said, "I guess we can cancel the rest of my hair-dressing appointments for the year." Over the past few days, the ravaging effects of Mom's chemotherapy regiment had taken ahold, which included her hair falling out in clumps.

"Mom," I said, reassuringly, "I don't think I have ever seen you look more beautiful." I walked over to the yellow handkerchief and picked it up, examining it. Strands of her thick, wavy hair clung to it. "What do you say we just throw this out?"

"Oh, Jimmy," she said, exhaling a deep breath, "I just don't think I am ready for that yet."

I understood completely. Mom had been raised in an era where curlers and perms and colorings played an important part of a woman's presentation. And although Mom was far from vain (how could she be when she was busy raising seven kids), she thoroughly enjoyed indulging in her hair. Hair that was now gone.

Despite a custom-made wig and multiple handkerchiefs, I don't think Mom's beauty was ever more evident than when she went bald during her chemotherapy days. Her baldness only seemed to enhance her indomitable spirit. Her eyes danced more openly. Her raw facial expressions confirmed her appreciation of life. Her prominent cheekbones exuded her infinite strength And the curve of her smiling lips were only that much more welcoming, appropriately framing the beauty of her words.

Accompanying her baldness, the truth of Mom's bravery in fighting her illness could not have been any more evident.

As I go along in my typical days of being an ER physician and the father of a child who has survived his own life-threatening illness, I can only tell you, without hesitation, that this baldness that accompanies one's fight for their life is as pure and as defining of one's character as any physical attribute can be. Without any words spoken, a patient's baldness from chemotherapy reveals a fighting spirit and a commitment to continue living. It reveals a strength drawn from reservoirs most people don't recognize they have until faced with crisis.

It commands my respect. And I rightfully give it.

Recently, at my gym, I couldn't help but notice one of the trainers, Barb, working-out with a woman who wore a handkerchief over her scalp. It was obvious that this client was intimately familiar with chemotherapy. It was very inspiring, to say the least, to watch this woman physically push herself through a workout despite her recent setback.

A few weeks later, surprisingly, I saw this same woman working-out without her handkerchief. Evidently, she chose not to cover up her baldness. And she looked stunning. As Barb and she worked out beside me in the cable room, I decided I had to speak up.

"Excuse me," I said to the woman. keeping it simple, as Barb looked on, "but I just have to tell you how stunning you look. I have no idea what you are going through, but I've seen you working out and pushing yourself these past few weeks and am thoroughly impressed. I wish you the best."

Well, Barb's client blushed a little as she thanked me. And later on, Barb came up to me and said that my words were exactly what her client had needed to hear since she was having a bad day. I hadn't been sure I should have said something, but Barb reassured me that my words were quite welcomed by this brave woman.

Especially in our ER, because of our regional cancer institute, we are privileged to treat many people who are wearing their baldness proudly as they undergo chemotherapy treatments. Both male and female. From the very young to the very old. And every time I have a patient who is bald for this reason, I make sure they know that they have my utmost respect. And if it is a child, that respect is also accompanied by a pile of stickers, a coloring book, and a Popsicle, if allowed.

A few weeks back, a brave little seven year-old girl greeted me as I walked into her ER room. She had been battling acute lymphocytic leukemia and, despite some mouth sores, still managed to greet me with her fading smile. On her head, nothing but baldness. At most, just a few patches of fine blond hair clinging desperately to their homeland. I smiled back at her as I approached, hoping my eyes conveyed my happiness to meet her. I must have looked like a big giant Smurf--I had donned a blue paper gown, a blue mask, blue foot covers, and cream-colored gloves. Until we figured out her immune status, we had to protect her from us.

"Hello, May," I said, extending my hand. "It sure is nice to meet you." We talked a few minutes about school, her best friend, and who her favorite doctors at the regional Children's Hospital were. Her mother sat at May's bedside, contributing to May's memories. "May," I continued, when there was a pause in conversation, "when did you lose your hair?"

She got quiet, hesitant almost. Her mom spoke up. "About three weeks ago, doctor." "Well, May" I said, my eyes hopefully conveying my sincerity, "I've seen many patients who have lost their hair because of their medicines, but I must say that you are by far the most beautiful." May looked up at me, serious now, and locked her eyes onto mine. I didn't flinch nor did I look away.

