Monday, November 14, 2011

Changing Faces

She walked into the ER's waiting room, her belly protruding from her third pregnancy, only to find an overwhelming number of people standing around, hoping to either be the next called to be taken back into the ER treatment area or, at a minimum, to cop the next available waiting chair.

Tugging a four year-old with one hand while pressing an active two year-old to her chest with the other, the young mother asked a security guard where she should sign-in to be seen. He pointed at the circular desk that sat in the middle of the room, behind which sat two nurses and a technician. Noticing the snaking line of people formed at their counter, she scowled to herself and dragged her gravid belly and two kids to join its end. After standing in the stagnant line for just a few minutes, frustrated, she marched to the left of the line to its front and sat her two year-old on the counter, letting go of her four year-old's hand.

The nurse, startled at the abrupt interruption during her triaging, asked her current client to please wait before focusing on the mother.

"May I help you?" the nurse asked the mother.

"Yeah," the mother answered, "my baby here got a fever two hours ago and I want her looked at. And as long as you all are looking at her, I want my son and me both looked at, too, since we'll probably get what she got." The nurse looked at the baby, sitting on the counter, cooing and slobbering over a lollipop given to her by her mother. The nurse felt the baby's forehead, feeling its coolness, and reassured the mother that they would attend to her and her children as soon as possible. "We'll get your histories and take your vital signs as soon as we take care of these people before you."

The mother obviously didn't want to wait. "You mean I have to go back in line and wait? Can't you see I'm pregnant with two kids hanging off me?" she yelled at the nurse while looking down, noticing her four year-old son missing. "Yes, maam, it does. Everyone before you has been patiently waiting their turn as well. We will be with you as soon as possible, though. If you would like a wheelchair to sit in while you're waiting, we can provide you with one."

"Screw that," the mother said to the offer, before screaming her missing son's name at the top of her lung, adding a few expletives that the entire waiting area heard. Her son came running from the back corner of the room and grabbed his mother's pant leg as she swatted his head. "Who the hell do you think you are," she said, "scaring me like that."

She retook her original position in line, the whole time grumbling and cursing into her iPhone to receptive ears. "Yeah, they making me wait on purpose. She don't like me." She was making a scene, surely, with her crescendos of frustration and anger very evident. Slowly she worked her way to the front of the line where nurse #2 was ready to help her.

"What can I do for you, maam?" the nurse asked her, paper and pen in hand, ready to write. The technician held the thermometer, ready to take one of three temperatures of this family. "You can help me by doing your god-damn job quicker," the mother answered snidely.

The nurse smartly ignored the comment, staring at the mother until the mother continued. "My baby here had a fever start maybe two hours ago and I want her seen. I want me and my son here to be seen, too, since we are gonna get what she's got."

The nurse and technician took the history of all three before doing brief exams and obtaining vital signs. The three were quite stable and none of them had a fever register. "How did you take your daughter's temperature at home?" the nurse asked, curious. "I don't have no thermometer at home," the mother said, "she was just burning up when I felt her."

The nurse reassured the mother that she and her two children appeared okay, and requested the mother have a seat in the waiting room until an available treatment room became available. "What?" the mother yelled, "you mean I have to go back to that waiting room?" "Unfortunately, yes, it does. I'm sorry for your wait today," the nurse answered. "How long is the wait out there?" the mother asked, adding a few more expletives. The nurse explained to the mother that the current wait was about three hours, but could be longer if life-threatening patients presented that needed to be immediately treated. The nurse then had the technician get the mother some formula, some diapers, and some snacks and juice to help with the wait. The mother, pissed at the world, stomped away from the triage area shaking her head.

Soon, the mother was on the phone again, cursing and bitching at an exaggerated level for the entire waiting room's benefit, leaving her four year-old unsupervised and running around the ER, swatting other young children. "Yeah, they making me wait even though I told them I was in a hurry." A waiting patient graciously gave up his seat to her, for which she said "About time" instead of offering her thanks.

During her wait, several patients signed in and were immediately taken to the back ER treatment area, skipping the wait. The mother complained. It was explained to her that patients in urgent need of treatment, such as those with intractable pain or having a stroke or heart attack, were immediately treated for possible life-saving illnesses. "I don't care about that," she said after her multiple complaints, "me and my kids need some life-saving treatment, too."

After a nearly three-hour predicted wait, this family's turn arrived to be taken to the next available treatment room. While being escorted down the hallway, the mother was very vocal in her her complaints, loud enough for all to hear, despite passing room after filled-room and cot after filled-cot in the hallways. Although she bore witness to the crazy atmosphere, this mother was bitter and defiant about being made to wait.

My physician assistant and I both agreed to attend to this family, dividing up the work between us, trying to make it a quick process. We had been given a "heads-up" by the nursing staff, both in the triage area as well as the treatment room's assigned nurse, as to the mother's disposition and lack of understanding on our busy day. Their stories supported their words. In fact, after this family was placed in their treatment room, we were told by the nurse that the mother made her wait until she finished her phone conversation, holding her index finger up to the nurse and refusing to talk until she was finished. "Why did you wait?" both the PA and I asked.

"That's nothing," the nurse added, "she also wanted two extra pillows after I adjusted the cot for her." Anyone who works in an ER knows how rare an extra pillow is, let alone two. "And," the nurse continued, "she is now demanding turkey sandwiches and pudding and juice for all of them." To placate them further, the nurse also got several blankets for them to cover with if they needed. However, this act of kindness wasn't good enough. "Hey," the mother yelled at the nurse as she was leaving the room, "these blankets aren't warm like they were the last time I was here. Take these back and get me some warm ones."

We treated the family. As suspected, the mother and four year-old son were both healthy with no abnormal findings. The two year-old had some mild nasal congestion and was otherwise as stable as the others.

After the PA and I explained the results of our exam to the mother, she demanded antibiotics for the three of them. We refused, explaining the overuse of antibiotics and their lack of need in their cases. "Then," the mother said, "I at least want a prescription for Tylenol so I don't have to pay for it."

My kids recently had URI symptoms and I knew for a fact that Equate brand acetaminophen was $2.86 a bottle. She, however, assured us that she couldn't afford that. I looked at the mother's gold necklaces, at her and her kids' designer clothes, at her iPhone and cigarettes hanging out of her designer purse, at her perfectly manicured nails, and finally at her eternal scowl while looking back at us. "And," she said, adding good measure, "I need someone to find us a ride home."

They found their own ride home. As for the Tylenol, I told the PA I didn't want to know what decision he made on writing the prescription. That decision alone, whether yes or no, could be examined by countless arguments as to the good and bad of our current medical climate.

Medicine is changing. Emergency departments are changing. In the decade-and-a-half that I have been an active, practicing ER physician, the changes have been astounding. Some good-astounding. Others frustratingly-astounding. Besides the current political and legal climates that exist, I feel firsthand the change in the attitudes of our patients and of our staff. The departments are being overwhelmed with non-emergent cases, and this is frustrating all that seem to be involved.

Is there an answer? Yes? No? Do you have one?

I was a people-person, enjoying the company of my fellow mankind. I am, admittedly, not enjoying their company as much. Instead, I am seeing more negative aspects and disheartening perspectives of humanity that are becoming more accepted by our community. I am seeing, too, the migration of great nurses and doctors away from our chosen field. Is this part of their reasons? Am I the next? I sometimes struggle to remember the great reasons I chose to pursue this career in medicine. Hopefully, with harder, more intense looking into myself, the good will be more in evidence. My father says that, at 81, he has never had a day in the forestry industry that he hasn't driven to work with a smile on his face. Most days I feel this way, too.

I only wish it could be every day.

As always, big thanks for reading... To my readers who have emailed their concerns by my lack of appearances on here, I thank you with much gratitude for your concerns. The family and I are well. To the nurses and technicians who endure triage and similar stories as above, thank you for all you do. 

Friday, September 16, 2011

The Reminder--EKG #6

Once a week, our residents in our Emergency Medicine program spend a complete morning attending hour-long lectures by various attending physicians from various medical fields, lectures that pertain to our specialty and contribute to their font of knowledge.

As with any lecture series, some can be fantastically entertaining while others can  be painfully boring, a timeline made of silly putty stretched much too long. I had no idea that the dry, cynical cardiologist I experience during a typical shift in our ER is the same guy who can deliver a funny, informative, engaging hour of information on cardiac resuscitation. Likewise, there is no amount of abnormal x-rays and CT scans that can save the dry delivery of the well-intentioned orthopedist talking about rare injuries. Sometimes, though, it is the subject material that can make or break the hour. Quite honestly, if I never hear another lecture on abscesses, I will be alright. I promise.  

Once a month, my duties include proctoring these morning lectures. Sitting through them, I have learned much. I have seen successful deliveries and I have seen miserable presentations. I have laughed to the point of almost being incontinent, and I have been bored to the point where watching a fallen eyelash on my desk sway from the air conditioner was much more entertaining. One of my favorite things to see in a lecture, though, is when the lecturer tries to engage our residents in a discussion on the hour's topic. Some of the residents are remarkably bold and astute during these types of lectures, participating without fear of being wrong with their answers, while other residents simply stare at their shoes or decide that the flaking cuticle on their left index finger suddenly needs their attention. Avoiding eye contact avoids engagement.

