Defining Emergency

I originally wrote this piece in December, 2010. Recently, I learned that it has been "reborn" in the social media world with over 120k shares from just one resource (thank you, KevinMD). Please feel free to share your thoughts and experiences...

Emergency, as per the all-knowing Webster, is defined as an unforeseen combination of circumstances or the resulting state that calls for immediate action. Furthermore, an emergency is also defined as an urgent need for assistance or relief.

These definitions sound pretty spot-on, right? When thinking about emergency room settings, even, one can easily correlate the words of Webster to what one would necessitate to be a situation requiring emergency medical treatment. A trauma. Broken bones. A heart attack. A stroke. A seizure. Respiratory distress. A cardiac arrest. The list goes on and on and on. When a critical illness or injury occurs, then, we should all be thankful that we live within a society where emergent, life-saving medical care is available.

Lately, though, it seems the system meant to provide this care is being bogged down by questionable decision-making. Instead of providing emergent care, it seems I spend at least half of my emergency room time now playing doctor to chronic illnesses. To pain control issues. To mildly elevated blood pressure readings. To months of nonspecific weaknesses and fatigue. To office appointments sent to the ER because "we are overbooked today." And our ER is not alone. I hear the frustration of my colleagues and see first-hand how overworked most of us who provide health care in the ER setting have become.

A month back, I was in the middle of a very busy shift. Several patients with chest pain (one requiring immediate catheterization), two patients with respiratory distress (one from skipping dialysis and one from a COPD exacerbation), and three patients from a motor vehicle collision presented almost simultaneously to our ER. Within minutes, all of these critical patients had been treated with efficient, appropriate life-saving care. The team on deserved kudos for doing their job well and making a difference in these patients' outcomes.

Walking back to the nursing station, then, I was surprised to find our secretary being berated by a gentleman in his thirties at the counter. His voice was loud and menacing. His face was pinched with anger. His fists were clenched by his side.

"Whoa," I said, walking up to him, standing between him and the secretary, "what seems to be the problem, sir?"

"We've been waiting two hours to be seen by a doctor!" he exclaimed. "What the hell is going on around here?"

Are you kidding? All he had to do was look for himself to find the organized commotion that was occurring in our ER setting. What followed was the briefest of conversations.

"Sir," I asked, "what brought you to our ER today?"
"My daughter's left ear is hurting her."
"For how long?" I asked.
"Two hours," he replied.

Two hours of ear pain? I get it--maybe he was worried about his daughter. I would be as well. But my daughter would also have gotten Tylenol and Advil and watched her daddy patiently wait for their turn to be treated once the dire situation had been explained. Better yet, we would have probably waited until the morning when a call could be placed to her personal physician.

I explained to him that we had multiple critical patients brought to us and we would be with his daughter as soon as possible. "We're all trying our best, sir," I added, "but you're going to need to be a little more patient."

The father stared me in the eye. I stared back. Finally, he blurted out what he had been thinking to say. "Well, then," he spoke, sarcasm dripping from his pathetic words, "try harder." It didn't end there, though. He continued. "This is bullshit waiting two hours to be seen."

Before I could respond, he turned his back and huffed himself back into Room 27 where, the nurse shared with me, his eleven year-old daughter comfortably sat watching TV. "And," the nurse added, "I had already explained to him why they were waiting to be seen."

After this, one of our regulars who had been to our ER over 200 times (since we started tracking in March of 2006) arrived via ambulance. Then a gentleman carrying a big bottle of Mountain Dew was escorted from his ambulance, by foot, into our ER because his main complaint was "I just want to take a nap and was too far from my apartment." Next, an asymptomatic patient with elevated blood pressure for three years, non-compliant with her medications for financial reasons (yes--I noticed the pack of cigarettes hanging from her purse), was sent to us from her family doctor to be cured on the spot. "Go right to the ER," she was told.

Can you appreciate the obviousness of the long waiting times in the emergency department? Although we all pride ourselves on providing expedient care, a four to six hour wait is sometimes the reality for some of our noncritical patients.

As if to hammer the point home, my last patient during my shift that night (I was working 5pm to 3am) was a sixteen year old female who had presented to our ER, via ambulance at 2am, with her mother.