"Seriously?" she asked. "Seriously," I replied. In her child's voice, she softly said "But I don't like it. Everybody stares at me."

"You know why, May?" I asked, grabbing her hand with my gloved one. "They aren't staring because you lost your hair. They are staring because they are amazed to see such a brave and courageous seven year-old. And that's you. Showing all these people that you can be beautiful and brave no matter what medicines you are on or no matter what disease you are fighting." She nodded at my words. "The next time someone stares at you, May, just give them your biggest smile ever!"

"Like this?" she asked before donning one of the most perfect smiles I have ever seen.

"Just like that." I told her, admiring her gaps from losing her baby teeth.

I'm not saying that if you are undergoing chemotherapy and have lost your hair, that you need to express your baldness. Hardly. Wear a wig or a bandana if you feel more comfortable. During your fight, you do what you need to do and don't worry about what the rest of us think. But if you are in my ER or if you pass a middle-aged guy who happens to take a second glance at you, don't be alarmed.

It's just me, sending you good energy and well-wishes. And recognizing your courage.

Yes, indeed. Bald is beautiful.

As always, big thanks for reading. I appreciate your time. Emma update--day 15 of 17. Swimming at the Great Barrier Reef today before beginning the long trip home tomorrow. If she comes home, that is! Australia, you have a new, wildly-excited admirer in my daughter. Thank you. See you in a few days...

Friday, July 16, 2010

"The Patient Is Deaf"

At my ER computer station, I signed on to treat my next patient, a 42 y.o. woman who had presented with abdominal pain and, just prior to arrival, had noticed some blood in her stools. Despite her complaints, her vital signs were stable.

I went to pick up the clipboard for Room 31, her room, when I noticed a bundle of 8 1/2" by 11" white copier paper trapped under its metal clip, the top page of the pile covered with a lot of rushed handwriting. Stuck to this top page was a pink Post-it.

I grabbed the clipboard, with all of these extra papers and pink Post-it, and walked to the station counter, setting the clipboard down on some open space. I grabbed the Post-it and read. "The patient is deaf." This explained all of the writing on the top page. Between our triage nurse and this patient's room nurse, a conversation must have occurred where the patient wrote all of her answers to the various questions asked on the paper.

I smiled to myself about how great our nurses are. Not only did they save me time by saving the written responses of the patient, but they also gave me a "heads-up" Post-it. In the event the nurse and I hadn't yet had a chance to talk about a patient, I welcome when they let me know about a patient's special needs or circumstances this way.

Reviewing the top page, I appreciated just how in-depth the nurses asked their questions. There was not much more I would need to review with this patient.

I walked into Room 31 to find a middle-aged woman lying on her left side, eyes closed, with her hospital gown loosely-tied at her back's nape. A scratchy, white hospital blanket covered her up to her elbows. Her hair was flat and matted, as if she had spent the last few days in bed with her pillow. An empty chair had been pulled up beside her cot on the side she was facing. The room was dimly-lit and, since the TV was off, a calming quiet pervaded the space.

Since I wasn't sure if she was napping, I gently nudged her toe until she opened her eyes and looked at me. I could see her initial fog of "Where am I?" lift before me.

"Hello, maam," I said, paying special attention to enunciating my words, "do you read lips?" She nodded her head "yes." I smiled at her and continued. "It's nice to meet you. My name is Dr. Jim," I said, pausing to spell out J...I...M in sign language for her, "and I will be your doctor today."

She smiled at me and asked for the clipboard. She wrote out "Do you sign?"

I nodded "no." "I can spell my name," I spoke, giving her my undivided attention, "and I can sign all the words to 'You Are My Sunshine'." I did a little of the first verse for her, which revealed her hearty, guttural, infectious laugh, the first verbalization I had heard from her.

I thought back to my kids' preschool teacher, a wonderful woman who had the foresight to recognize sign language as a fantastic learning tool at their age. Because Ms. Denise's own son was deaf, she had made learning sign language one of her top teaching priorities, a priority she has carried with her to her new elementary job. My kids are a part of a group of lucky kids who have benefited from her forward thinking.

