Monday, January 31, 2011

Sick-kid Season

I love kids. Always have and always will. And when it comes to sick kids, I feel fortunate to have been trained in a demanding EM residency program where the pediatric emergency department was directly attached to the main trauma center. As a result of such exposure, treating ill kids became as natural to me as treating ill adults. Those little buggers, with their fevers, snotty noses, abdominal pain, and piercing shrills, don't scare me. Some get an "A" for effort, though, pulling out all of the stops in their vain attempt to get me out of their room. Regardless, because of my comfort, I try to see the really sick kids that come through our doors during my shift.

Over the holidays, with the flu season in full swing, I treated many children who were swept up in the epidemic. Some parents simply needed reassurances that they were giving their little Johnnie and Susie all the proper care, while other parents, with their heavy concerns, were right to bring their children in for a workup, including some IV hydration and anti-emetic medication. All-in-all, there was a much heavier flow of pediatrics than what we typically see.

Walking into Room 22, then, thanks to an alert by the nurse, I knew I was about to face another sick child. "This one is 'punky', Doc," she had said, "he hardly flinched when I started his IV." Never a good sign.

I quietly pulled back the curtain to the room and entered, finding a fatigued two-year-old boy sprawled on his back on the medical cot with his cotton sheet kicked into a ball at his feet. His oversized hospital gown had one loose tie in front, opened to reveal his skinny frame. His blond bangs were sweaty, matted to his forehead, and his skin was pale. Before introducing myself to his parents, I walked up to him and felt his forehead with the back of my hand. He was "burning up," as we say and, more importantly, didn't even shrug to a stranger's touch.

I shifted my focus to his parents, walking up to the young mother sitting in a chair alongside her son's cot. She looked as wiped-out as her son, the livelihood of her existence threatened by her son's illness. She was tearful, a mother's angst clearly etched into her face. I took her right hand in the both of mine, squeezing it reassuringly. "We'll get him feeling, better," I said, nodding to her sleeping son as I spoke. She dabbed her eyes with a Kleenex and gave me a feeble smile.

Next, I walked up to the father, his disheveled baseball cap barely clinging to his head as he paced three steps back and forth in a tight corner of the room. We shook hands and I held his gaze for a few extra seconds, trying to silently reassure his concerns. He, like the mother, was young, worried, and quite upset over his son's circumstances. He looked me in the eyes and took a deep breath. "Can you really make him better, Doctor?" he asked, a glimmer of hope escaping his watchful eyes.

"Let me talk to you both, do a thorough exam of your son, and order some tests and treatment for him, okay? But yes, I do think we'll get your son to feel better by the time we are done treating him." Their son looked like several other patients we had recently treated for influenza.

Between the two of them, I learned that they were first-time parents and married. Although neither of them were ill, their son went to daycare two days a week, where they thought "a bug" was going around. He had been born full-term and was up-to-date on his immunizations. This was his first major illness, barring a few past ear infections. Over the past few days, they watched their son eat and drink less, urinate less, become less active, and start a fever that they couldn't control. Eventually, all of their son's symptoms worsened and became boggled in their minds, totally confusing them (like any first-time parents) as to what symptoms were most serious and needed addressed immediately.

That's where we came in.

After a thorough exam on this patient, I had no suspicions for focal illnesses (such as pneumonia, bronchitis, or strep throat) on this patient. His temperature was quite high (103.7) and he appeared clinically dehydrated, so we treated him with a Tylenol suppository, aggressive IV hydration, and some IV Zofran, a God-sent anti-emetic that helps control nausea and vomiting. Then we sat back and waited--one, to see how the child would respond to our interventions and two, to review the results of our blood and urine tests as they returned.

Within the hour, I was walking into my work station with another patient chart only to find Dad standing at the counter, waiting to talk to me. He was smiling.

"He's doing better already?" I asked. "Come take a look," Dad said, practically grabbing my hand and pulling me towards his son's room.