I walked into her room to find this patient and her mother both lying in the cot, laughing while watching TV, the patient in no obvious distress. I introduced myself to them before I started asking questions. "What can I do to help you tonight? What brought you to our emergency room?"

The girl looked at her mother and started giggling, my first sign that she would survive whatever her ailment may be.

"Well," she said shyly, "I've had some burning when I pee for about a week. And," she added, not done "I have something gross leaking from down there (she swept her hand towards her pelvis as she spoke)." Upon further questioning, I learned that she had been diagnosed with a yeast infection from her family doctor one month ago but failed to get her prescription filled. I also learned that she was sexually active with not one, but two partners. Unprotected.

I was disheartened. "What made you come to the ER at 2am when these symptoms have been going on for over a week?" I asked, hoping there was some rhyme or reason to her seeking out emergent care at this time. There wasn't. Her answer to my question--"Why not?" I didn't even approach her on why she came in by ambulance. Some things are better not known, I guess, especially at 2am.

I'm not sure this is the system that was imagined when emergency departments started gaining favor in our society. Don't get me wrong, though. I, like all of my colleagues, are 100% committed to providing respectful and appropriate care to anyone who shows up in our department, whether it be a critical, life-threatening illness or a chronic "nuisance," so to speak.

I can only hope that people will be patient and understanding as we all cope with the evolving changes that seem to be occurring with our health care system. And my hat is off to all the medical folks who work hard, day after day, treating our fellow mankind as best we can within this currently accepted system. Because, even as bogged down as we can sometimes become, what an awesome privilege we have in meeting and greeting and treating our fellow kind. Of helping them out in their time of need.

As always, big thanks for reading. Please feel free to share any ideas or opinions you may have had in dealing with your local emergency department...my best, Jim.

Helium-Filled Dreams

Despite the furious pace of the emergency department, he sat within his private bubble of calm on a hallway cot situated just outside the entrance of Room 31. He sat upright, facing the opposite direction from which I approached, with the thinning brown hair of his broad occiput splayed across the upper edge of his pillow. From this approach, I paused for several seconds to appreciate this serene, surreal view of a patient who appeared unaffected despite the scurrying of several staff and ambulance teams around him.

I had signed onto his chart hoping he would be a quick in-and-out patient among the endless sea of critically-ill patients that arrived at our doors that evening. He was 24 years old and his complaint seemed minor--diarrhea and nausea with vomiting for less than twelve hours. His care wouldn't take that long, I figured.

I approached his right side from behind, lightly touching his right shoulder as I came to a stop beside him. He remained facing forward despite my touch.

 I leaned into his ear. "Hi, Michael. My name is Dr. Jim and I will be taking care of you this evening."

Slowly, Michael turned his face toward me. "Hello, Dr. Jim," he answered, his voice mumbled and slurred as if his tongue were thickened and glued to his inner cheek. I strained to interpret his simple response.

Our eyes connected, his widely-set in the perimeters of his orbits. Through his smudged and thickened outdated spectacles, I was able to look at magnified brown eyes, lightly speckled along the edges of their irises with black flecks. His eyes danced with glimmers of fluorescent reflections, conveying a false sense of happiness. His smile emerged in response to my smile. His eyes bore into my face, searching for a judgment that never came.

Michael had Down's Syndrome.

I continued to look at Michael. I smiled at him. He continued to smile at me. I soaked in his enlarged eyes, innocent and searching. I noticed his broad forehead, his thinning hair, his scant eyebrows that horizontally framed his upper eyelids. I noticed his cheeks and jawline, sprinkled with brown sparse whiskers. I noticed his poor dentition, a chipped upper front tooth demanding my immediate attention. I noticed his thick neck sprouting from his dingy white t-shirt. A thin, white hospital blanket bunched and wrinkled at his girthy midsection. Old, worn-out basketball sneakers escaped the lower portion of the blanket.

"Michael," I said, returning my eyes to find his gaze still in the process of measuring me up, "it is my pleasure to meet you. What can I help you with tonight?"

Michael took a deep breath before exhaling his story. He wasn't feeling well. More specifically, he was feeling tired and rundown. He felt that he was developing some diarrhea but, when I pressed for more specifics, he simply said he had "gone the bathroom three times today" instead of his typical one time. "I mean poop, Dr. Jim," he clarified. He also stated that while eating his dinner, he felt like he "was going to puke." He denied any further complaints as I patiently went through a list of symptoms. His actual feelings of nausea had since resolved after his arrival to our emergency department.