After a few minutes of general conversation, with me speaking and her writing, I began asking her a few more detailed medical questions. She grabbed the clipboard and flipped over the first page, now writing on the second, clean page. "Can you wait until my husband comes out of the bathroom? He can speak." She continued writing. "He just got here."

I nodded my head "yes" while I spoke. "Absolutely." As if on cue, the curtain pulled back to the room and a middle-aged, medium-height man in jean shorts and a t-shirt with wispy thinning hair walked in. He gave his wife a genuine smile before turning his attention to me. "Hello, sir," I said, approaching him with my hand extended, "I'm Dr. Jim and I will be your wife's doctor today. Nice to meet you."

He too had watched my face intently as I spoke, but it wasn't until he answered me that I connected the dots. Slowly, with thickened syllables and deliberate slowness, he answered me back. "Nice to meet you." The patient's husband was deaf, too. Like his wife, he could read lips and sign. But when he answered, unlike his wife, he verbalized his words alongside his signing. Very impressively and adequately, I might add. After just a few words, I was able to adapt to his speaking skills.

Between the small-talk, the rest of my history-taking, and the physical exam, I was able to witness the magic of their relationship unfold. It was extraordinarily ordinary, watching this couple interact. I don't know what exactly I had expected, since this was the first time I had interacted in the ER setting with a deaf couple, but they were a typical married couple who, through their various forms of conversation, skillfully interrupted and joked with one another.

Standing on the patient's right side of her cot, with her husband on the left, I was pleasantly reminded, yet again, that we fellow humans, despite our individual differences, are more similar than what we sometimes recognize. That, in the end, we all want nothing more or less than our neighbor.

It was during the explanation of the rectal exam, between the husband and wife, that I saw just how typical and ordinary this couple was. With the nurse now in the room, I explained to both the patient and her husband the necessary reasons for the exam. I explained how the exam would be done and what we would be looking for. When I was done speaking, as the nurse and I began preparing for the exam, the husband began gently teasing the patient about the exam, making a ring with his left thumb and index finger and sliding his right index finger through, mimicking the exam. Laughing the whole time he was doing it.

Well, the patient (probably nervous about the exam) did not seem to appreciate her husband's attempts at humor and, before we knew it, there was a flurry of hand movements between these two that could only be interpreted as a full-fledged argument. It was fascinating to watch. Despite our presence, they argued for about twenty to thirty seconds before their hands calmed down. The husband, after giving his wife the last signed-word, spoke clearly to her. "I'm sorry." He wouldn't be teasing her about this exam again. Ever.

Tenderly, they entwined their hands. The same hands that had just finished an argument.

I walked up to both of them, smiling, my gloved-hands ready for action. Before initiating the exam, though, I held up my right index finger to them, asking them to wait. When, at last, the room's calm returned, I did what I knew would make us all smile again.

I signed "You Are My Sunshine." Laughter filled this deaf couple's room.

This patient ended up having a lower GI bleed. As a result of this, we admitted her and she had a colonoscopy that revealed a bleeding polyp that responded nicely to the GI team's interventions.

Sometimes, I can only shake my head at how lucky I am to be doing this ER physician thing. I signed up for this job, yeah, but I had not expected my personal interactions with patients and their families to be as fulfilling as it has been in my career. Maybe even more fulfilling than providing good emergency care. Sure, like any other job, there are times through a shift when the hassles can outweigh the good. But, after the privilege of meeting this amazing couple as well as similar patients, you tell me how the rest of that shift could be a bad one?

It couldn't.

As always, big thanks for reading. I hope you all have a great weekend. Emma update--today is day 11 of 17. Yesterday was Kakadu National Park and today she continues the visiting and learning of the Aboriginal people and their customs. How lucky is she! See you early next week...

Tuesday, July 13, 2010

Ten Frowns and One Smile

Lately, I have noticed that I don't seem to be all that affected by grumpiness. And this place where I am sitting, immune to another's bad mood, seems to be a very good place to be.

I think as humans, we all go through phases where another fellow being's mood can affect us profoundly. In the ER, especially, the spectrum of moods can vary from unbridled elation to haunting despair. Between the staff, the patients, and their support systems, emotional investments can change on the dime. Another's pain can become your pain, another's happiness your happiness. And, whether we want it to or not, another's foul mood can run rampant among us, it's contagious, sticky fingers grabbing on to us and not letting go.