In the past year, though, several of our ambitious residents have asked for a slot of lecture time to review EKGs, to go over interesting cases from our ER, or to review subtle abnormalities in lab work or x-rays. They are willing to put in the extra time to become better doctors. The presenting residents manage the hour how they like and, quite honestly, I am very impressed with their presentations. And those comrades who normally stare at their feet? Even they participate in the spirited conversations that lead from these presentations. It is nice to see their confidence grow in a nurturing setting, a far cry from being lambasted by an asshole surgeon during their surgery rotation.

So, it was with this frame of mind a few months prior that I sat proctoring one of these resident presentations. It was on abnormal EKGs and, as I expected, it was going very well, the residents very interested in interpreting some very bizarre tracings. After a heated discussion on EKG #5, the resident continued with his presentation, clicking the computer button to advance EKG #6 to the big screen. Little did I know that this next EKG would transport me back to wistful memories.

Most of the EKG tops are whited-out, protecting the patient's confidentiality. The official interpretation of the EKG is also whited-out, to make our residents honestly review and interpret the EKG on their own. What isn't whited out, though, is the name of the EKG tech who performed the EKG on the patient. And there, in the left lower border of the EKG's information box, sat the technician's name.


Oh, Gigi. How you are missed! As talk continued in the room, voices dimmed as my mind raced back
several years, to thoughts of a spectacular human being who reminded me of the power of human kindness and compassion. Of the lost art of wanting to learn about your fellow human being. Of just being a good person wearing a big smile as much as one can. She was a hero of mine, and I wrote a piece about her that still makes me choke on my tears (Heroes Among Us--Gigi). Personally, she was a person who cared about me, who cared about my family, and mostly, who cared about my son's battle for his life. She was real. A co-worker like her I will never have again.

The residents finished interpreting the EKG and before clicking to EKG #7, I held up my hand to speak. I hesitated before speaking, all the residents' eyes on me.

"There is something more important about this EKG than it's tracing,"  I began. "Look at the  name of the technician on the left lower border." All of the residents' eyes glanced at the name and then turned back to me. "Do any of you remember this technician?" I asked, knowing that Gigi left right before our most senior residents arrived. They all shook their heads "no" to my question.

"Well, then," I continued, "let me tell you about this magnificent lady." And with that, I proceeded to share Gigi's story with them (I knew she would have let me). I told them how she treated patient's in their room, spending the five minutes it takes to get an EKG learning about the patient, their family, and their illness. Sometimes I heard laughter, sometimes I saw the beginnings of tears, but always I witnessed the boundless kindness and caring compassion that Gigi gifted to every patient she encountered. Then I told them about her concern and hugs through my son's illness and beyond. She saw through my anxiety, my hurt, my pain, and my fake smile as I struggled to maintain my professional life while my personal life was in shambles.

She is one of my heroes and when she passed too soon from this life, I knew the angels were singing in heaven.

The residents continued to watch me as I finished talking. "Just remember," I said, "that it is a privilege to help a patient and their family through a time of need. You can make this 'a job'," I continued, "going through the motions of what is expected of you, or you can embrace the privilege you've been given and do your job with pride and compassion."

The room was quiet. I was still being watched. "That's all I have to say about that EKG, then." Most of the residents slowly turned back around to face the big screen, to review the next EKG, but a few lingered. I think they heard what I had to say, but one can never be sure.

I'm not naive. I know there are people who probably laugh at the thought that one can always be compassionate and kind, especially in a busy ER such as ours. And they would be right. It is impossible to extend oneself to every encountered patient. Heck, even I get cynical and sarcastic, some days worse than others. I am human, after all. But my hope, by continually harping it, is that some of our residents remember why they went to medical school. Not for money. Not to play the number games that we now must play (insurance company numbers, patient survey numbers, patients seen per hour numbers). Not to expose oneself to lawsuits. But rather, to make a difference, a real difference, in some of their patients' lives.

Thanks, Gigi, for the reminder.

Big thanks for light of this past weekend of the tenth anniversary of 9/11, I wanted a story to remind us that we are all in this world together. Try as we might, we can not unweave the fabric of humanity. To the victims and their families of 9/11, you are not forgotten...your personal pain is our the heroes, we are eternally grateful for your bravery. Thank you... 

Wednesday, August 10, 2011

He Is Loved

He was sitting upright in his treatment cot as I walked into Room 28, his three-year-old eyes turned upwards and focused on the blaring nine-inch corner TV. His young parents, barely in their early twenties, stood to the left of their son's cot, their eyes fluttering between me, the TV, and their son. Within seconds, all three sets of eyes had settled on me, the stranger who had just invaded their privacy. I smiled at them. Before introducing myself, however, I walked up to the TV and turned it off, appreciating the sudden disappearance of Sponge bob and the arrival of a much quieter, calmer room.

I held out my hand first to the little boy.  Because of his age, it was only appropriate that he first look to his mother and father for approval before taking it. They approved, after taking in the stethoscope around my neck.  "Hey buddy," I said, taking in this little guy's appearance while I grasped his small hand, "I'm Dr. Jim.  It sure is nice to meet you!" He smiled shyly as I shook his hand with exaggeration. Next, I focused on the patient's parents, holding out my hand to each and shaking their's warmly.

All the while, I focused on the appearance of this patient and his parents. The patient was healthy- appearing for his age, existing in that stage of healthy-chunky and thinning-out, his cheeks no longer swollen lumps of baby fat. He wore pajamas, littered with small holes and sprinkled with stains of various fruit juices. His face was smudged. His teeth were discouraging, little decaying flecks of brown. His arms and legs needed a good scrubbing. Underneath his nails, I could appreciate the fine-line of brown that would require a bar of soap and a good brushing to make clean again. His hair was slightly matted and blondish-brown, the subtle curls poking several strands in an unexplainable pattern.

Yet, he smiled. Big and beautiful, innocent and endearing. Bad teeth and all. He smiled at me. He smiled at his parents. He smiled at the nurse who came in to check on him while I was in the room.

The parents, she taller than he, paced beside the cot. She was the talker, he the backer-upper. With every question I asked, she would answer it first with a concise answer, sometimes being quite insightful. He would listen to her answer and then, like a well-oiled machine, add "Yeah." Nothing more and nothing less. They both, like their son, wore clothes that were scrappy and stained, well past the normal point of a necessary washing. Their hair, his short and brown and her's long and blond, was oily. Upon smiling at me during introductions, I noticed the same teeth as what their son had. Plaque build-up was very evident from my close stance. I imagined them to be chocolate Chiclets, if there was such a flavor of Chiclets, fragmented from being dropped to the ground. Their exposed skin, that not covered by their t-shirts and shorts, had a sheen of grime.

Yet, they smiled. Just like their son.

I sat on the foot of the cot, facing the parents. "What," I asked them, "may I do to help you out with Joshua today?"

The mother moved from her standing spot along the counter to the head of the bed, where she held the back of her hand to Joshua's forehead. She turned her hand and held her palm to Joshua's cheek, letting it linger there for a while, the way a mother's hand should linger when touching her child.

"We were so worried, Doctor," she said, her smile dissipating and her face gaining an anxious quality, "about Joshua's fever.  It wouldn't come down for us."

"Yeah," added her husband.

She continued, her voice quivering slightly. "It's been about three days of sweating and chills and high fevers for Joshua. We just don't know what to do anymore."

"Yeah," added Joshua's father, his eyes darting from Joshua to his wife to me.

After a little more talking, I discovered that she had been under-dosing Joshua's acetaminophen and had not been aware she could use concurrent ibuprofen intermittently. The nurse had educated both mom and dad, in triage, to Joshua's proper dose after she had recorded a temperature of 103.4 F. As a result, I was now examining a child who was smiling and had broken his fever. And despite his slovenly appearance, this was one cute kid who appeared to be very happy and very loved.

Sometimes, a three-year-old boy can make for a very difficult exam but, in Joshua's case, he could not have been a better patient. Whether it was the fever breaking, his starting to eat and drink again, or just his baseline personality of unadulterated happiness, he was a pleasure to treat. Thankfully, he appeared quite stable despite having bilateral ear infections (acute otitis media). What could have been a very serious illness turned out to be something less that could be treated with high-dose amoxicillin. In addition to good fluid intake and proper use of acetaminophen and ibuprofen, I expected Joshua to be back to his normal self in a few short days.

Typically, after treating a child with ear infections and having a thorough conversation with the parent(s), I would race to fill out the appropriate chart paperwork, including prescriptions and discharge instructions. With Joshua and his family, though, things were different. This was a patient who made me reevaluate my first impressions. Because although Joshua and his family were indigent and struggling with proper hygiene and material things, never once did I doubt his parents' love for him. They sat with him on his cot. They played with him. They helped me coax Joshua to open his mouth so I could visualize his throat. They held him over their shoulder so I could listen to his lungs more clearly.

They did everything, with ease, that I look for to make sure a child is safe and loved.

I guess love comes in many forms. Part of my love for my children includes that they be clean, dressed appropriately, be respectful, and learn from an early age to appreciate good hygiene. Although, truth be told, my wife and I shower our kids with the more important stuff--lots and lots of unconditional love. That kind of love outweighs all. Whether for financial reasons or lack of knowledge, or maybe for reasons I simply didn't uncover, Joshua's parents seemed to struggle with certain learned parental roles. What they did endorse, however, was to show their son patience, concern, worry, and happiness.  And love. Lots of unconditional love.