But this is where his story got good.

"Michael," I said, "what specifically did you eat that made you feel like you were going to throw up?" I was trying to confirm that Michael just had an adverse effect to something that didn't agree with him rather than developing a food poisoning or a case of gastroenteritis. Unlikely, given his symptoms were improved, but I wanted to be thorough nonetheless.

Michael went on to explain that he was just placed in a City Mission for the first time earlier in the day. He was sure that it was the food that made him "get sick." It was simple food, he explained, "some mashed potatoes and gravy and a roll with butter and some green beans." He paused a few seconds before adding, "And it definitely tasted better than the food in jail."

My mind began racing to ask all of the questions that were now bustling inside my head. I went with the most obvious question first. "Michael, how do you know what food in jail tastes like?"

"I just spent forty days in jail for violating my parole. So I ate a lot of meals there."

"Parole for..."

"Breaking and entering," he answered, completing my sentence. I did another glance over of this person sitting in front of me.

"Michael, you didn't hurt anyone, did you?" He assured me he didn't. He said that he had entered a distant relative's apartment without permission to stay overnight on the couch. His relative hadn't taken kindly to this action, from what I could gather. Following this, he was caught stealing from a grocery store.

"Michael," I continued, "why are you staying at a City Mission? Are you homeless?"

"Yes," he answered. I asked him about his family. "All I have is my mom, and she can't take me in because she is on a fixed income."

It was at this moment, I remember quite vividly, that I excused myself for a minute from Michael. I explained to him that I wanted to find a room to perform his exam in and also go check to see if the blood work ordered on him in triage had returned. Actually, though,  I had removed myself from Michael's interview because I had visited almost every spectrum of my emotions, from pity and sorrow to fear and shame, during our session.

After asking a nurse if she could move Michael into any available room so I could continue with my exam, I sat down at my work station and took a deep breath. I contemplated why Michael and his history had moved me in such a way. After all, I felt quite lucky to meet so many different people from so many different walks of life. Over my numerous years as an ER doctor, I have met people that I never would have had the fortune, or misfortune (as some would say), to otherwise meet. Michael continued this path.

Michael, in his simple ways, stirred a variety of my emotions that I was having trouble reconciling. He was viewed a criminal by our legal system. I'm not naive to think that there was probably more to his story about being imprisoned. And yet, he was without a supportive family. He was homeless. He had Down's Syndrome. He was probably without hope. Ugh.

My thoughts immediately went to my sister, Susie, who has had a long and fulfilling career as a Special Education Teacher. It was she who got me to volunteer for my first Special Olympics as a teenager. That experience, not unlike this one with Michael, had left me with many strong emotions even then. Hope probably being the strongest of them. Hope that the world treated the participants in those Special Olympics with respect and kindness and compassion and love. I thought about how Susie probably affected more lives with her hopes and dreams than what she would even give herself credit for.

As Michael's doctor, as my sister a teacher to many of her students, as parents to any child--aren't we all humans connected by the threads of hope on the blankets of one another's life journey? Don't we hope that with time and patience, with supportive attention and an abundance of love, and then with more love, each person we encounter in our lives will propel forward just from the experience of knowing us?

Was Michael propelled forward in his life because he knew these things? Did Michael's mother ever hope for him to become a criminal? Homeless? A lost soul in the fabric of our society? I hope not. Did she hope for help in raising Michael to become the best that he could become with his abilities? Did she lose hope for Michael somewhere along his journey? Does she sit at home hoping that Michael will be found amongst the debris that has become his life? Is she so apathetic that she no longer holds any hopes for Michael at all? Did she lose hope for herself?

Did Michael ever feel hope for a future that would lead to a productive, happy life? Was he nurtured to be someone with self-worth and a firsthand knowledge of how to receive and give love? Was he surrounded by anyone who only hoped for his best?

I realized that with Michael, as his story unfolded for me, I found myself hoping more and more for a better tomorrow for him. I hoped that his past hadn't permanently damaged him. I hoped that Michael could see himself as someone of worth in our society. I hoped that people were involved in Michael's life who appreciated his presence.