Sometimes, if we are lucky, the foul mood may slink right off us, heaping itself into a useless pile on the ground. A pile we can kick out of the way or, at a minimum, step over and continue on our way.

Typically, I am an upbeat guy. And recently, despite a crazy work schedule and my daughter heading to Australia and the death of a beloved aunt, I still feel good. Even more so than I would expect. It's hard to beat me down. Maybe it's attitude. Maybe it's being overworked and sleep-deprived to the point where the little shit stays little. Maybe it's getting frequent reminders of compassion and kindness by my fellow man. Maybe it's the sunshine. I don't know, really. What I do know, though, is that I am currently being buffered by all that is negative and I wish I held the secret as to why. Bottle it right up and ship it to the store shelf.

Recently, in the midst of yet another crazy, fast-paced shift in the ER, I felt like maybe I had found the answer. What was it? Simply that my fuel tank could be filled with one, and only one, high octane smile.

That day in the ER, the collective mood of the patients seemed to be that of anger, draped by the curtains of bitterness and frustration. No matter where I looked, I was greeted with the tortured faces of waiting patients. Smiling, it seemed, had been banned. Cots lined the hallways, waiting chairs were filled, and family members paced the hallway as if encouraging us to step into their treatment room. Of course, I'm sure waiting four hours to be seen played some small part. Some of the staff had, unfortunately, been affected by this cloud of misery. Others among us, despite the glaring looks and several obnoxious, open remarks by waiting patients and their families, continued to smile and diligently go forward with providing care.

I walked into Room 20 to see my next patient, a tall fellow in his retirement years, returning to the ER for a second visit in three days. Following one of my partner's discharge instructions, he had returned for worsening abdominal pain. "You're going to like this guy, Jim," his nurse had told me in the nurses' station just minutes earlier.

Walking into the room, I immediately sensed what the nurse had hinted at. I was greeted by the patient's huge heartfelt smile, despite him stoically gripping his abdomen (from pain, I presumed). His wife, sitting in the corner, wore a smile that matched that of her husband's. "Hello, doctor," they both said with a nod of their heads as I introduced myself, "thank you for seeing us." Their appreciation appeared genuine.

The patient, despite his own four hour wait and discomfort, was very gracious in his demeanor. "Doctor," he continued, "I didn't want to come back, but the pain seems to be getting worse. I know you have sicker people than me to deal with, but I appreciate you taking your time to treat me." How can you not like someone like this?

He recapped his abdominal pain complaints for me, from when it started to the present. It was apparent that he was probably having a worsening exacerbation of his diverticulitis. After an exam, we ordered the appropriate tests, including a CT scan of his abdomen. We gave him IV fluids and IV antibiotics as well as some pain medication.

Waiting for the results, with a backlog of filled-rooms and no place to put new patients, I used my rare, spare minutes to recheck several of my patients, saving this patient for last. Finally, walking back into the room, I was greeted with the same big smiles. Although the patient's smile may have been a touch loopier than his last one (from the morphine-derivative), his wife's smile was just as genuine as previously. And contagious. I couldn't help but smile back.

"How can you still be smiling with all that's going on out there?" the wife asked me. I explained that it was much easier to return a smile and kindness when it is shared with you. "Well," she continued, "I hope my son knows how to smile when he is having a day like this, too."

"What does your son do, maam?" I asked.

"Oh, he's an ER physician in Alabama. I can only hope," she continued, "that we raised him right and he remembers to smile when he is having a chaotic day. It's funny, but whenever I picture him working, it's always in a slow-paced, clean, brightly-lit ER. Not anything like the day your ER seems to be having today."

I assured her that, for the most part, our days are not typically this chaotic. And, I thought to myself, if smiles were genetic, then there was no way in hell that this couple's son would do anything but smile when facing a stressful day.

I talked a few minutes longer with the both of them, filling up my energy tank off their smiles and good-naturedness. Prior to excusing myself from their company, the husband briefly dozed off. Remarkably, he was still smiling in his sleep. "How the heck does he do that?" I asked his wife.

She shook her head and laughed. "He smiles all the time. If he isn't smiling, something is seriously wrong. His calm nature and smiles are the reason I said "yes" to him forty years ago." I thought back to how he had greeted me, despite having obvious pain, with that big smile of his.