I talked to them a bit. They had an apartment, although they struggled to make financial ends meet. They both came from broken homes. "I don't know what a good mother should be like," the mother said with honest introspection. "Yeah," added her husband. I assured them that they already seemed to have mastered the most important part of parenting, by giving their child unlimited love and attention, but there were other ways they could improve Joshua's life. Because they wanted the world to be Joshua's, they were willing to do whatever that might take. Thus, I called social services to have them follow Joshua's family. Maybe find some parenting classes. Give suggestions for whatever they may need. Basically, just bring their attention to more of the learned parenting skills.

Later on in my shift, I was fortunate to take care of another child, this one dressed well in designer clothes, clean, with perfect four-year-old baby teeth. Uppity parents. Unfortunately, this child and his family had nothing on Joshua and his family. Not...a...thing.

Sometimes, I gotta love my job and the cool people I get to meet.

As always, big thanks for reading. I hope this finds you well and your summer going smoothly. We are vacationing in the New England states and enjoying every minute of our family time. Soon, the posts will become much more regular (as soon as the writing rust wears off)... 

Friday, July 8, 2011

Godspeed (Sweet Dreams)

Ah, summertime. Sunshine. Warm weather. No school. Mounds of sports. Shrieking, playful kids. Sleeping in. Swimming at the club. Yes, this is the stuff that we who live along the shores of a Great Lake anticipate and dream of, especially in the midst of a three-foot snow dumping. Life is good when those dreams come true.

Ah, but, summertime. Time to eat picnic foods and have an extra drink and snack on another opened bag of chips. French onion dip included, thank you. Big burgers with Greek sauce. All beef wieners loaded with pickles and ketchup and mustard. Milkshakes topped with real whipped cream to slurp while watching the distant sun's setting over the discrete line of two worlds merging, our world with its blue-green waves gently swishing the emerging shadows toward our shores and that invisible red-glowing world that the sun slowly dips into, hiding from our searching eyes, to gather it's next-day strength of warmth and light.

I've enjoyed my summer so far, no doubt about it.  I was ahead in my work hours for my July to June contract and, as a result, had a few weeks off that were unplanned as some of my partners got extended hours to meet their contract obligations.  Lucky me.  More kid-time.  Bike-rides.  Tennis and swimming.  Lacrosse and soccer. More shooting hoops in the backyard. Especially, though, for me--no cell phone calling, no texting, and no computer time.  I revolted, in a benign way, to the thrusts of technology into my private life. Thus, no recent posts.

Thanks for hanging along with me. Am I alone, though, in embracing a few weeks without modern conveniences? How many of you miss the days of your childhood where fun seemed more easy to come by, where friends knocked on each others' doors just to see if someone could come out to play. I miss the days of my childhood where a typical day was an unplanned day, spent playing kick-the-can, kickball, hide-and-seek, fishing, and taking long country-road bike rides and hikes through the woods. The day was finished off, of course, with one of Mom's delicious four course meals. Then a bowl of vanilla ice cream drizzled with Mom's famous homemade peanut butter chocolate fudge.  Finally, it was off to bed, completely exhausted, wondering what excitement the next day would hold.

We don't do enough of that these days, what with all the organized sports and practices and such. Swimming practices at 7 am and 8:30 am, meets at 6 pm. Baseball batting and fielding practices and all-star league play. Lacrosse warm-ups. Tennis tournaments. Soccer practices and games. Basketball camps. A half-hour minimum of book reading per day. Not only our kids, but most of the kids of our friends do the same thing. It is not forced, though, and the kids love the various get-togethers with their diverse yet close-friends to do something they enjoy. As a parent, you gotta endorse that, especially since my sharp parental eye is not spotting any creepy "badness" happening that seems to be permeating our teenage society. No drugs. No alcohol. Just plain ol' fun. But my favorite and most important times of day, the meal times, have become a struggle to maintain among all this organized frenzy.

Besides ignoring technology, I have also been trying to boost up my own physical activity.  It's summer time--translation, more short-sleeves and swimsuits. This equates to me as more gym time and weight-lifting, more yoga, calming walks, and lots of daily stretching. Oh yeah, and my morning sit-up ritual.

Recently, I've struggled with my sit-up routine. It is my least favorite of all of my workouts.  But thankfully, I found a way around it. Since I am usually on our bedroom floor at 9 am, in front of the TV, ready to go at it for 20 minutes, and not wanting to watch Steve Wilcko or Jerry Springer, The Doctors or extended hours of The Today Show, I have begun watching concerts of some of our favorite artists on DVD. Sarah McLachlan, of course. Celine Dion from Vegas. Mary Chapin Carpenter from years ago. And The Dixie Chicks.

The other day, while grunting and sweating out my sit-up routine to An Evening With The Dixie Chicks, I had to stop. Catch my breath. Wipe my eyes. Not from being tired or sweaty, though, but because one of their amazing songs took me back almost ten years, to a time when our summer wasn't what I described above.  It was a much different summer. A summer with no sports. A summer with little joy. A summer of no typical activities of fun-in-the-sun.

It was the first summer we guided Cole through his year-long chemotherapy regiment.  A summer filled with angst and worry. As I sat up to get a better look at the DVD while crossing my legs Indian-style, I turned up the volume and let the song's lyrics and the genius musical interpretation by The Dixie Chicks transport me to that time, washing me over in emotions to powerful to control. The power of an amazing song always seems to stun me to a different level of consciousness.

When the song ended, though, I couldn't help but smile. And marvel at how far my family and how far my son Cole had come. How a summer a decade ago represented nothing to me of familiarity. And how far, how amazingly far, we had come. Suddenly, I realized that I missed my childhood summers very much, but I didn't miss that summer of Cole's illness where the true spirit of summertime passed us by. I understood a deeper appreciation for the summers we have now, both with the similarities and differences of summertimes past.

The power of a song, the power of a memory, and the power of our responses to both is a thing of beauty. From this power, my new appreciation for these more recent summers that don't imitate my own childhood ones.

Oh, I forgot to tell you the name of the song that sucker-punched my emotions--Godspeed (Sweet Dreams) on You may need to type it in as a search as "An Evening With The Dixie Chicks--Godspeed." A worthy search. In this clip, it is even explained how the song got its origin, another amazing story in and of itself. I hope you can appreciate the connection this song made with me during that haunting summer.

I hope you are having a good, bustling summer so far, my friend, and thanks for reading...

As always, big thanks for reading. I hope this finds you well and enjoying an amazing summer.  Thanks for bearing with me through my technology rebellion...     

Friday, June 17, 2011

With A Little Help

Friends. The family that we can choose, some say. You can't live with them and you can't live without them, others say. I've heard, "I don't know why I am still friends with them!" and I've heard "I don't know what I would do without my friends." The comments and feelings stirred among people when talking about their friends run the whole gambit of emotional investments.

I was thinking the other day about my various groups of friends, searching for the commonality that they all hold.  I have friends from my childhood and high school, friends from college, friends from medical school, friends from residency years, and friendships built from our life in this same town we have lived in for the past 15 years.  Because my wife and I settled into a city where our closest relatives live two hours away, our friends hold even more weight in our lives for the part they have played, sometimes even physically and mentally substituting for our family on special occasions.

Yes, we all need friends.  Better yet, we all better damn-well appreciate our friends. A good friend, tested and true, will be there through the pretty and ugly, through the happy and sad, and through the fun and miserable life moments.

I came up with a lot of reasons for the friends I have chosen or have chosen me over the years.  First and foremost, I like people that don't take themselves to serious.  After all, life is not such a stellar example of structure and order, and through the many moments of a typical day where something can go unexpectedly wrong, I like the person who can adapt with the situation and laugh off the change in plans.  So you thought you were going to be going to NYC for the weekend but your car broke down in the Poconos?  If you check in a motel and enjoy the Poconos, I like you.  If you bitch and whine and obsess over your ruined plans, I really hope to not spend more time with you in the future.

Diversity.  A key commonality among my friends.  My best friend growing up was Himer, an awesome buddy throughout our school years, classes and school sports and first dates and all.  His parents were much more liberal than my conservative parents, and somewhere between our different upbringings, we found a common bond of friendship.  My roommate all four years in college?  Christopher, straight from the rat-race we call Long Island.  Me--country boy, small-town, Adidas shorts and Hanes t-shirts, sneakers.  Chris--city-bred, big-town, Ralph Lauren pressed khaki shorts and purple shirts, penny-loafers. I took him four-wheeling and he took me to Manhattan. Oh, I can't forget about Gailie, my fellow Biology buddy who was a Catholic princess, through-and-through. Together, we were inseparable (along with Tony and Barnes and Dave) for much of our college days.  Best friend in medical school?  Easily KT, a Jersey girl with a heart of gold and an eye on public service.  We shared a bond of tennis and creative writing among many other things (including who to trust and distrust in our competitive class).  My best friend in residency?  Tomer, my Jewish, sharp-witted, cowboy-boot-wearing buddy for always, who watched my back during our 30 hour call-days.  Thankfully, sprinkled among all of these friends were more and more friends who impacted my life.