I realized that Michael was stirring hope within me...

Michael's exam was normal. His blood work returned within normal limits. I gave Michael a sandwich, something to drink, and most importantly, I made a point to sit with him several times before his consult with social services concluded and discharge from our emergency department was completed. Adult services would be following with him.

I hope he felt that we cared.

I hope my helium-filled dreams for each human I encounter will always remain a part of me. I have Michael to thank for reminding me of the important stuff...

As always, a huge thanks for returning to read my words. I hope this finds each of you well and enjoying a beautiful summer season. My heartfelt thanks for those who sent me personal emails. My best, Jim...

Bingo Resilience

Her wary eyes, magnified from her thick-lensed spectacles, watched my every move as I pulled Room 21's curtain to the side and entered her room. In her early eighties, it was apparent to me that my entrance into her life was more important than the abdominal pain that brought her to our Emergency Department. In the corner sat a slight man with wispy gray hair poking out from the border of his baseball cap, his elbows resting on his thighs as he leaned forward in his chair. His wrinkled face and tired appearance made me question if this man was her son or husband.

I returned my gaze to this patient and gave her a smile as I approached her bedside. Her stoic face softened slightly as I watched the corners of her eyes relax. Her mouth's edges lifted slightly into a hesitant return smile. She was on guard.

Arriving to the side of her cot, I extended my hand to introduce myself. "Hello, Ms. Westin. My name is Dr. Jim and I will be taking care of you today while you are in our Emergency Department."

"Hello, Doctor," she replied, barely grasping my hand in welcome. "Please call me Bertha."

"Nice to meet you, Bertha," I answered before turning to the gentleman in the corner of the room and approaching him. Once again, I introduced myself.

"Thank you, Doctor. My name is Sam. I'm her son."

Her son. Standing closer to him, I could see that Sam had his mother's eyes--slightly hazel but more fatigued-appearing. My mind wanted to know what in his life was giving him this look of defeat.

"Nice to meet you, Sam. Thank you for being here with your mother today."

Sam nodded to my words. My response words--actively thanking him for taking the time to accompany his elderly mother to the Emergency Department--were something I had been saying for the past few years to adult children who accompanied their elder parent to our department. It was my way of acknowledging and validating their efforts in helping their ill parent in a time of need. Of putting to the side their own needs and demands. Of dropping everything at that very moment to be at their parent's side during an Emergency Room visit. This supportive action was one that I respected immensely. Often, it was the adult child who could convey just a little more history or provide just a bit more support that could make a difference in my course of treatment of their parent.

It was a loving gesture that was not lost on me.

I turned back to Ms. Bertha and began questioning her. She had developed abdominal pain in her midepigastric to left upper quadrant about four hours prior to her arrival. It was not accompanied by any nausea, vomit, diarrhea or constipation. She had no fever. She denied any chest pain, shortness of breath, or recent trauma. She denied any urinary complaints. This abdominal pain was unusual for her. It had presented soon after she had eaten a BLT sandwich for lunch. Of course, like Murphy's Laws would dictate, the pain had completely dissipated by the time I examined her.

As I questioned her, I could see her slowly letting her guard down with me. She began to smile her big, beautiful smile more easily. She became more conversive. She became down-right fun. We laughed together at some of our small talk while I finished my history-taking and began my physical exam.

Her physical exam was perfect. Nontoxic. Benign. I couldn't find a thing wrong with her.

Because of her age, we did the standard precautionary testing, including blood work, an EKG, and a urinalysis. While waiting for her test results to return, I stopped in several more times to perform recheck exams and make sure she remained comfortable. She did. Each time I stopped in, I became more and more aware of her piss-and-vinegar disposition and sense of humor. Especially talking about Bingo, she seemed to light up at the sense of fulfillment this church-going sport brought her. "Yeah," Sam added, "don't try to get between Mom and her Bingo chips." Ms. Bertha, it seemed, did not take lightly to losing a recent big prize by one empty block on her card.

Finally, I went in for the final time with all of her returned test results. All results were normal and favorable.