We got back to his son's room and, before opening the curtain, the father stepped aside, sweeping his arms as if welcoming me to step into his home.

Pushing aside the curtain, I was extremely happy to find their son sitting upright in bed, licking an Italian ice while watching a cartoon on the TV. He looked at me with apprehension, turned to his mother who gave him a reassuring wink, before turning his attention back toward the TV, continuing to lick his popsicle. He was a new kid.

The mother jumped from her chair, then, and rushed me, giving me a big, grateful hug. "I can't believe how good he looks," she said, muffling her words into my shoulder. "Yes," I said, happily agreeing with her, "he looks great!" She left my side and went back to her cot-side chair, sitting clumsily down before wrapping her hands back around her son's torso. Her face held the most genuine expression of thankfulness and love that could ever be.

Within the next hour, as the patient's labs returned with adequate results, the nurse and I took turns going into the room to educate the parents and answer their questions.

How frequently are they supposed to use Tylenol and ibuprofen?
What doses of Tylenol and ibuprofen are they supposed to use?
How should they use the Zofran prescription we'd be sending them home with?
What type of fluids should they give their son?
What foods would be okay to reintroduce back into his diet?
How much sleep should they let their son get?

It's easy to see how confusing it can get the first time your child has a serious illness. Their questions for us were endless and repeated several times, but we, in the medical field, all know that education and knowledge is most empowering to recover from an illness. Our patience in the parent's education is paramount. Besides making sure each of their questions were answered, we also wrote down their instructions for them to take home.

By the time we were ready to discharge this patient, he was a new kid, running around his room, drinking watered-down juice, coloring the staff pictures, and covering himself in the stickers we gave him.

To us, another successful but predicted response to our interventions with a child with the flu. To the parents, though, this was nothing short of a miracle. The clouds had parted, the rays of sunshine had dispersed before refocusing on the head of their sick child, and the gods had sung. Anyone who has had a sick child recover knows these feelings of exhilaration that follow the many pangs of doubts that haunt us during our child's illness.

I've been there...have you?

The nurse and I stood together at the counter and watched this young family walk out of our ER after being discharged. Three big smiles, plus two more if you count ours.

It was another good day in the ER...

As always, big thanks for reading. I appreciate the nominations and support for the 2010 Medgadget awards for best medical weblogs...thank you, thank you. I hope this finds you well...

Monday, January 17, 2011

My Buddy, For Always

A few months back, I had been cleaning out my overflowing desk folders when I happened upon one filled with lots of letters and pictures and cards from my kids. Some older, some more recent. All of them precious.

Of course, despite the folder's bulge and disarray, not a single thing would be discarded. I wouldn't even think of it. And in a Clark Griswold moment (when he was sitting alone in his house attic watching old family videos) , I leaned back in my office chair and began to rummage through the collection, slowly being taken back to moment after memorable moment of my children's childhoods thus far. Deep sighs, silent smiles, and bittersweet emotions rushed me.

Yes, time certainly does fly by. Darn it all. If only a rewind button or a pause button had been invented to control the pacing of our lives, I'm certain that we would all be pushing it frequently. Shamelessly. Without abandon. Heck, I could almost guarantee my finger would be calloused from my efforts.

While reviewing the collection that sat in front of me, though, I was reminded time and again of one giant thought--that I am a lucky guy. A very, very lucky guy. Two beautiful daughters and one resilient son. Kind and compassionate, all of them. Various notes printed in crayon and colored pictures documenting the world from their view were soon scattered all over my desk, my lap, and taped to my office walls.

What follows is one of the pieces, currently hanging on my office book shelf, that I am allowed to share with you, courtesy of my son, written several years ago as a homework assignment in third grade for Mrs. F. My heartfelt thanks from me to her. And to heck with grammar and punctuation and new paragraphs. The beautiful childlike cursive and use of "my dad" ten times is all I really needed.