As I walked out of their room, I looked up the hallway. Scowling faces greeted me in the waiting chairs. I looked down the hallway. Scowling faces greeted me from the cots lining the wall. I looked intently at the face of the nurse passing me as I stepped into the hallway. Her frustrations were obvious. I turned and looked back into the room I had just stepped out of. The patient was still napping. And still smiling. His wife was watching me watching her, a small wave of her hand accompanying her continued smile.

I smiled back. And I felt the needle of my gas tank pass "full".

What makes some people react to a situation with misery versus reacting with a smile and good energy? Eternal smilers, so to speak? Yes, I recognize that for some patients in the ER, the misery is understandable and situational and unique--whether from pain or frustration or impatience. Heck, even we get frustrated and impatient from the emergency department's flow, despite giving it our all. And yes, I know the answer to my question is not simple and is individual. I know the answer may be complex and multi-faceted. Even recently, though, at several local graduation parties, I was able to observe how happy, laughing, optimistic people tend to gravitate towards one another, while non-smiling, serious or pessimistic people tend to "sit at the same table".

Which table are you sitting at? And why? And are you happy with your seating arrangements?

Me? Well, you can give me ten frowns and one smile and, like Wonder Woman with her deflecting bracelets, the frowns will bounce off me. The smile, however, will be absorbed, internally feeding my soul.

Keep the ten frowns. And give me one big smile.

As always, big thanks for reading. Emma update--day 8 of 17 in Australia and loving every minute of it. Just jumped a plane from Sydney to Darwin where amazing wildlife and nature beckon her. Thank you to all who sent your well-wishes and prayers to Emma and our family. Next post will be Thursday or Friday...

Friday, July 9, 2010

Traveling Pain

Because of our jobs in the emergency room, we tend to see the extremes of human behavior. We may be cursed at, spit at, or physically assaulted just five minutes before being incessantly hugged and complimented by the same patient, an elderly woman with dementia. We may be talked down to or screamed at by the frequent narcotic abuser. We may be treated with the kindness, respect, and compassion, the way our parents taught us to treat others, by yet other patients, despite their not feeling well. The combinations of personalities and behaviors are endless. And interesting.

As a result, most of us have learned to be on-guard with our observations and our emotions. Because of so many interactions with patients and their families and friends, we have become experts, to use the term loosely, in quickly recognizing the differing personalities that may dominate a treatment room during a visit. Demanding? Check. Abusive? Check. Genuine kindness? Check. Attention-seeking? Check. Fun-loving? Check. Shy? Check.

Once we recognize a patient's personality, we can tweak our approach, our interview, our exam, and our treatment to fit that individual patient. It becomes easier to climb over the hill and treat the medical emergency that brought the patient to us.

Walking into Room 22, I was surprised to find a woman in her mid-thirties lying on her treatment cot, appearing quite comfortable as she watched TV. However, as her eyes darted in my direction while I walked through the door, she immediately began rocking and writhing in her bed, loudly moaning her misery.

I stood and watched her for a few seconds. Her behavior was interesting. It appeared that this patient was trying to tightly blink her eyes, to produce some tears, while she kept glancing out of their corners to gauge my reaction. I continued to stand quietly by the foot of her bed.

Finally, she calmed down enough for me to introduce myself. "Maam," I said, acknowledging her pain, "I'm sorry you're in pain. As soon as we talk and I do an exam, I'll be able to share with you what I think and what work-up and treatment you may need."

It turns out that this woman, diagnosed with irritable bowel syndrome, chronic abdominal pain of unknown etiology, and fibromyalgia, drove two hours with her boyfriend and two children to spend a long vacation weekend in our town. Within an hour of arriving, she developed her abdominal pain and decided to seek out an emergency room for treatment. "Honey," she had said, repeating the story for me, "you take the girls and have fun while I go get something for this pain." The ambulance picked her up at her hotel and brought her in while the family went to the beach.

Out-of-town visitors presenting to our ER with chronic pain issues always make me a bit more cautious of suspecting narcotic abuse, and this woman certainly seemed to fit the part. Sure, etiologies do exist for abdominal pain that can come on suddenly and wax-and-wane, but this woman, with a little distraction of conversation, seemed to be able to turn her pain outbursts "on" and "off" with the flick of a switch. As I palpated her abdomen, she would scream out even before I touched her. And during one scream, when I asked the patient her daughters' ages, she stopped the screaming immediately and answered my question as if we were at a restaurant having a dinner conversation. Hhhmmm.