In the few hours I spent with her, I continued to appreciate Ms. Bertha and her son, Sam. I was happy for both her feeling better and her excellent test results. I was happier at the sense of caring that existed between mother and son. I was happiest that, at age 83, Bertha seemed to continue to enjoy life and found beauty in the simple things that it offered. I was also appreciative that losing a Bingo game still evoked passion from her.

On review of her previous visits, I had noticed that she had never been to our ER before. I questioned her on this prior to discharge.

"Ms. Bertha," I said, "I noticed you haven't been here before. What made you nervous enough to come in for your abdominal pain today?" I wanted to make sure I had covered all of my bases before safely discharging her to home.

"Oh, that was probably my doing," Sam answered. "After the past few years," Sam continued, "I didn't want to take any chances with Mom's health with her belly pain today."

"Plus," Ms. Bertha added, "I really hated my doctor the last time I had to go to the ER. That was in 1975." She paused slightly before continuing with a wink of her eye. "Don't worry, though, Dr. Jim. I really like you."

I must have blushed at her kindness because she called me out on my "red cheeks."

"Can I ask what has happened in the past few years to you, Ms. Bertha, that had made your son worry about you today?"

And then, Ms. Bertha's real story came rolling from her mouth, her words tumbling right into the pit of my heart.

With a mixture of sadness and smiles, Ms. Bertha and Sam, in the next five minutes, told me how Ms. Bertha's life had played out to this point. She had lost four children--two sons (one to cancer and one to AML with a concurrent brain tumor) and two daughters (one tragically in the late 1980s from a motorcycle accident). Her husband had died five years earlier. In the past year, she had buried two siblings. This recent loss of her siblings had convinced Sam that his mother's abdominal pain was going to bring terrible results. Sam was her only immediate family left.

When they were done sharing, I could only shake my head in disbelief. I grabbed Ms. Bertha's right hand between my two and warmly rubbed it. "Ms. Bertha," I said, "I can't even imagine how you could share your smile and piss-and-vinegar attitude (saying piss-and-vinegar made her giggle like a young school girl) with the world after all that has happened to you. What keeps you going?"

She looked me in the eyes, her magnified hazels piercing my soul.

"Bingo," she answered.

We all laughed. Her resilience and true personality made me smile. My goodbyes to Ms. Bertha and Sam were heartfelt.

As I stepped from Room 21, I was hopeful that, thanks to Ms. Bertha's inspiration, I too would find my "Bingo" someday.

I will keep looking...

As always, big thanks for reading. Ms. Bertha and her son were an inspiration to me. I am constantly amazed at the gift I have been given to meet so many diverse and beautiful people. 

What's your "Bingo?"

    

The Kick Ditch

A moment of reflection...

After finishing an amazing novel, The Fault In Our Stars by John Green, I put down my hard-copy and marveled at the power of the written word. This power was most evident by my multiple ear-tagged pages--pages that held expertly chosen words construed into sentences, paragraphs and chapters of brilliancy by this gifted author. Simply put, Mr. Green's eloquence affected my core, constantly leaving me in awe at how he pierced my emotional protective shell with his intimate portrayals and intrusions into the struggling lives of others.

At one point in this book, a main character was sitting on her lawn, staring at her aging swing set, wistfully remembering the innocent beautiful moments of her childhood. Moments that were no more. And with this visual of her swing set, I was suddenly transported back to my own childhood--back to the powder-blue swing set that sat in our family's yard alongside the lilac bushes and sandbox. Back to the rusted swing set with the plastic pony sitting under the mulberry tree at Gramma's house. Back to my small town's playground of numerous swings dangling from both rigid piping and clanging chains. Back to the numerous handmade swings crafted from wood planks and tires hanging from old roping that we hinged along obnoxiously obtrusive tree branches that overshadowed our chosen paths. Our paths of childhood...

Perhaps the most stunning visual of these revisits to my past, though, were not the swing sets and random swings themselves, but rather that linear trench of worn earth that seemed to befriend each and every swing. You know that trench, right? I would bet that each of you had at one point or another in your childhood also dragged your toe through one of these trenches during an innocent, happy moment of your promising youth.  It was a time when the big old world was held at bay and your smaller, more intimate world was all you pictured your future to be. This trench sat unassumingly right underneath each swing, below ground-level, filling up with water after a hard rainfall, catching a loose flip-flop off the ill-prepared foot of an eager child or housing that stubborn rock that lied in wait to stub our toe.

