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...

Monday, April 4, 2011

Another Birthday

Today is my birthday.  Yep, today.  On this fourth day of this fourth month of this year, I officially have turned 44.  Should I buy a lottery ticket with these numbers?  Something is whispering to me that if I ever had a realistic chance to win, it would be today.  Nah, who am I fooling--I think I'll just keep that errant dollar in my pocket.

44 is an odd age, though.  Am I middle-age?  Am I the new thirties?  Is my life half over?  Or more than half?  That thought makes me shudder.  I look at some of my patients in the ER, those in their 20's and 30's, and in my mind I am dealing with someone in my own age group.  Maybe they have less wrinkles and a fewer amount of life experiences, sure, but otherwise we are the same, aren't we?  That is until they call me "sir," a word I am growing less fond of the older I get.  And suddenly, I am reminded that no, I do not have as much in common with this college student sitting on the treatment cot in front of me as I might have thought.

Still, birthdays are pretty special when you are surrounded in your life by people who make a big deal of them.  Being one of seven kids, I've already received texts by four of my siblings and some nieces and nephews to "have a great day."  The phone calls will follow tonight, with multiple renditions (mostly bad) of the song "Happy Birthday" sung to the answering machine or myself.  When my mother was alive, she and Dad would always call and sing "Happy Birthday" in harmony from their two different receivers, Mom carrying the high notes and Dad trying to blend his deep, husky off-tune baritone to compliment her.  Since she passed on, Dad still keeps this tradition alive.  It is bittersweet, to say the least, to have Dad call and sing a solo "Happy Birthday" to me.  A big sigh typically follows, and longings for my mother's missed presence follow that.  The beauty in this, though, is that over the two years prior to Mom's lost battle to leukemia, we recorded every "Happy Birthday" sung by them to my family.

My kids and wife, though, are the real reason the excitement level in our house today is immense.  For the past week, there has been whispering between she and my kids that suddenly stops when I enter a room.  There has been hushed huddling in front of the desktop computer, a flurry of hands blocking the screen's view when I walk into the office.  There have been shopping trips to the mall, the kids returning with big grins on their faces and filled shopping bags held behind their backs.  "Don't look, Dad!"  has become the newest greeting in our house.  Tonight I will eat my favorite cake, chocolate from scratch (which includes a cup of coffee) topped with mounds of creamy peanut frosting, made lovingly by my wife from Mom's recipe.

So today, then, is the day.  My 44th birthday.  I was woken up with hugs, warm and heartfelt and accompanied by morning breath.  And chimes of "Happy Birthday, Dad!"  There is no better sweetness in this world than hearing these fluent, tender words from your children's innocent mouths.  Birthday wishes from my wife, too.  A flurry of activity followed as they got ready for school.  A grab of my hand by my youngest, who lead me to the dining room table to proudly show me the presents that await my opening.  Their homemade cards and homemade gift wrap make my smile double.

Then, too suddenly, the buses came to take my kids to school.  My wife left in the SUV to work her school-related job.  And, just like that, all of the excitement contained within our four walls just minutes earlier dissipated, a big balloon of happiness and anticipation popped... to be filled up again upon their return.  I go to sit alone in my office.

I have the morning and afternoon off, but work an odd evening into morning shift tonight.  So I sit here in my silent home, giving up the hope that cranked techno music from Robyn on YouTube will bring back all of that excitement.  It didn't.  Instead, a life lesson smacks me in the ass.  Hard.

My birthday and this swirling excitement that comes with it is not just because of the day.  Or the cake.  Or the presents.  It is because, simply, on this day, I am reminded of just how blessed I am to be surrounded by so many people in my life who love and care for me.  The simple texts, the emails, the phone calls, the snail mail birthday cards--all warm hands coming from near and far to wrap themselves around me on this day.  There are no better birthday gifts...

Sitting here, introspective and reflective of my life so far, I find that I am beyond grateful.  Grateful for it all.  The family.  The siblings and parents.  The nieces and nephews.  The cousins.  The friends.  I am a lucky guy.

After all of this, I looked at a brown envelope sitting on my desk, sent to me by one of my best friends through medical school--KT.  To know KT in this life, to have her friendship, is one of those precious gifts I sometimes take for granted.  She is, after my wife and Mom and sisters, one of the most remarkable women that I will ever know.  Her kindred spirit and friendship is unmatched.  And besides, how many other family physicians do you know still make social calls to their patients' homes?

What follows is a cursive note she sent (along with a beautiful book and two birthday cards).

Dear Jim,

     My friend, my brother...how does it feel to you to be celebrating a life so full?  I am acutely aware of the significance this year of similar double digits!
     At 11, I was hiding in the woods with my friends, telling secrets, crushing on Bobby Joe across the street (be still my heart!)  I was a child in a giant's body!
     At 22, I owned the world...I was a college graduate and I was going to medical school!  I was sizzling!  Life was mine to take!
     At 33, I was a mother, in love with my girl, struggling to mesh my original dreams of being a doctor with my dream, unexpectantly better, of motherhood.  I couldn't get enough of my daughter if I ate her!  She was and still is a force in my world!  What a ride I got, eh?
     At 44, I know contentment, really and truly.  But I also know worry...  My life and love has blossomed as my family came to be--a daughter, a son, a dog, and oh yeah, a husband.  I know I am not invisible--my achy hips let me know that every day!  But I am more alive now than ever before.  I have loved, lost, given and gained...
     What will the next half bring?  55?  66?  77? 88? And, oh yeah, I plan on doing 99.  You too?
     So, my brother in this walk...I wonder what you would say about 11, 22, 33, 44?  I think I can guess a few of the emotions.  We have been blessed in love and in friendship, haven't we?

Big hug, Jim!  Have an awesome birthday!  KT

How's that for a birthday gift?

May everyone have a birthday like mine today, where they are reminded of the beauty of the people in their lives.

Now, where are my presents???

As always, big thanks for reading.  May KT see the beauty and specialness in her writing voice here today.  To my family and friends, especially my wife and kids, thanks for making this a special day...I am smiling here.