"Maam," I said, after finishing her physical exam, "your findings are very atypical. You have good vital signs, no fever, and your abdominal exam, outside of your bursts of pain, is not revealing anything specifically wrong." As if on cue, she began to moan and rock within her cot again. It was over in just a few seconds. I continued. "We'll get some blood and urine samples to test, perform a pelvic exam, and give you something to make you more comfortable."

She nodded before asking the question I presumed would come. "Umm, doctor," she asked, "what are you going to give me for pain?"

"Toradol," I answered, watching her face closely for a response. Yep, there it was--her grimace. Toradol, as many patients know, is a non-narcotic IV and oral pain relief medication. It works great for several emergency illnesses, including kidney stones and migraines, and is a good alternative medication to offer someone in pain that might be suspected of having narcotic abuse issues. Of course, half the patients will say it doesn't work or they are allergic to it.

"But it doesn't work for me," the patient said, again on cue.

"I'm sorry, maam," I said, "but that is what I can offer you as we do your work-up. She decided to refuse the toradol dose.

As we waited for her results to come back, I had asked the nurse to leave this patient's curtain open a little bit and observe her. Sure enough, when this patient didn't think she was being observed, she calmly watched TV and even, at one point, climbed out of the bed and used the telephone while opening a top cabinet drawer. She was probably disappointed to find the q-tips, the strep-collecting tubes, and the tongue blades that greeted her. The other drawers, of course, were locked.

And every time the nurse or I entered the treatment room, the patient would begin rocking and moaning almost immediately. And stopped again as we walked out. Walk-in--scream and moan. Walk-out--TV-watching time.

Coincidence? Or not?

Her test results, as we suspected, returned negative. Every single one. Surprisingly, this patient gave me information to call her family doctor, which I did, and found out that she had significant pain control issues despite having a thorough, negative work-up and multiple visits to varying emergency rooms. "Please, do not give her any narcotics," her doctor had explicitly asked, although I had already arrived at this decision on my own. "I suspect," he continued, "that she may be abusing pain medication."

I went back into the room and explained everything to the patient, including my conversation with her family doctor. "I can give you something for the pain, maam," I said, "but it will be a non-narcotic, similar to toradol."

"Forget it," she said, easily jumping out of her cot to begin changing from her gown. "I think the pain has passed." I wished her the best before stepping out of her room. Before leaving, I was told, the patient got upset that we would not call an ambulance to transport her back to her hotel. "How about the beach, then?" she asked.

At the end of the day, most of us in medicine want to be wrong when our hackles go up and we suspect someone of narcotic abuse. Unfortunately, though, this sub population of patients does exist. And in certain geographical regions, it can be quite large. Unless I am extremely suspicious, as I was in this case, I will typically treat pain complaints and then try to figure out if the source of pain is real or made-up for abuse reasons.

Would it be wrong of me to say that we are happy when the pain turns out to be real?

I finally figured out who this patient was on the phone with, though, when she was in her treatment room. It was Sandra Bullock. Calling this patient to tell her that she wanted her Best-Actress Oscar back.

As always, big thanks for reading. I would sincerely like to thank all of you for your awesome comments in wishing my daughter the best and safest of trips. To the commenting Australians, thank you for your reassuring words...she arrived yesterday and has already fallen in love with Sydney! Well done. Have a great weekend and see you next week...Jim.

Tuesday, July 6, 2010

Dear Australia

Dear Australia,

I am sending you one of my greatest life treasures.

She is my oldest daughter, Emma, and she is just a few weeks shy of her fourteenth birthday. She is inherently reserved but has, within the past year, blossomed in ways that I could only have imagined. In ways that a father can only hope and dream. With her silly sense of humor, her emerging sense of adventure, her advancing maturity, and her loyal commitment to her friends and family, a visit to you, with your rich, diverse culture, seems like an amazing opportunity for Emma to continue her beautiful blooming.