Even in my city life now, I surround myself with diverse friends.  Some of my best friends from the creative world?  A very cool, committed couple named Christine and Marcy.  Not only did they foster my love of the writing world, they also fostered my love of pets, of wine in quantity, in music, and in myself, helping me seek out ways to make myself better through some trying times.  My other friends all hold some diverse characteristics within their personalities that keep me coming back.  I love the fact that I do not seek "like" individuals, but rather people that can teach me and open my eyes to the many beautiful differences of their lives from mine.

Finally, without a doubt, the biggest commonality among my friends is humor.  Straight-up.  If you laugh at my silliness and I laugh at yours, we will be friends.  Prank phone calls, crazy texts, recognizing life's many absurdities, morning "sore-face" after a night of frenzied laughing and joking over a bottle of wine--those are the friends I gravitate to. Inappropriate and risque perspectives will get you bonus points, even.

Just last night, we were at an amazing dinner with six friends, eating great food (thanks, Michele!), drinking great martinis (thanks, Eric!) and wine, and just laughing and howling for four straight hours. No subject was off-limits and by the time we were hugging our goodbyes, we had solved most of the world's problems. Driving home, my wife and I both noted just how much fun we have with our friends. We are blessed to be surrounded by such cool people.

A better example?  Here is a reference letter our good friend Mike wrote for my wife when she was applying for a full-time position in a local school district.  It is just a rough draft, but one that he thought "might just get her the job."  Thankfully, he got serious and started at square one again, producing the perfect reference letter needed.  However, I tend to agree with him that this original letter may have gotten her the job in a much quicker fashion:

Dear Mr. K.,

I am a writin this letter to let you know that Karin is an awsim persin who would be a great choic for your new secretary girl. She haz a nice houz and drives a really cool bug! Her kidz are nice too and are clean most of the time. She haz good toes and a strong back. Lord knowz shez been carryin that husband Jim of herz  for years. She must be an angel from heven to be able to put up with his bull-shit, so she certainly can handle workin for you.

Karin is a great cleaner and bakes good tastin stuff. At a party once she made these reelly good brownies that made us feel reel mello. She must have a majik touch! Jim would never know that because he is always suckin down his fancy vodka drinkz. I think if he were smart enuf he would have hiz own moonshine still. I’ve only seen Karin reely drunk a few times so you don’t have to worry about her.
Karin is a reel cool mom too. She lets her kidz eat all the candy that Jim buyz at Sam’s Club and they still have most of there teeth. I bet those kidz will even gradute high scool one day despite the upbrigin of there pa. He has good intentionz but is a bit misgided when it comes to raisin youngins. I think he waz born in the woods or somthin.

Karin is good at managin stuff too. She can go to work all day then come home and cook and clean and get those kidz where they need to be…all the while Jim is “gettin his nap on”. It is amazin that she keeps that guy around. Allthou he is sorta pretty and has a nice set of gunz on him. I did see him without hiz shirt once and wuz amazd by what wuz there….. but this iznt the time to go into that!

Karin is reel easy on the eyes too. She would add some class to that school buildin. She haz nize hair, skinny ankelz  and amazin elbows. She smellz nize too. I bet she showerz almost every day and usez fancy lotionz. She certinly would not smell up the place.

Well, I hope you hir Karin for the job despit any shortcomins of her husband. Maybe he won’t come to the chrismas party so you wont have to meet him.

This made me laugh for days.  And days.  Only a good friend would waste an hour of his time to pull something like this off, right?  By the way, my payback to him?  Threatening to put his innovative letter on my blog and actually going through with it!  Didn't think I would do it, did you Mike?

Appreciate your friends.  Appreciate your acquaintances.  Appreciate the people around you who bring good humor, diversity, and a light-perspective to balance the seriousness that life sometimes holds. And appreciate the reflection of you that is mirrored back by all of your various friendships--this insight may prove to be invaluable and priceless.

As for me, I'll just keep laughing and smiling my way through this journey we call life.  With a little help from my friends, of course.  

As always, big thanks for reading... do you recognize the common thread that runs through your various friendships? Please share... and Happy Father's Day to all you fathers out there, especially those who treat the title of "Dad" or "Daddy" with the utmost are a heroes, each and every one of you.     

Friday, June 3, 2011

To Like Or Dislike

I was shocked by her appearance. Although she was in her early 50s, she looked closer to 80.  Matted peroxide hair.  Dull, lifeless eyes.  Sagging skin and deep wrinkles.  Protruding cheek bones.  Cracked, dry lips with a hint of yesterday's lipstick caked in their corners.  Gray and yellow-stained teeth, some chipped. In her prime and before alcohol and cigarettes became her every thought, I could imagine an attractive, lovely woman.  Now, sadly, what sat in front of me on the hospital cot in Room 12 was nothing short of a shell of a human being.  This was a woman who lived a hard life.

She had presented to our ER in respiratory distress.  Although she already had an established diagnosis of emphysema, she continued to smoke two packs of cigarettes a day.  On top of this, she had just finished a ten-day drinking binge, the last five of which she spent either passed out or drinking.  She claimed to have not eaten in that time.  I was called to her room because she was in such dire respiratory distress.

"Maam," I said after introducing myself, "how long have you been having trouble breathing?"  She was gasping for air, her nasal folds flaring with each struggle to breath deeply in.  Through her thin hospital gown, I could see her ribcage and diaphragm heaving, compensating for her non-compliant lungs, trying to pull that extra oomph of air into her body.

"I...don't...know," she managed to answer, each word a struggle for her.  Her hands, I noticed, were pale, their spidery veins popping through her thin transparent skin.  They gripped the top rail of the cot for dear life.

Immediately, I ordered breathing treatments.  Steroids.  BiPAP (a machine with an attached mask that would force supplemented oxygenated air into the patient's lungs every time she initiated a breath).  Blood work.  A stat chest x-ray.  The rapid intubation kit and ventilator for stand-by.  I asked more questions, questions she could answer simply by nodding her head.  "If you get worse, maam," I spoke, asking the most important question of all, "we may need to insert a breathing tube into your lungs, hook you up to a ventilator, and do your breathing for you.  Do you want that if it comes to that?"

A "yes" nod.  She tried to speak.  "I've...had...that...before," she gasped.  "You've been intubated before, maam?" I repeated.  She held up two fingers of her left hand in a peace-sign.  "Twice," she said.

Within the half-hour, surprisingly, she began to turn around for us.  I spent considerable time in her room during this period, making sure she would not decompensate before our eyes.  With the additional attention of two stellar nurses and a respiratory therapist at bedside, she thrived and slowly improved.  Finally, as her lungs began to fill with more air, her nasal flaring and ribcage retractions subsided.

After stabilizing her breathing, we began to treat her other problems.  For malnutrition and dehydration, we gave her several liters of normal saline and a "banana bag," a liter of fluid supplemented with thiamine, folic acid, and multi-vitamins, giving it a yellowish-color.  For her withdrawal tremors, we gave her Ativan, a longer acting valium-derivative.  We fed her ice-chips.  We gave her anti-nausea medicine and several low doses of pain medication for her evolving alcohol-induced pancreatitis.  Her chest x-ray revealed pneumonia in both lungs, and we began antibiotics to cover her for the common community-acquired organisms as well as for aspiration organisms (only God knew if she swallowed some puke into her lungs).

Finally, after a lot of attention and energy given to her, she was at the point where I could sit down a few extra minutes with her, making sure I understood all of her history and didn't miss anything.

"Maam," I started, "have you ever tried to quit smoking?"  "Yeah," she said, her voice now a little stronger, more gruff, "but I don't really want to.  I like it."  She looked at me with challenging eyes as she said it.

"And maam," I continued, "do you consider yourself to be an alcoholic?  Have you ever had treatment for it before?"  She answered immediately.  "No, I'm not an alcoholic.  I like my booze, but I don't drink nearly as much as my husband.  Now he's an alcoholic.  But I'm not."  She enunciated "he," spitting out the word like it was poison.  Her denial was remarkable.  And expected.  "Do you want help while your hospitalized for your drinking, then?"  "Why," she asked me, "if I don't have a problem?"

I asked her about abuse.  She denied physical abuse but claimed "that he yells at me a lot."  Again, she refused to accept any counseling.

Finally, as I was finishing, she said "Can I ask you a question, Doctor?"

"Of course you can, maam," I said.  "What can I do for you?"

"Well," she said, "I don't understand why doctors can't take care of my problems.  I don't like coming here all the time for belly pain and breathing problems.  Why can't they just get it right the first time I come in?"

I was shocked.  Completely and utterly thrown off my game.  Hackles up.  The nurse, standing at the room counter with her back to us, writing on her chart, turned her head around to face the patient, her mouth gaping and shoulders tightening.  I'm sure mine were, too.  Although we don't expect appreciation, we certainly don't expect to be blamed for a patient's medical problems, either.

"Maam," I said in my calmest , most respectful voice, "you have emphysema and, yet, continue to smoke two packs a day.  You have pancreatitis and, yet, continue to drink.  You completely ignore your body's needs, not drinking water or eating food for five days.  You are hacking up phlegm and don't use your inhaler or pursue treatment of these symptoms, resulting in pneumonia.  You've been intubated twice and have come to the ER multiple times.  And you can't understand why your doctors 'can't take care of your problems'?  Have you considered that your problems might be from your own poor decisions?"

I stopped and stared at her.  She stared back.  I waited for her to speak.  I was going to stand there all day if I had to.  Finally, with the nurse now standing along her other side, the patient spoke.  "I guess you are right.  Some of these problems are my own fault."