The kick ditch.

I attributed my high-flying on the swing of life to my proper leg-swinging, straightening them to touch the sky when going up and bending them at the knees to reach back as I came back down. My legs I could control. Yet, that little ditch kept my momentum going always, even allowing me push off to gain higher altitude.

This darn "kick ditch" image. After seeing it time and again with every memory of every swing I've ever screamed from, I began to think of what the kick ditch represents to me--of the many things that are present in my life that I did not give the proper attention. Things and people who have helped me with my forward momentum. Things that sit right in front of me, lost from my attention because something more glossy and glamorous distracted me.  Things that were content in sitting back within their clouds of anonymity. Things that I have not properly given the silent thanks and the appreciation they deserve.

My kids. Friends. Family. My spiritual lights and guides. Work. Simple gestures of kindness from strangers. Appreciation from patients and co-workers. Understanding and love from people whom I would least expect it. Compassion from non-judgmental people. Kick ditches that continue to support my momentum throughout my ride in life thus far. Kick ditches that I am now giving more cognizant attention.

Besides my legs, I also believed the people who stood behind me as I swung, pushing me to higher gains, would always be there. And yet, they aren't. Without blame and for a variety of reasons, it seem that the people pushing us on our swing are constantly changing with the snapshot moments of our lives. While reading this pivotal scene in the book, my mind was finally able to recognize the power of my little ditch in allowing my forward-motion. The power of my own legs to go higher and higher. All along, it may have been these "kick ditches" and my own legs that were most responsible for thrusting me forward in my life.

Recently, I turned 47 years old. Not a memorable birthday for most, but probably the year that I will remember most vividly in my lifetime. It has been a tortuously unpredictable year, a year of countless and uncontrollable changes. A year that I am blessed to have survived. A year of very intense internal work and self-reflection (accompanied with a significant amount of self-laceration). I have come to learn some really amazing things about my life and life in general. About the power of me. Clearly, I have learned that I am fractured. That each and every person around me is fractured. Mostly,  I have learned that we all have the opportunity to embrace, ignore, or further trample our fellow neighbor during life's struggles. I have learned to embrace. I have learned to appreciate those who embrace. I continue to appreciate those who want to push my swing forward. I appreciate the power of my own legs in controlling my gains in altitude. I appreciate the "kick ditches" that only want to help support my forward motion.

It is humbling to learn that our choices and behaviors can affect so many people in so many ways. It is humbling to learn that others' choices and behaviors once had the power to affect me in so many ways. I am thankful for the people who can forgive. I am regretful and sorry to the people that can't forget. I am appreciative of the people who remember the goodness that makes me special in my own way.

Most importantly, I've learned that love, kindness, compassion, friendships, and family can sustain one through just about anything. I have also come to learn sad realities; that each and every one of us have people in our lives that can judge and abandon us the minute our fractures are exposed. The people who once offered you the most support, who tirelessly pushed you on the swing, might just up and leave. If they do, are you prepared to dip your toe into your kick ditch? Are you prepared to swing your legs as hard as you can to control your own flight through life? Instead of allowing another to sit in judgment and trample you, are you prepared to offer your too-proud hand to the one who wants to help you from the ground on which you are plastered?

Don't be one who forgets that you too are human and will never be immune to your own fractures and missteps. That one day you too may need forgiveness. Be the one who offers a hand to help up a fallen neighbor so that when you need a hand, your fallen neighbor will be there for you. Be the one who forgives so that when you need forgiveness, it will come for you. Be the one who strives to see the goodness in another the same way you want someone to see the goodness in you.

Be the one who helps another swing higher when they dip their toe below ground. Be the one who keeps those around you moving forward to higher ground in their lives.

Be a kick ditch.

