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 sometime...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... 

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 home...in 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...          

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...