Emma received her invitation to tour your great country last fall. After opening the mail and reading the information, she had no hesitation. "Mom and Dad," she said, quite boldly, "I want to go to Australia." I remember the look that passed between my wife and I. What happened to our little baby girl? The one who took a year to grow her soft, pretty blond hair on her infant head? The one who passively observed life and all of it's offerings? The one who's sweet chime of giggles was slowly replaced with the hearty, innocent laugh of adolescence? Was this the same girl who now, with uncontained excitement, wanted to up and leave us, her family, for seventeen adventure-filled days in your unique continent?

Yes. She was one and the same.

With gusto, we pursued the incredible facts of Australia, she with the six States and two Territories. She with the abundant physical resources. She with twenty million strong, seventy percent of who live in her ten largest cities. She with the varying weather, wildlife and vegetation that could be no more different than ours.

We pursued the meetings and critically reviewed the itinerary of travel plans that Emma would follow with this commitment. And then we as a family decided.

Yes, Emma, you can go to Australia.

From this decision, beautiful Australia, we have already learned many things. As parents, my wife and I are just a little nervous, truth be told, about offering up our daughter to the world. But knowing that she will be embraced by your comforting arms and and your compassionate people make this an easier decision for us. Emma has never looked back, not once, on her concrete decision to visit you. And as much as we want to shelter Emma in our cocoon of love and safety, we feel that the time is right for her to spread her wings and fly. Really, really spread them. And soar above the confines of our small corner of the world.

So Australia, on behalf of my wife and I, our families and friends, and Emma's siblings, we thank you for taking care of our precious daughter and loved one. Thank you in advance for showing her that the world doesn't have to be viewed as a big, bad, dangerous place. She will learn that, with caution, our world, beginning with you, is a marvelous, amazing potpourri of cultures and and sea of friendly, compassionate faces. That, no matter where we live, we all want the same thing. Acceptance. Compassion. Peace. Smiles.

And love. Especially love.

Thank you, Australia, for playing a part in my daughter's journey of life.


As always, big thanks for reading. I especially want to thank Peter for his kind words, via email, as we prepared our daughter for this amazing experience. Next post will be Friday, July 9. See you then...and hopefully, by then, my heart will be a little lighter.

Friday, July 2, 2010

The Damaged Eyes of Alcoholism

I walked into the dimly lit treatment room, Room 31, to find my next patient quietly and calmly lying in her cot. She had curly graying hair which, when added with the deeply creased wrinkles of her face, made her look much older than her stated age. Despite her attempts to welcome me with a warm smile, her greeting seemed forced. Her smile was but a thready, thin blanket failing to cover the the cold of her pain.

The pain of an alcoholic.

Standing in the corner, huddled together as a unified front, stood two teenagers. A boy and girl. Unlike their mother, they made no attempt to cover their worry. Their appearances were youthful--Converse Chuck Taylor sneakers, straight-legged jeans, graphic t-shirts, and hip stylish haircuts. But their eyes, those pained and aching eyes, bore an unfortunate truth to the years of sadness they had endured. Of their lost innocence.

I introduced myself to the patient before focusing my attention a little more closely on her children. Despite their worry, they were gracious in returning my hellos, introducing themselves.
I turned back to the patient. "Ms. Smith," I asked, "what happened that brought you to our ER this evening?"

Ms. Smith looked at me blankly, a confused haze slowly overtaking her face. I spoke again. "Do you know why you are here this evening?" She continued to stare at me, worrying me with her silence, before eventually nodding her head "no." She spoke. "I have no idea what happened."

I turned to her children. "Can either of you tell me what happened with your mother?"

The son stared down at his feet in response to my question. The daughter, however, connected with my eye contact and spoke up as she nervously tucked her wispy, blondish curls behind her ears. "I think she had a seizure." She got quiet then, her eyes getting more glassy as we continued to hold one another's gaze.

"Please, go on," I encouraged her and she bravely continued her story. She and her brother had been out and, upon returning home, had found their mother lying on the kitchen floor, unresponsive. An abrasion on their mother's forehead and a bleeding tongue greeted them upon closer inspection. After finding a pulse but failing to arouse their mother with yelling and shaking her flaccid body, they called 911. They all rode in the ambulance to the ER. They later put together, with the help of the paramedics, that their mother had probably had an alcohol withdrawal seizure. "She tried to quit cold turkey a few days ago," the daughter continued, shaking her head, "and I told her she needed to go somewhere to get some help."