"Not some of them, maam," I said, "all of them.  By accepting personal responsibility for them, though, maybe you can move on and start treating yourself and your body a little better."  Although I'm sure my words fell on deaf ears, I still needed to have my say.  Especially when we all worked so hard to turn this unappreciative patient around from her multiple medical problems, some life-threatening.

I grabbed the patient's hand.  "Listen, maam," I said, "I wish you well.  I want nothing but the best for you.  But if you don't change your habits, I am sure I will see you in our ER again.  And again.  And, one of these times, I fear, we won't be able to undo your problems."

I let go of her hand and turned to walk out the door.  She was admitted to the ICU and was going to be transported up shortly.  Before leaving, though, she called out.  "Doctor!"  I paused and turned around.  "Yes, maam?"  She hesitated before speaking.  "Thank you for your help today.  I'll think about the counseling, okay?"

I nodded to her.  "Good luck," I said before continuing out the door.

One of the most frustrating parts of my jobs is dealing with patients' frustrations of their medical problems, simply because of their lack of personal responsibility.  It's rampant, too.  I cannot cure patient's who do not put their own effort into their health.  None of us in the medical field can.  We are here to help you along your journey, to walk sided-by-side with you in your, hopefully, healthy path.  Of course, some people do everything right, by the book, and still have medical issues.  That's different. But if you want to eat profuse and bad meals, please don't expect us to cure it with a simple "sugar" pill. If you want to eat fatty and greasy foods, please don't get pissed at us when your cholesterol pill isn't helping.

I love my ER patients.  Seriously.  I have met some very cool people over the years, from both different and similar walks of life, simply from what I chose to do for a living.  I appreciate and enjoy learning the diverse stories that rest behind their faces.  Sometimes, though, I get frustrated.  We all do in the medical field.  At the end of the day, we are all human, whether we perch ourselves on a pedestal or not.  And, regardless, we want the best for you, the patient.

To my patients that have made my job rewarding, a simple thank has been my pleasure learning about you and helping you on your healthy path.

As always, big thanks for reading...I hope this finds you all well.  Enjoy the weekend...

Tuesday, May 31, 2011

The Appreciative Cashier

With every breath, may we remember you, the brave and proud soldier, who has given more of yourself than any of us have the right to ask.  God Bless each and every one of  you.  Originally posted on March 5, 2010, this essay is my thank you.      

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

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

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

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

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

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

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

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

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

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

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

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

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

They read "United States Army."

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

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

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

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

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

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

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

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

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

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

As always, big thanks for reading.  And, big thanks to the families of our current soldiers and veterans for our freedom.  Thank you, thank you... 

Monday, May 16, 2011

Make Yourself At Home

Every ER has its regulars--those patients who return multiple times for a multitude of complaints.  Sometimes their complaints are easy and minor, yet other times their complaints can be quite concerning, demanding our full attention.  Regardless, that familiar face and voice can become quite a mainstay to a typical ER day.  Depending on the patient, these repeat visits, over and over and over, can be the stuff that can sink an already hectic day.  Or, remarkably, elevate it.

With multiple visits to an ER, then, a patient can learn the ropes of how our system works, using it to their advantage.  For example, what are our busiest times?  Most of our regulars know not to come in the evening, especially on a weekend or Monday night.  Which doctors are working?  They learn quite quickly which ones are more generous with the pain medications.  Which nurses will be available to lend them an ear and a sympathetic nod of the head?  Which case managers can get them free rides home and complimentary prescription refills?  The list of "inside information" can be exposed and manipulated quite easily in the right hands.

We even get frequent "anonymous" phone calls, answered quite brilliantly by our secretaries, asking for the name of the currently working physician.  "Umm," the phone caller starts, "my family doctor told me to come to the ER right now.  But I'll only come in if Dr. Smith is working."  "Well, sir," the secretary will say, "if you are sick enough to visit the ER, I don't think it would really matter to you who is working."  "But can you just tell me who is on?"  To which our secretary shakes her head as she answers.  "I'm sorry, sir, but I can't give that information out."  The first click of the phone never seems to come from our end.

So walking into Room 12, I was quite prepared to see one of our more frequent patients, a pleasant, middle-aged woman with chronic abdominal pain of five years.  Unfortunately, she is very susceptible to alcohol-induced pancreatitis and hasn't yet mastered her drinking problem.  As a result, her abdominal pain and drinking issues keep her in a perpetual state of requiring our ER services.  The more she drinks, the worse her abdominal pain becomes.  The worse her pain becomes, the more she drinks (to dull the pain).  A vicious cycle of dependency, for sure.

I smiled at my patient as I walked into the room.  "Hello, Ms. Tinnell," I said, extending my hand, "how are you today?"  I paused, before adding,  "I haven't seen you in a few weeks!"

The patient's face lit up.  Obviously, I thought to myself, I must be one of the docs generous with the pain medications.  Ms. Tinnell looked worn-out, very sallow, and just overall miserable.  She was holding her belly, despite her happiness to see me.

"Hi, Doctor," she said, "I'm glad you are on today.  I'm hurting real bad here, sir." 

"Was it your drinking again?" I asked, cutting to Ms. Tinnell's chase.  She nodded her head in the affirmative.  "Ms. Tinnell," I said, "how do you expect to get better if you don't want help with your drinking problem?"  We had been over this time and again, but she didn't want any offered services for her abuse issues.  That said, I sure couldn't leave a patient like Ms. Tinnell suffering, either.  Despite bringing all of these problems on herself, I still needed to address her pain issue.

After finishing the interview, I performed an exam.  Leaning in to listen to her heart, I smelled her staleness, her sleep--that scent of just rolling out of bed in two-day old clothes.  It was a smell I abhorred.  "Ms. Tinnell," I said, "are you taking care of yourself?  It smells like you haven't showered in a few days.  Have you been binging again?"

"Oh, no, Doctor," she assured me, "I just had a couple last night to help with the pain.  That's all."  I looked closely at her disheveled self as she tried to sell me her line, shaking my head "no" as she spoke.  "Okay, okay," she said, after watching my reaction, "you are right.  I've been drinking for three days straight."

"Well," I asked, "what are we going to do about this?  I want to help you but I'm not sure how I can.  Are you willing to be admitted for your pain?"  She nodded "yes."  I continued.  "Are you willing to talk to someone this visit about your drinking?"  Again, she nodded "yes."  "Good, Ms. Tinnell," I said.  "I will order up a work-up, give you some IV fluids with nausea and pain medication, and start working on admitting you to the hospital, okay?"  I had no doubt her chronic pancreatitis had been exacerbated by her drinking. 

Once again, she nodded "yes" to me.

And then, Ms. Tinnell reminded me of how frequently she comes to our ER.  "Um, Doctor," she said, before I could step out of her room, "can you get me an extra pillow?"  "Ms. Tinnell," I said, "you know how hard it is to find an extra pillow around here!  I'll look, but I doubt I will find one."  She continued.  "Then how about some extra blankets.  And not those regular ones, either.  I want the warm ones from the toaster oven."  Those warm blankets were usually saved for trauma patients, to keep them warm as we undressed them to closely examine their injuries.  "Okay," I told her, "I'll have one of our aides run a few down to you."  She continued.  "And Doctor, do you know if the pudding you have today is lemon or chocolate?  Your chocolate pudding doesn't sit well with my stomach."  Oh, the cafeteria pudding is now my fault?  I chuckled to myself.  "Ms. Tinnell," I said, "you and I both know you won't be eating anything for a day or two, not until we get your pancreatitis under control."

Finally, the big question that I knew was coming.  "Doctor," she asked, "what are you going to give me for pain?  You remember that the one that starts with a "D" works best for me, right?"  "Yes, Ms. Tinnell," I answered, "I know the dilaudid (a morphine derivative) helps you the most with your pain."  She was only going to get half of her typical dose, though, to start with, since her renewed energy in making all her requests was quite impressive to me.

I stepped out of the room, but not before I heard Ms. Tinnell giving her nurse explicit instructions on where and where not to place the IV.  "Honey," she was saying, holding up her left arm, "they always get one here.  Are you new here?  I don't think I've seen you before."

I stepped out, shaking my head.  This patient obviously felt right at home with us.

Twenty or so minutes later, I walked back into Ms. Tinnell's room to check on her as well as explain that her pancreas enzyme levels (amylase and lipase) had returned from lab and were quite elevated, signifying, for her, a flare-up of her pancreatitis.  She was not alone in the room.

"I feel much better already, Doctor," Ms. Tinnell said, before I could even approach her bedside.  "That "D" medicine works great!"  I smiled at Ms. Tinnell as I walked up to her guest, and older gentleman, who was sitting in the room's corner.  "Hello, sir," I said, "may I ask who you are?"  I was not going to share any of her private information without knowing his identity.  "Oh," Ms. Tinnell answered, "this here is Johnnie.  He's my new boyfriend."  I held out my hand to Johnnie, shaking his.  "Nice to meet you, Johnnie."  Johnnie smiled, revealing his sparse, yellow-stained teeth.  He appeared quite comfortable, sprawled out in the room's only chair, covered with one of the hospital blankets that Ms. Tinnell must have chosen to share.