My Inspiration

My Inspiration is my dad because he teaches me things I need to know. He also helps me when I need him or if I get hurt my dad is there to help. My dad is a great cook and my favorite thing he makes are egg whites. My dad helps me in my baseball skills and helps me in other sport. My dad has helped me so much in my fort in the woods. My dad drives me places I need to go like baseball practice and baseball games. At night my dad would come in my room and say goodnight. Then we would play this game. My dad works so hard so we can do things we want to do like go on vacation. My dad helps me clean up the yard when my mom says to clean the yard by myself. When I grow up I want to be just like my dad.

Cole in 3-F

As soon as I had read this piece, I stood from my office chair and hurried myself into our foyer, to the northern wall, where my favorite picture of my buddy and I was hanging in an antique frame among the numerous other framed pictures. I stood on my tiptoes, barely reaching its lower border, until I successfully lifted it from its hanging nail.

I returned to my office and sat back down, focusing on the picture. Immediately, I was taken back ten years to the beautiful North Carolina coastline. To our family vacation. To a healthy Cole. To the summer before Cole would spend a full year on his induction chemotherapy to beat his illness.

I posted the picture above. In case you don't know, I am the one on the right, with the wedgie.

I still look at this picture often, always amazed to think that it was taken at a time when our life was pollyanna, when bad things happened to other people--not to us. I look at my son's little hand, raised up into my own, and feel the surge of the bond from our contact. I carry a sand pail in my right hand, ready to tackle another project together, my buddy and I. Together. Regardless if it entails building a sand castle or fighting a life-threatening illness. I am there for my kids, always.

Finally, look at the view that faced us as we walked forward. The big, big ocean, although only a small part of our bigger, bigger world. The enormity of symbolism in this picture staggers me. Come hold my hand, Cole, I must have thought, I'll take care of you. And together, we head on into the waves, into the roughening path that life sometimes leads us on.

Blindly and unknowing, we walked, but with a strength and a conviction that any obstacle will be faced to the best of our ability.

And although it took a couple hard-fought battles, we won Cole's war. He won his war.

I don't think I need to tell you who my inspiration is...

As always, big thanks for reading. I do cook more than egg whites, I promise. And my wife does help pick up the yard, sometimes (she asked me to let you know--lol). I hope this finds you well and that you are both inspiring and inspired in your own life...

Monday, January 10, 2011

Take A Picture

Like anyone else who works in the ER, I wish I could take pictures and videotape some of our more absurd, inebriated patients. Of course, though, I can't--patient confidentiality and all that blah-blah stuff. But how great would it be to sit a patient down, after they sobered up, and show them how ridiculous their behavior was while in our care? Maybe, even, send a copy to their proud parents or spouse.

Personally, if I ever had twelve beers and ten shots of tequila before proceeding to crap and vomit all over myself, I would like a picture or two to convince me it really happened.

It was 2 am and I was standing at the counter of our nursing station nearest the ambulance bay doors, finishing a chart while dreaming about going home within the next hour, when the doors suddenly swung open and a prehospital team proceeded to wheel a disheveled patient into our ER hallway. Usually, the team contacts us by radio to alert us of their pending arrival with a patient, so their unannounced visit was a surprise to all of us.

The chief paramedic shrugged. "Sorry," he said, "but we picked her up at a bar just a few blocks away and didn't have time to call."

On their cot, obviously intoxicated, sat a peroxide-blond female, in her mid-twenties, with her head slumped to her right side and her breasts barely contained by her skimpy halter. Her hair was messed, the hairspray she spritzed earlier in the evening unintentionally spiking clumps in all directions. Her face was streaked with tears, darkened trails of waterproof-less mascara collecting at her chin. Drool gathered at her mouth's angles.

So, so pretty.

Of course, I was intrigued. "She was at the bar," the paramedic continued, "drinking for the past three hours, when her friends got concerned because she wasn't 'acting right.' Remembering she had diabetes, they called us to come 'check her out.' When we got there, she was passed out on a bench in front of the tavern, a puddle of vomit at her feet. Her finger stick was 87, so we decided to bring her in. She doesn't have any signs of trauma, doc."