As always, big thanks for reading. This post festered in my mind for quite a while and I felt the need to purge before moving on to more patient stories. This past year I have learned much about the human spirit, both mine and those around me. This awareness has made me better and stronger. It has humbled me in ways that were necessary. I hope that you have the power to admit your weaknesses and triumphs from your self-reflection and internal work if you bravely embark. I hope you have the power to help a fallen being. A special thanks to those in my life who have remained true to the course of my life moving forward in the best of ways.  To my kick ditches--you know who you are. Jim

Underneath

Hello, all. Ideas and stories are gaining clarity in their stew pot, gently being brewed and tenderly stirred by my gaining energy and renewed attention to the complex range of fragile emotions and simple beauties that envelope a typical work day in a busy trauma center. I am again eager to capture in words these pure moments. In the meantime, a good friend brought to my attention the many layers of meaning to the below post. Rereading it, I found it filled with new perspective from when I originally wrote it just three short years ago. I hope you, too, find new meaning in old words.    

Walking into Room 33, my next patient, who had come to the ER complaining of cough and cold symptoms, seemed just as I had expected.  He appeared relaxed on his medical cot, lying back at 45 degrees, facing the room's door, his legs comfortably extended in front of him and his gown tied correctly behind him.  He was a few years shy of middle-age and appeared to be in good physical shape. His sandy blond hair, sprinkled with gray, framed his slightly weathered, apprehensive face.  Between coughs, he managed to give me a faint smile.

"Hello, Mr. Brown," I said, extending my gloved hand and introducing myself, "I'm Dr. Jim.  What can I do to help you in our ER today?"

He coughed before answering in raspy voice.  "I had a bad cold about two weeks ago.  It lasted about a week before going away."  Another cough.  "But now," he continued, after taking a deep breath, "it's back.  Back with a vengeance, actually." Yet another cough.  "I've had three miserable days of this stuff," he said, swirling his hand in front of his runny nose, reddened eyes, and dry lips, "and have tried every over-the counter medicine out there."  Cough.  "I just don't know what else to do."

As he spoke, my senses were acutely attuned to him.  I listened to see if he was speaking full sentences of five or six words or fragmented sentences of just a couple.  I listened for audible wheezing.  I watched to see if his diaphragm and intercostal rib muscles were struggling, under his gown, in their respiratory effort.  I noticed the skin coloring of his arms, the pink of his nails, his reddened, irritated nares, and the slight sheen to his forehead.  I listened closely to his cough, to observe if it was of a dry, hacking quality or a wet, congested effort; whether it came in short, interrupted bursts or was continuous and drawn-out.  I watched to see how quickly he recovered from these coughing spells.    

The patient probably thought that I, standing beside his cot with my stethoscope in hand and a smile on my face, was simply waiting for him to finish his coughing and complete his story.  And I was.  Of course, I was eager to learn of any other input he might share so that we could get him on the right road to recovery. What Mr. Brown didn't probably realize, though, is that as important as his providing a detailed history may be,  these obscure observational moments, wordless and symptom-producing, can provide just as much, if not more, information to a treating physician like myself.  I, for one, would much rather hear the cough than have a patient struggle in his description of it.  Penile discharges, though?  That's another story.

Back to Mr. Brown.  Even without doing my physical exam, I suspected he might be suffering from a community-acquired pneumonia.  "Sir," I said, touching his shoulder, "I'm going to perform a physical exam now."  He nodded his consent.  Starting with his head and taking my time, I closely looked in both of his ears (clear), his eyes (slightly bloodshot from his coughing spells), his nasal passages (angry red with significant turbinate swelling), and his throat (red, no exudates or swelling, mild anterior lymphadenopathy).  His tongue was dry and his breath smelled of neglect, like skipping a brushing.

Moving the exam along nice and smoothly, I next focused on his torso.  "Mr. Brown," I said, "we need to remove your gown so I can listen to your heart sounds and auscultate your lungs."  Trying to help, I untied his gown's back tie while he untied his neck.  Slowly, he pulled off his gown, somewhat hesitantly.  And after he did, I understood his reluctance.

His entire anterior torso, extending from his left shoulder to his chest to his abdomen, was a patchwork of skin-grafting.  Thin, transparent, papery patches of transposed skin were bordered by longitudinal, thickened keloid scars.  Some of the patches were less transparent and more natural-appearing, some of the scars less protruding and more flesh-colored, but it was obvious that multiple skin-grafts from multiple body sites had been a necessary, life-saving event at some point in Mr. Brown's life.

"I know, I know," he said, watching my eyes closely absorb the view of his torso.  "I never remember to mention these skin grafts.  Out of sight, out of mind, I guess."  He was almost too blase, leading me to believe that these physical scars walked hand-in-hand with his mental scars.