I walked back to the cot and stood .  "Ms. Tinnell," I said, "your pancreatitis is flared-up again.  I called the medical doctors and case management.  They are both going to be in to see you quite shortly, okay?"  She nodded "yes," again.  "We'll admit you like we planned."  A part of me thought maybe, just maybe, she was going to back out of her admission, since we made her more comfortable and eased her pain.  But she didn't.

As I stepped away from her cot, preparing to leave her room, Johnnie grunted.  It was a signal to Ms. Tinnell.  "Oh, yeah," she said, "I hope you don't mind that Johnnie is using the oh-two."  I looked from Johnnie's nose, where two nasal prongs hovered in their silent swishing, and followed the clear plastic tubing that led to the oxygen hook-up on the hospital wall.  It was set on two liters.  Until this point, I hadn't even noticed that his tubing wasn't hooked up to the green tank that sat behind his chair. 

They both must have followed my eyes as I took in the scene.  "Yeah," Johnnie said in a low, rumbling voice, "I need to save my oh-two since I'm running low."

This was a new one for me--a patient's visitor hooking himself up to the hospital's oxygen.  Not the patient, but one of their visitors!  It gave a whole new lever to the phrase "make yourself at home."  I shrugged at the both of them.  "I guess it would be okay," I answered, "since you are only going to be here a few more minutes.  When you go upstairs, though, you'll have to check with your nurse before you hook up to any more hospital oxygen."

Again, I started to walk out of the room.  Before I could, though, Johnnie had cleared his throat yet again.  I turned around, now growing a little impatient. "Yes?"  I asked him.  He looked to Ms. Tinnell.  "I ain't gonna ask him," she said to him, "you have to."  "What is it, Johnnie?" I asked.

"Well, do you have an extra chair that I can put my legs up on while I'm waiting here?"  Um, no.  Sorry, Johnnie, I thought to myself as I shook my head.  He continued.  "Then do you have an extra pillow and more warm blankets?"  "Johnnie," I spoke, "we don't have any more pillows.  I looked.  And those warm blankets are for trauma patients.  We gave you three between the two of you--you don't want to take any more in case someone really injured needs them, right?  We'll get you some regular blankets if you want them."  He looked at Ms. Tinnell before speaking a final time.  "Well, then, how about some pudding or a turkey sandwich?  Nobody's even asked me if I want coffee or something to eat yet."  The words were spoken with entitlement dripping off every syllable, not as a question. 

It was obvious Ms. Tinnell had shared the secrets of our system with her new boyfriend.  Ughhhhh!  And to top it off, right before walking out of the room, Ms. Tinnell did her own little throat rumble.  "Doctor," she said, looking quite comfortable lying in her cot, "the pain is coming back.  Can I have more of that "D" medicine to help me?"

According to Ms. Tinnell's nurse, the requests from their room continued throughout the entire ER visit.  "Do you have any extra tooth brushes?"  "Why won't channel 68 come in on the TV?"  "Can someone get me some reading magazines from the waiting room?"  Imagine a typical hectic ER day--the noise, the crowded hallways, the prehospital sirens going off, the commotion, the incessant phone ringings, the scurrying staff, the enormous traffic of patients coming and going, the arrival and departure of ambulance after ambulance.  Now, imagine getting called into the same room repeatedly for such above issues.  

I am quite fine with helping someone, anyone, in need.  It's what I signed up to do, what any of us in medicine do, really.  But, between Johnnie and Ms. Tinnell, I was feeling, once again, that our kindnesses and our system were being taken advantage of.  It appears to be a growing problem with emergency departments across the nation as we struggle to redefine our roles in our changing medical world. Despite the pressure from administration and patient satisfaction surveys, there will always be patients and families that we simply cannot make happy. I felt we had gone above and beyond providing for our patient and, especially, for her visitor.  But where is the endpoint?   

Right before Ms. Tinnell was transferred to her medical admission room, the nurse approached me.  It seemed Johnnie was upset that our case managers couldn't provide him a free taxi ride home.  I shrugged my shoulders at her, exasperated. 

"It looks like Johnnie is just going to have to find his own way home, I guess," I said.  The nurse smiled, adding, "Or make himself at our waiting room."

I could only hope they had some extra pillows out there.

As always, big thanks for reading. I hope this finds you all well...          

Friday, May 6, 2011

Scratching Below

He was a good-looking guy, my next patient.  Even before walking into his treatment room to introduce myself, I had overheard the nurses talking about him in their nursing station.  "Did you see those brown eyes of his?" his primary nurse said.  "And that hair," added a tech, "so wavy and thick."  "I like his smile," added a second nurse, one who had helped settle this patient after he arrived by ambulance.  I could only have imagined the argument between the nurses as to who would get to be this patient's primary nurse.  I had no doubt that lots of pillow fluffing, extra blankets, repeated exams and vitals, and a turkey sandwich were all in his future.

The aggressive, single, newly-graduated nurse won out.  Secretly, I had my money on her.

I walked into the room to find a gentleman in his mid-twenties, sitting upright in his cot, in a properly worn hospital gown (I had no doubt the nurse helped him put it on correctly).  He seemed tall, six-foot maybe, and weighed around a buck eighty.  He was thick-shouldered and clean-cut, in good shape, his brown hair appearing recently-cut.  He was modern and hip--tattoos poking out from the sleeves of his gown.   

The nurses were right, of course, he was a good-looking guy.  In fact, I would have even agreed with their assessment that this patient could have modeled at one point.  More for Land's End or Eddie Bauer, though.  He would have had to imbibe in plain chicken breasts and no carbs for months to make it into a Hollister or American Eagle ad.

Good-looking or not, this patient was in our ER to be treated.  And doing a quick, cursory once-over, I could tell that all was not right.  This patient's brown eyes were dilated, tracking my every move, his deer-in-the-headlights glances matching his nervousness.  He was breathing rapidly as well, fidgeting with the pulse-ox monitor clipped to his finger.  Before I could approach him and introduce myself, his anxiety was revealed in his rapid-fire speaking.  "Are you the doctor," he blurted out.  "Yes, sir," I answered, "I am your doctor today.  I'm Dr. Jim."

He paused to take me in, looking me up-and-down.  I remained quiet during his assessment of me.  Finally he spoke.  "Do you work out?"  Of all the questions and comments I was prepared for, this one surprised me.  "Yes, sir, I work out.  You, too, I take it?"  He nodded his head yes.  Obviously, physical appearances meant something to this patient.

I decided to gain control of this interview.  "Mr. Nalstead," I asked, "what brought you to our ER today.  What can we do to help you?"

"I think I'm having a heart attack, Doc."

"Why do you think that?" I asked him.  "Are you having chest pain?"  He certainly didn't come across as a patient at risk of having a heart attack.

"No," he answered, "but I'm having a hard time breathing.  And sometimes I get palpitations, like my heart is going to pound out of my chest."

I reviewed his cardiac risk factors with him.  The patient admitted to smoking and his father was being treated for hypertension but never had a heart attack, himself.  "What are you doing when you develop this 'hard time breathing?'" I asked him.

"Usually I'm just sitting, Doc, and thinking."  "About?" I asked.  He continued.  "About my kids."  "How many do you have?" I asked, guessing, from his age, one or two.  "Three," he answered.  I wasn't too far off.

"How old are they?" I continued, interested now in his social history.  And although it is hard, after working in the ER for so many years, to catch me off-guard, this patient's answer did.

"They are 22 months, 19 months, and 16 months."  He paused, staring at me, waiting to see what my reaction would be.  I wore my poker face, though.  I'm sure he was anticipating what my next question would be.  I was no Ob/Gyn, but even I could figure out that this scenario was not possible with just one mother, one woman.

After asking him, he admitted to me that "I had gone through a pretty rough period, yeah."  He had three children to three women.  In a remarkably short period of time.  Currently, none of the three mothers of his children would let him see his kids.  Whenever he thought about his kids and his lack of involvement in their lives, he started the rapid breathing, the nervous tremor, and the heart palpitations.  Raising my suspicions for an anxiety disorder.

I dug deeper.  As it turns out, this patient had had a pretty miserable childhood.  A piss-poor father-figure.  A mother who cut him down repeatedly.  Alcohol and drugs since his early teens.  Prison time.  Although he denied any recent alcohol or drug abuse to me, I suspected he was teetering on using again.  It was a vicious cycle that needed to be broken.  And he knew it.

After doing some baseline tests to make sure he was clinically sound, I sat back down with him. His testing results, I assured him, were excellent.  "So you don't think I'm having a heart attack, Doc?" he asked me.  "I'm sure," I reassured him.  We talked a little further about how he had to break his cycle of behavior, though.  "You have to," I repeated, sternly, "if not for you, then, for those three little kids out there in our community who don't know their father's love."  My words must have gotten to him--I saw the glistening brown eyes well-up before tears spilled onto his cheeks.

We offered him counseling.  He took it.  We offered him a follow-up appointment with a family doctor who was accepting patients.  He took it.  I offered him a short-term prescription for a few anxiolytics.  Six pills.  He took it.  He asked me about my social life--and I shared with him that I was married with three kids.  "Are they fun?" he asked.  I simply nodded my head "yes."  In my mind, though, I imagined my life without my kids, a thought that made me shudder. 

The patient stared me in the eyes.  "I want to do this, Doc.  I want to be a good father to my kids."  By all appearances, he appeared sincere in wanting to break the cycle he was caught up in.  I could only hope.