Well, thank you fellas.

As the paramedic was speaking, as if on cue, the patient cocked her one eye open and, realizing she had an audience, started wailing and shrieking, her cry alternating between forced hiccups and gasping sobs. The hallway filled with various heads poking out of the treatment rooms, wondering how a hyena ended up in our ER.

"Room 23," the charge nurse said. The paramedics hurried off with their patient.

A few minutes later, walking back to my computer station, I passed Room 23, slowing down to check-out what was going on with our new patient (yes, I was nibshitting). I'm glad I did, though, if for no other reason than to find the paramedic holding this patient in both arms, a hero carrying his damsel-in-distress, while transferring her dead-weight from his cot to ours. I stopped and waved to him, laughing, and he shook his head in disgust. "Sometimes I hate my job," he muttered with a smile.

I stopped in and did a brief primary exam, listening to the patient's heart and lungs, confirming her stable vitals, and making sure she had no evidence of trauma. She didn't. All the while, she kept asking for the bouncer from the bar. Over and over and over. "Maam," I finally said, "nobody came with you. I'm sure the bouncer had to stay to finish out his shift."

"Ahh," she slurred, "screw him. He has a small penis, anyway." As she spoke, she pinched her thumb and index finger an inch apart from one another, giggling to herself while amusing us. "How do you know that?" her nurse, Barb, asked. "Well, duh," the patient replied, "I can hardly feel him when we have sex." I almost threw up in my mouth from her sharing so much (or so little) information.

So, so classy.

As the nurse removed this patient's clothing to put her in a gown, we discovered that the patient had on three layers of compression garments around her middle--a spanx, a girdle, followed by another spanx. For those of you not familiar with spanx (and I wasn't, so the nursing staff kindly informed me), it is a stretchy, spandex-type piece that, after you hold your breath and squeeze yourself into it, acts like a casing to your sausage body. Miraculously, you look thinner and more fit. Without going to the gym or watching your diet. Your difficulty breathing, profuse sweating, and pinched-up, cyanotic face, though, might just be dead-giveaways that you are wearing one.

"Why in God's name," Barb continued, not learning her lesson about asking questions from before, "are you wearing three of these? I've never seen anything like this."

"Well, duh," the patient answered again, "maybe so I can get laid by a guy who likes skinny girls." I get it--three layers tripled her chances.

I'm assuming that she was assuming that she looked more attractive all squished into her itty-bitty jeans and shirt with the help of her garments, but really? Did she think this situation through? What guy, one who was probably out drinking at the same bar as her, would be able to remove three of these things? Would the effort be worth it? Would his spanx-removal talent have a big payoff? Sober, I doubt any guy would be able to succeed in getting this patient out of her spanx, but throw some drinks into the equation and what do you have? Besides the fumbling, frustrated fingers of her date? Failure, through and through.

All the while, the patient continued talking in a slurring half-whisper, occasionally bursting out in giggles from her self-amusement. Several times, she belched so obnoxiously that it would have made any beer-guzzling, football-watching male proud. And one time, she dug her finger so high up her nose for a booger that I think her elbow was resting on her chin. Needless to say, I was fascinated by her influenced behavior and lack of awareness.

Finally, though, my biggest shock of the evening came from what the nurse shared with me. It seems that as the tech and nurse finished undressing the patient for observation, they were unpleasantly surprised to find this patient and all her southern female parts barely covered by her thong underwear.

Her American flag thong underwear!!! Three square inches of red, white, and blue fabric.

I was never less proud to be an American.

For various reasons, I found this news appalling. And so did the nurse and tech. Never before, in my vast experiences, did I see some skimpy underwear fashioned in this manner. When did a manufacturer start finding it appropriate to place the American flag, our sacred national symbol, on a little triangular patch that covers a woman's privates. Or worse (I'm shuddering here), a man's? I mean, let's reason this out. If our flag touches the ground, out of respect, isn't the protocol to attempt to lift it up from the ground (if possible) and, if not, burn it. Yet, it's perfectly okay for someone to wear our prideful flag pressed against their privates? Something about this thought just didn't sit right with me.