"May I ask what happened, Mr. Brown?"

"It happened when I was young, in elementary school.  Believe it or not, I had been playing with matches.  No, not on the playground," he chuckled here, "but in my backyard.  All I really remember is my shirt catching on fire, a lot of pain, the smell of my skin burning, and then my mother's screaming." He coughed a few times, his face mildly grimacing with the effort.

"I'm so sorry, sir," I said sincerely.  Imagine spending a large chunk of your childhood undergoing multiple reconstruction surgeries, missing school and losing friends, at a time when those things matter, in the process.  Being treated differently than the healthy kid standing next to you.  Not to mention the constant pain.  And feelings of lessened-worth.  Too many doctors appointments, no sports, lots of dressings.  I was letting my mind race in that brief minute.

I looked more closely at this patient.  Everything had seemed to change after seeing what was underneath his gown.  And now I understood his symptoms even better.

"Sir," I said, "do these scars restrict you when you need to take a really deep breath?"  He nodded "yes."  I continued.  "And do you get a lot of pain from these scars with your coughing spells?"  "Doc," the man smiled, "I think you get it.  It's been pretty hard with the colds this year, but these scars sure don't make recovering any easier."

I did get it.  Because of his torso scars, his thorax, when stressed with illness, couldn't expand as easily as yours or mine. His fibrous scars and skin-grafting, lacking pliancy, prevented him from taking as full a breath as necessary.  Kind of similar to being wrapped and squeezed by an anaconda, I would imagine.  His work effort, thus, was increased.  And not exchanging air in the depths of his lungs, because of this momentous effort needed, would set him up to acquire pneumonia.

Not only this, but now I understood why he probably put a lot of effort and time into staying in decent physical shape.  "If I put on even ten pounds," he told me, rubbing the scar tissue around his umbilicus, "I start to hurt right here, from the outward pressure.  It seems any weight I gain goes right to my stomach, of course, and not my ass or legs.  Hell, I'd even take a double chin.  So I really have to be careful with my diet and exercise unless I want to have constant pain."  Talk about the pressure of eating right and hitting the gym.

Me?  I work out just so I will always look better than my brothers.  There is a lot of pressure being the best-looking boy in the family.  Clearly, he had better reasons than me to visit the gym.

After finishing Mr. Brown's exam, we got an x-ray, some baseline blood work, and an EKG.  His WBC count was slightly elevated, going hand-in-hand with a very early consolidated pneumonia viewed on x-ray.  We took no chances--he was placed on a strong antibiotic, given albuterol and atrovent nebulizer treatments and a machine to do the same at home and, probably most important, he was given a strong cough syrup with hydrocodone to ease the stress that his cough was bringing.  He was quite appreciative upon his discharge, his cough lessened and his breathing a little easier.

"Thanks, Doc," he said, after he was dressed, "this was a good visit."

Meeting Mr. Brown initially, everything was just as I had expected.  Until we removed his gown.  And then, I saw what was underneath--the physical limitations of his body during a time of illness.  And underneath this, I was fortunate to learn of his hidden strengths and the stoic fortitude that his life experiences have taught him.  He seemed the better man for it.

I gave this some thought, about how much we all have in common with Mr. Brown.  How we show the world what we think they want to see.  But underneath, don't we all have something we are hiding, just like Mr. Brown?   Something that may even be limiting our full potential?  May it be physical.  May it be mental.  May it be spiritual.  May it be all.  More importantly, underneath, buried in doubts, don't we all have more good that we can give this world of ours?  If we just get over our fear of showing... What.  Lies.  Underneath.

Mr. Brown, thank you for your trust to show me your underneath.  It made a difference.

As always, big thanks for reading. Despite our best efforts, none of us are perfect. All of us are fractured. Scarred. Some of us wear our damage more evidently than others, our physical and emotional scars recognized by both compassionate and (unfortunately) judgmental people. Ultimately, when your damage and scars are revealed, it is my hope that you be surrounded by those who recognize their own imperfections and give the kindness and compassion that they may someday need returned.  To judge another, rather than to lend a needed hand, will make the helping hand you someday seek more elusive.

A toast to all of the fractured, compassionate people in my life...