I left his room, after my last recheck, thinking about all of this patient's problems, problems that were buried deep below a good-looking exterior.  On the inside.  Hidden from anyone who didn't take the time to uncover the true essence of his person.  An exterior that didn't match our society's standards of what we suppose a good-looking person has within them. After all, if a woman is beautiful or a man is good-looking, why would they have any internal turmoil?  Why would we think anything but their outer beauty would be matched by their inner beauty?  What do they have to be upset about?  How could they have any problems?

It goes back to the common thought--physical beauty is temporary, spiritual beauty remains forever.  We are all guilty of judging a book by its cover, aren't we?  I know I am, despite my awareness of trying not to.  However, I have learned, with time, that I find much more pleasure from a book by opening it.  Pretty, pretty cover, maybe.  But what are the words saying inside?

Thankfully, this patient reminded me that, yeah, I am in my mid-forties, and my body and looks might be fading a bit (some characters in my life would probably argue more than "a bit"), but I have inner peace.  I am loved.  I give love.  If you make me look like an ogre, but guarantee me my love and inner peace, I will take that deal and run with it.

I walked back to my desk.  His primary nurse approached me.  "Hey," she said, "is it okay if I discharge Mr. Nalstead?"  I nodded my head "yes" to her, adding "He is a pretty nice guy, isn't he?  I hope he can turn his life around."

She looked at me like I was crazy.  "Are you kidding," she said, "he has been in jail and has three kids to three different women!  I'm not up for instant motherhood!"  She chuckled at her words. I was surprised, this response coming from her, when just a few hours prior she had been thinking this guy was the most glorious specimen to come from the human race.

Scratch below the surface...

As always, big thanks for reading.  And a big thank you for your patience with my frequency of posting... 

Tuesday, April 19, 2011

The Barn Door Is Open

One of the things that continually amazes me, intrigues me even, about medicine is the scale of personalities that exist within our community.  From the obnoxious "know-it-all" to the warm-hearted "everybody's friend" types, you can find just about any recipe for a personality among us.  Take a dash of kindness, a pinch of self-doubt, a teaspoon of over-eagerness, and a dollop of sharp wit, and viola, you may have this nurse during your next visit to the ER.

Me?  I'd like to think that I am a straight-shooter, the furthest orbit away from the central pedestal that so many doctors feel they deserve to be perched on.  Their livelihood depends on this precarious position.  Mine doesn't.  I ask my team to call me Jim.  I don't wear a white coat during a shift (except in the family room, where I insist on a higher level of decorum to be followed). I welcome anyone to question why I am doing something in a certain way.  I am kind and compassionate.  I love to laugh and smile among the infectious camaraderie of a good team during a rough shift   

However, I am human, too, which means I sometimes need to really fight myself during a crazy shift or odd patient-encounter to avoid cynicism, sarcasm, anger, or disappointment.  Although rare, I have had some breaking moments.  For example, to have a patient with a top-of-the-line cell phone, decked out in a designer outfit and $300 dollar running shoes, with a pack of cigarettes hanging from their pocket demand (in an irate, demanding manner) a free ride home and free prescription fills is still something I struggle with, although my answer remains the same.  "No."  And patients who have attained their medical degree via a ten minute Google search prior to their ER visit, trying to dictate the course of their treatment, can test my limits in a weaker moment.

My idols, those inspiring physicians I've encountered through my career, seem to be the "regular Joe" doctors who have a quiet confidence and a humble self-assuredness combined with a normalcy of expected kindness and respect.  They don't want their coffee brought to them, they don't want everybody to bow at their feet, and they don't feel the need to brag and show-off their endless knowledge base (a pet peeve of mine--I'd rather one show me how good they are, through their actions, rather that waste their words by telling me).  They just want to be a friend, a mentor, a good person defined by their entire world, not just their world of medicine.  Their greatness as a physician is simply an extension of their excellence as a human being.

It is a fact I stress with our residents.  "Don't emulate just one of us," I say, "but rather, skim from each of us the characteristics you want to carry with you throughout your life, your career."  I reiterate that none of us, their mentor physicians, are perfect.  We are all human.  I can only hope that they choose to combine hard-work, compassion, and humility among their other qualities.

If I ever decide to pursue a big head and an uppity view, though, about my professional accomplishments, I think I will fail miserably.  Too many times through the day I am humbled by reminders that I am nothing special.

Case in point?  Just last week, during another busy shift, I was standing in front of the counter of Room 22.  In the treatment cot lie Mr. Smith, his mental status dwindling and his extremity weaknesses gaining.  His wife, expectedly concerned and apprehensive, sat in a corner chair just a few feet to my left, watchful of her husband and our treatment team.  Her worried look, her disheveled gray hair, her furrowed brows, her dilated pupils, the way she edged her body forward on her seat, utilizing but a few inches of its support, all spoke of her love of her husband.  Of her inherent sense that something was terribly wrong.

And she was absolutely right in her suspicions.  Mr. Smith's CT scan had confirmed a significant intracranial bleed, a stroke of devastating proportions.  A stroke that limited us, between his previous strokes and extensive medical history, in our aggressiveness.  Together, the ER nurse and I had walked into the room to share their grim news with them while we contacted the neurology and neurosurgical teams.

"Mr. and Mrs. Smith," I spoke, quietly and gently, yet urgently, "I have some disheartening news.  It appears that Mr. Smith has had another stroke, this one quite involved within the entire brain."  We talked at length about the findings, our plan of action, of how aggressive they wanted our team to be, despite our hands being tied from this CVA's severity.

Mrs. Smith took the news much better than I expected, her acceptance belying her body's expressions. While her husband floated in and out of awakeness, she explained their position.  "We were told last time that the next stroke could be the final one.  It appears we have arrived at this final one, yes?"

I couldn't help but like Mrs. Smith.  Her inner strength was simply astounding.  I nodded "yes" to her, but added "Let's at least have the specialists see your husband and make their recommendations to you."

Now she nodded "yes."  "But," she added, "neither of us want heroic measures."

I understood.  "I'm just going to remain here with you a few minutes," I said, "if that's alright, while we wait for the specialists to arrive."  Although the ER was busy, I wouldn't let that fact prevent the nurse and I from providing a few minutes of necessary companionship.

And then, it happened.  Another realization of my humanness.  After removing my supportive arm from around Mrs. Smith's shoulders, I stepped back to the front of the counter, bowed my head, and cupped my hands in front of me.  I looked to the floor, to my brown Clark clogs, as I started to say a silent prayer for this family.

Instead of finishing my prayer, though, I became distracted.  Thoroughly and completely.  Because there, in this extreme moment of crisis, in the middle of my wishful thoughts for this family, I noticed my zipper.

My wide-open unzipped zipper.  How long had it been down?  I shuddered at the thought that my zipper may have been this way for several hours and through several other patient encounters.

Not only was my zipper open and lingering at its lowest possible point, but its edges were widely gaping, exposing my hunter green, 3% spandex and 97% cotton, boxer briefs.  My hip-huggers were there for the world to take in at possibly one of the most inopportune moments.  "Hello," they screamed, "look at me.  Look here!"  Ugh!  For some unexplained reason, I remember thinking the situation would have been better had I chosen to wear my tighty-whities that day.

Slowly, I tried to cover this embarrassment with my cupped hands, but to no avail.  I shifted my legs back and forth, trying to see if the sway of my motion might magically reacquaint my zipper edges.  No go.  I looked up at the nurse, who was oblivious to my predicament, and Mrs. Smith, who was not.  She was focused on my every move. It didn't help, either, that she was sitting in her chair, eye-level of my indiscretion.  Secretly, I think she was quite entertained by my distraction.  Heck, I'd go so far to say that she enjoyed watching me squirm of embarrassment.

Suddenly, though, she looked me in the eyes, her eyes sparkling with amusement and yet glistening with sadness.  I returned her gaze.  We both remained quiet. All was okay.  I abandoned any sense of correcting the situation and remained leaning against the counter.  Graciously, she turned her head from me and refocused on her husband.  As did I.  As was the nurse this entire time.

By the grace of God, I got paged overhead for a phone call.  Probably the neurologist, I thought.  I excused myself from the room and rushed to my physician station, where I yanked up my zipper before attending to any other tasks.  Later on, as we do in our twisted ER ways, the team would have a hearty laugh at my expense.

Yep, I'm human.  I put my underwear on just like the next person.  As do every one of my fellow physicians. Oh, and my zipper will occasionally fail me and that's okay.  How can one possibly get an exaggerated ego with that in mind?

I will remember Mrs. Smith and her quiet resolve, her inner strength, in the face of such a crisis.  And I'm sure she will remember me, too, but, unfortunately, not for the same reasons. 

I hope my residents take my words to heart and emulate the best I have to offer.  Which, during that shift, was this advice--never, ever go into a patient's room without checking your zipper first!

Otherwise, I'll just keep preaching kindness and compassion.  And, oh yeah, humility...

As always, big thanks for reading.  I hope this finds you all well.  On HHI for the week and having a grand ol' time.  Any embarrassing medical stories you'd like to share?  Please do... 