Let's be proactive. I say we gather all the existing American flag thongs out there and have ourselves a big--no, make that huge-- bonfire. Quite honestly, though, that's one bonfire I would probably dread attending.

I did get to eventually leave at my scheduled time, 3 am, after signing out my active patients to the overnight doctor. The patient, who had no sober friends or family available to come take her home, did fine throughout the night's observations, barring the occasional outbursts of swearing, drunk mumbling, and promiscuous suggestions. When she sobered up, however, according to the morning team, she turned out to be a very nice, pleasant young woman who just happened to "have a rough night."

"She could have been your sister or mine," the nurse added.

"Umm, no," I thought to myself, "I don't think so." I wasn't about to picture any of my sisters in an American flag thong, let alone being ridiculously drunk while holding their thumb and index finger an inch apart.

My final thought...maybe I don't need to take a picture or videotape this stuff, after all. Really, the mental image is reminder enough for me. Who needs a timeless picture to document such dread? Or the nightmares that would follow? If anything, I guess you can just take a picture of me, the treating physician. I'll give you permission. Just excuse my gaping mouth, my surprising eyes, and my befuddled expression when you get it printed...

As always, big thanks for reading. If you own a pair of American flag thong underwear, do me a big favor and throw them out. STAT! See you soon...

Monday, January 3, 2011

The Beaten Path

It has been almost five years since my mother lost her brave war against leukemia. Within this time frame, sadly, some of Mom's familiar traditions have become more of a fond memory rather than a continued reality. For example, although we can all cook a Christmas ham, it was Mom who criss-crossed those seasoning cloves just right on the hind, drowning them again and again with her secret glaze until the browning and flavoring were perfect. And it was Mom who decorated our home and Christmas tree into a welcoming, warm winter wonderland, season after season. Sure, my wife and sisters could probably duplicate her feats, given enough time, but it's just not the same without that extra ooomph of Mom's energy swirling among all the festive activities. Of her love swirling among her family.

The realization (or maybe, rather, fear) that someday my kids wouldn't remember Gramma, with her specialness and unique ways, was so strong, so biting, immediately after her death that I, along with my siblings, worked hard on trying to keep things just the way they were before she died. We tried to arrange the food in the fridge like she did. We continued keeping a pen and paper on the counter in the kitchen, right where she did. We folded towels just right, "like Mom taught us." We changed bedsheets from the cotton variety to flannel and then back during the revolving seasons of each year. We spritzed her perfume in the bedroom, desperately trying to keep her scent fresh. Writing cards, cooking a favorite meal, shopping in excess (with seven kids, if something was on sale, you bought ten of it), calling one another on Sundays...

Not only us kids, but Dad, too, seemed to expend a momentous amount of energy into recreating a surrounding environment much as Mom would maintain. As if somehow, despite Mom's permanent absence, submerging ourselves into a specific physicality of life would sustain our memories and souls.


Slowly, we each learned (at different paces and different depths) that it was okay to create new memories. New traditions. That it was not a betrayal of Mom or her memory to not bake a ham on Christmas or to not fold the towels in tri-fold but rather bi-fold. Memories injected with her presence, I learned, would always make me smile, no matter how things may now be done.

As a result, new traditions have begun to emerge within my family, poking their hesitant faces through the stomped, packed-down soil (laid by moi) and into our sunlight. They are now welcomed whole-heartedly. Fresh Polish sausage and perogies have become our Christmas dinner staple.

Dad, like a few of my siblings, will still occasionally struggle over the exactness of maintaining Mom's traditions. However, he too has gradually learned to let go of some of the uniqueness of these traditions and, instead,"go with the flow." His smiles and good-naturedness seem to walk hand-in-hand with releasing some of that burden. As they say, a remake is rarely as good as the original.