The mother, intently witnessing her children struggling, started crying as she spoke. "I haven't had a drink for two weeks, honey."

With her words, the son looked up from his feet. "No, Mom, that's not true. You were drunk just over the weekend." The mother offered no excuses to his words.

Just then, the room's curtain pulled open and in walked a middle-aged man, his face strongly resembling the children's faces in both looks and worry.

"Daddy," the girl exclaimed, jumping away from her brother and into her father's arms. "Hi Dad," the son added shyly, giving his father a brief smile before turning his eyes downward again. His pain was palpable.

"Hello, sir," I said, introducing myself, "you must be Mr. Smith."

"I am," he replied, thanking me for taking care of his ex-wife. He turned from me back to his children. "Are you both okay?" he asked, pulling them into his chest for a hug. I caught my breath at his genuine display of love and concern for his kids. It was just what they needed at just the right time.

The kids smiled and looked up into their father's eyes, nodding their heads "yes." Their worried eyes relaxed and I was able to see some small sparkles mirror off their reflection as they continued gazing at their father.

Before turning to a physical exam, I asked a few more questions. It turns out that this patient had an extensive alcohol abuse history. Eight years prior, she had successfully completed an alcohol rehabilitation program and had remained sober for six years, before succumbing to alcohol's temptations again just two years earlier. According to her children and ex-husband, the past few years had been "hell" and had affected all of their lives in a very gloomy, detrimental way. They were just nearing the point of giving up on her, I'm afraid, when two weeks back, the patient announced to her family that she was done with alcohol "for good."

"That didn't last long, though," the son added, "because she got drunk that very night and passed out."

On exam, this woman appeared very fatigued, both mentally and physically. She did have the forehead abrasion that the kids had noticed on their kitchen floor, her eyes nervously flittered horizontally (known medically as nystagmus) within their reddened borders, and her tongue, on the left side, was bitten. Her vital signs were stable and the rest of her exam was unremarkable. It was evident that she had had some type of seizure, most likely an alcohol withdrawal seizure.

We did a full work-up. Her head CT was negative, her labs reflected dangerously low levels of both magnesium and potassium (which we began immediately replacing via her IV), and her alcohol level was zero. Besides addressing her electrolyte imbalances, we also gave her IV multivitamins, hydration, and thiamine to protect her damaged body.

We admitted this patient, much to her family's appreciation. She needed specific medical attention for her alcohol abuse and withdrawal seizure. After arranging all of this, I went back into her room to find this patient and her family much as I had left them, with much love being shared between the children and their father and their mother quietly sitting in the cot observing her children. There was much sadness, for me, from the many facets of this scenario.

"Maam," I said, after reviewing her work-up and disposition, "do you want to stop drinking? Will you accept some help for your problem with alcohol?"

Her answer was music to my ears, and it came without hesitation. "I have to stop drinking," she said. "If not for me, I need to do this for my kids." She paused and looked at her kids, who were now watching her intently. "I love you both too much to continue on this path anymore." With those words, both kids gingerly walked over and wrapped their arms around their mother, the daughter now openly weeping.

How do I know this patient was sincere about wanting help? As I spoke to them about their options for several available in-patient rehabilitation programs, she seemed to be intimately familiar with most of the options. This mother had done her research and had begun taking her own steps toward sobering up and becoming the mother she could be to her children again. She appeared very sincere in wanting nothing more.

I looked at both children hunched over the railings on either side of the treatment cot as they hugged their mother. Despite the daughter's weeping and the son's hesitancy, I could see that their eyes, despite their sparkling and youthfulness just minutes earlier as their father had hugged them, had become edgy, wistful, and nervous again. Old and young and, unfortunately, back to old again, reflecting their aged, hurt souls.

I am not naive. I know it is going to take a lot regained trust and renewed love to keep these children's eyes permanently young. To erase the damage caused by their mother's alcoholism.

Then again, maybe I am naive, because a large part of me thinks that this mother can succeed. For her children's sakes, I can hope for nothing more.

As always, big thanks for reading. I hope your holiday weekend is a good one. Next posting will be Monday, July 5. See you then...