Tuesday, April 12, 2011

What To Do

Briefly, I want to thank Dr. Billy Goldberg and Dr. Christopher McStay, emergency medicine physicians from NYU, for being gracious and entertaining hosts during my Sirius XM interview with them on Doctor Radio the Thursday morning of April 7th.  To their producer, Melanie, a huge kudos for your cool kindness and for seeking me out for this interview.  I am honored by this flattering experience.  You have played a part in making this small town boy's dreams approach his reality...    

It was my birthday.  Because I wasn't home with my wife and kids, eating cake and being silly and opening presents, reminding them over and over again that it was my special day, I was just a little bit sulky while ho-humming it, struggling to make it through my odd 5 pm to 3 am shift in the ER.  This, despite a birthday cake, balloons, several cards, chocolate, and many hugs and birthday wishes from my fellow coworkers, my friends.

I needed an encounter to remind me of my blessings.

As I sat at my computer in the physician station thinking this thought, I felt a sudden light tap on my shoulder.  "Excuse me, Dr. Jim," a nervous voice spoke, slightly quivered and breathy, "would you be able to see one of my patients?"  I turned to find one of our newer hires, a young energetic nurse who had just graduated from nursing school the previous year and was fresh off of her ER orientation, speaking.  I liked her.  I liked her eagerness, her good attitude and her priorities of providing excellent, all-around patient care.  I hadn't been, though, in a serious patient situation to really see her abilities and knowledge tested.

"Hi Chris," I said, "what can I do to help you?"

She spoke quickly as I stood from my chair and we began walking.  It was a woman in her late fifties, Room 22, one of Chris's patient rooms.  She had come in by ambulance and her clinical picture was making Chris nervous.  "Her blood pressure is really low and I can't seem to maintain her oxygen levels.  She looks bad."  She had been sent from her group home to an outpatient clinic appointment because "she didn't look good for a few days."  From the outpatient clinic's alarming find of this patient's condition, she had been sent to us.

"Oh," Chris added, right before we entered the room, "I have to tell you--she has severe MR (mental retardation) and she can't tell you anything.  All of her extremities are contorted, too."

As with most patients in this situation, I expected to find a three-inch information binder, usually maroon, sitting on the counter.  There was no binder.   I also expected an aide, familiar with the patient and her history, to be sitting in the corner chair or, better yet, standing at the patient's bedside.  Again, no aide.

The only people in Room 25, besides the patient, were a tech and another nurse helping Chris settle this patient.  Where was the binder?  Where was the aide?

Uh oh.  "A young woman came with her from the office, but said she had to go move her car and would be right back," Chris said, shaking her head.  "That was ten minutes ago.  She didn't leave us a binder or tell us anything."  Sadly, it would be over an hour before this aide came "right back," and our team was now in a struggle to get any information that we could on this patient.  What was her baseline condition?  We didn't know.  Had she been ill recently?  What was her past medical and surgical history?  Sorry, no information there.  Was her resuscitation status DNR (do not resuscitate) or was she a full code?  Did she have a living will?  Who was her power of attorney?

Don't know.  Don't know.  And don't know.  We were at a loss for any viable information.  At least we had a name, though.  That was a start.

I walked up to this patient's head, slightly forward-flexed at her neck off the pillow.  Her eyes were open, brown and dilated, a little reddened at the sclera, and she appeared to be trying to focus on something.  Anything.  Her skin was pale, ghostly white, dry and wrinkled.  Her hair was wispy gray, brushed straight back over her crown, a little greasy.  She was in a gown, but her pants still needed to be removed.   As Chris had warned, her upper extremities were rigidly flexed at both her  elbow and wrist joints.  Her legs were a little more pliable, resting in a flexed position but easily straightened at the knee.

I brushed some stray hairs from her forehead to her crown, resting my hand on her head. "Maam," I said, bent over and talking into her ear, "my name is Dr. Jim.  We are going to take real good care of you, okay?"  Her eyes found mine but, other than a brief blink, didn't give me any indication of her awareness.

I looked at her concerning blood pressure, 74 systolic over 40 diastolic.  Her heart rate was adequate, 88.  Her respiratory rate was quickened, 24, and her oxygen level was low at 89% on two liters of oxygen via a nasal cannula.  She appeared to be struggling for a deep breath.

"Chris," I said, "open up the fluids and give her two liters of normal saline.  Switch her cannula to a non-rebreather mask at 15 liters of oxygen."  As Chris did this, I did a brief primary exam, followed by a more intensive secondary exam, all the while paying attention to this patient's fragile vitals.

This poor soul, this patient without a history, was dry.  Very.  Her tongue was cracked and fissured.  Her skin was tenting, lacking hydrated elasticity.  Her urine from a foley insertion was scant, darkly-colored, and strongly odiferous.  Her heart was regular, thankfully.  Her lungs, though, had diminished air movement through them, with accompanying sounds of rhonchi and wheezing, suspicious for pneumonia.  Her abdomen was soft.  She didn't appear to grimace with my deep palpations.  Her rectal exam was positive for blood.  A rectal temperature recorded hypothermia at 95 degrees fahrenheit.  Her extremities had faint pulses but their skin coloring was as pale as her core.  Her body was frail and struggling.

This patient was septic, plain and simple, infection threatening to overtake her entire body.  Hypothermia.  Low blood pressure.  Low oxygenation levels.  Suspicion for dehydration.  Suspicion for pneumonia.  Suspicion for a urine infection possibly spread to the blood stream.  An unclear mental status change from an unknown baseline.  And, add to that, a suspicion for a GI bleed.

We ordered our workup.  Blood cultures and blood work.  EKG.  Chest x-ray.  Urine work and cultures.  We continued aggressive IV fluids while covering the patient with a warming "bear-hugger." We started immediate IV antibiotics, gave her breathing treatments, and put her on additional respiratory supportive measures.  With rhythmic purpose, I observed Chris and our ancillary services kick up the care.

Still, we had no information.  No binder.  No aide.  We searched for her group home's number and address.  We had called the outpatient clinic but, since she was a new patient and was so critical, they had not wasted much time delving into this patient's past before sending her to us.

We proceeded as if this patient was a full code.  We had to--it's what you do in these circumstances.  Initially, the patient did okay, responding to our fluids and respiratory interventions.  Her oxygenation picked up to 95%, and her blood pressure increased, 98/62.  But still, she looked fragile.  Pathetic, even, in her misery.  My gut instincts, usually spot-on, told me to be ready for this patient to crump at any moment.

And she did.  Her condition took a turn for the worse at the very moment we succeeded in contacting her power-of-attorney, her concerned brother.  After talking to him, we followed his wishes of doing everything in our power to improve his sister's critical state.  She was a full code.  He sounded quite reasonable and was hurrying to our hospital to be with his sister at her bedside.  Quickly, to stabilize the patient's breathing concerns, we emergently intubated her and connected her to a vent.  Despite sedating and paralyzing her, however, her arms remained quite contracted while her legs and neck relaxed.  We started medicines to elevate her dangerously low blood pressure.  We started central lines and arterial lines to continue giving IV fluids and monitoring vitals.

Then, concerning results began to roll in.  Acute kidney failure.  Severe dehydration.  Significant pneumonia on x-ray.  Low red blood cell counts, probably from a GI bleed, requiring transfusions.  Skewed electrolytes, including a high postassium.  Infected urine.  

She would need an ICU admission, which we pursued and obtained.  She would need emergent dialysis.  She would need critical care from a variety of sub-specialties in attempts to improve her condition.  She would need continued life-saving medications and interventions.  She would need a lot of good energy and a little luck to come back from being so ill.  Hopefully, we started her on the right path.

I sat back in my chair after all the action, exhaling a deep sigh while mentally reviewing this patient's ER course.  Our team had done well and I was proud of them.  I was worried, though, for this patient.  Chris came in and spoke.  "Just so you know, the aide returned."  Chris paused and took a deep breath before continuing.  "I let her know we have called the agency and they will be looking into where she had been for the past hour or so.  Now she is teary-eyed and, frankly, she should be.  Oh, and she has the binder if you need to look at it."  Again Chris paused, before finishing.  "Is that okay," she asked with sincerity, "that I called the agency?"

I looked at Chris, smiling at her.  "Chris," I said, "you did good.  It was the right thing to do."  Simple and direct.  Yeah, I thought, we got ourselves a keeper with this nurse.

I didn't meet the brother, although I heard he was a pleasure to deal with.  Loved his sister.  Had her best interests at heart. Disheartened by her turn of health.  He had been escorted to the medical ICU after his arrival, where they were waiting for him.  I couldn't help but wonder, though, what his life had been like to grow up with a severely-handicapped sister.

After things quieted down, when I was alone again at my station, I looked at the computer screen's lower right-hand corner. Yep, the date said it was still my birthday.  Just a few more hours remained.  Suddenly, though, I didn't feel so old.  Or so ho-hum.  Or so out-of-sorts from not being home celebrating with my family.

Instead, I felt appreciation.  For being healthy in my mid-forties.  For being surrounded by cool people in my life.  For knowing I had family at home waiting for me, ready to enjoy my upcoming time-off with me.  For having a sound mind.  For having flexible joints and limbs.  It wasn't lost on me that, by the luck of the draw, this patient's life could have been any one of ours.

Happy Birthday to me.

As always, big thanks for reading.  A big thanks for the numerous birthday wishes, too.  Several key facts have been changed to maintain patient confidentiality within this story, but the essence of the encounter remains true and thought-provoking.  See you in a few days...