Just like the rest of us, Dad has also created some of his own rituals and traditions. And recently, while visiting him over the holidays, I was reminded of one of his rituals that I hope he never abandons.

It was during the drive home to visit my father that I explained to my wife that I was struggling to find material to write through the holidays that did not carry too much "heaviness" to it. It seemed all I was observing in the ER were patients and families with too many problems, too much heartache, and too high a level of expectation that we could fix all of their problems. On Christmas day alone, I continued, I had seen several elderly adults, without any complaints, "dumped" off in our ER by family who then immediately left to resume their holiday celebrations. "You'll have to keep Mom a few days," said one son, "so don't call me to come pick her up." After seeing an older gentleman for "trouble walking for ten years," abandoned by his family in our waiting room, I was losing a little faith.

Where was the love?

As we approached my childhood hometown, much like we always do, we turned off the main highway onto a small country road, a road that leads to the cemetery where my mother is buried. Single-lane and winding, my kids love how I beep before each sharp curve to alert an opposing vehicle or pedestrian that we are "coming around the mountain." It is a five-mile country journey that we have grown to love, anticipating the moment when we can pull off the bumpy dirt road and into the cemetery, where Mom is always waiting for our visit, right beside Christ on his crucifix. A visit back always starts this way.

Cautiously, because of freshly falling snow, our vehicle ascended the cemetery's small entrance knoll, turning left and then right and then left again, until we parked alongside the field where Mom is buried. As the kids always do, they hurried from our SUV and ran to Mom's grave stone, appreciating the fresh evergreen wreath, the new plaque, the winter flowers, and the leftover sea shells brought by Gracie the previous summer.

As my wife and I took our time getting out of the vehicle, my wife pointed down to the snow-covered ground and exclaimed, "Jim, do you see what I see?" I looked to where her finger was pointing, to the aisle leading to my mother's grave, but remained oblivious to her point.

"Look at all the other grave sites and aisles leading to them," she continued, "and tell me what you see."

I looked around at the cemetery, paying extra attention to the aisles. They were covered in freshly-fallen snow, hardly disturbed, except for the occasional lone foot prints leading to a stone and back. I looked back at the aisle leading to my mother's grave site. And then I got it--my wife's amazingly simple point.

"Do you see the footprints?" she asked, as I looked down to appreciate the well-worn path made by my father's size 15 winter boots, a path that lead right to my mother. His multiple trips back and forth were evident.

And suddenly, at this very moment during this very holiday season, I had found the love. A diamond of wonder among the sparse holiday rubble of disappointments.

My father will soon be turning 81 and, yet, twice a day, every day for the last five years, he has visited my mother. Through thick and thin. Through sunshine and snowstorms. Through the emerging dawn and the pending dusk. Rearranging fresh flowers, lovingly trimming weeds, and cursingly wiping bird poop for her stone's top. Crossing himself time and again while whispering his prayers. Sometimes, I imagine, wiping a tear from his eye. Sometimes, I'm sure, smiling his big smile while immersed in a warm memory.

And down at my feet, where I stood, was the proof of his five-year tradition--his beaten path leading to and from Mom's grave.

I smiled big, hugging my wife for pointing out this almost-missed moment. How could I have not seen this beaten, well-worn path? I grabbed my cell phone and immediately took several pictures, one included above, although none captured the minute details of each of my father's boot prints. It didn't matter, though. The moment had imprinted itself into my mind, forever.

And suddenly, as I looked toward my wife, who had joined my kids at Mom's grave site, I spun myself around, taking in the magnificent surrounding mountains while breathing in the clean country air. This world of ours made sense--the clarity of things changing, of the constant coming and going of new and old traditions that would continue to feed our wanting souls.

I wonder what traditions my children will continue when they become adults. Me? I know one tradition I hope to someday emulate or be the recipient of...

The beaten path.

To Karen, thanks for pointing out the obvious to me. As always, a big thanks to you for reading...I hope you each had a great holiday season and are enjoying the new year.