Monday, March 16, 2015

It's All Innocent

Happy Monday, everybody!

Although I pride myself on catching the obscure snapshots of typical life moments that occur daily while dealing with patients and their families in the emergency department, occasionally there are times when I am so focused on the task at hand that I completely fail to see a glaring moment of obvious humor, sadness, or tenderness. At times like this, then, I am glad to have our hard-working nurses and techs with me in the room to bear witness to such events.

For example, recently I treated a 62 year-old retired kindergarten teacher who presented to our emergency department for a nosebleed. By appearances, she was exactly what you would picture a retired kindergarten teacher to look like--perfectly permed grey hair, kind eyes, folded "liver-spotted" hands resting in her lap, and the perfect amount of wrinkles at the corners of her eyes and mouth. If not for the actively dripping blood from her left nare (nostril) and the gory blood stains on her white cardigan sweater, I would have sworn she was there to simply to review my ABCs with me while I shoveled down a few cookies with a glass of cold milk.

Upon a brief interview, I learned that she had been feeling fine while visiting friends in our town. Suddenly, after a hard sneeze she started oozing blood from her nose. "I think I am allergic to my friend's cat." I smiled. Those of us in medicine know that most illnesses can be blamed on three things--cats, the flu shot, and fibromyalgia (public notice-->please do NOT get in a tizzy because I DO believe in the diagnosis of fibromyalgia).

Despite attempts at pinching and stuffing tissue after tissue into her nasal passage, this WWII Polish immigrant could not take care of the situation on her own. She learned that packing a bleeding nose was not as easy as packing potatoes into the perfect perogie. Thus, it was our team's pleasure to get to meet and treat Ms. Ilene for her medical issues.

After examining Ms. Ilene, I explained to her the process we would pursue in stopping her nosebleed. Initially, we would pack her nose with some cotton pledgets soaked in a vasoconstriction solution to shrink the diameters of her bleeding vessels. After five minutes, we would remove the pledgets. Finally, we would insert a modern-day torpedo-shaped product, coated with a clot-inducing mesh, and inflate it with air to the point where it would press against her septum to tamponade the bleeding vessel. She would keep this packing for several days to prevent further bleeding.

"Ms. Ilene," I warned her, "this may be a bit uncomfortable for you." By previous experiences, nosebleeds sometimes were a breeze to treat and other times could be quite a dastardly experience for the patient. Regardless, I loved treating nosebleeds, and she had a significant one that required us to be a bit more aggressive.

Just as we had explained, we successfully placed and removed the soaked pledgets. Moving on to the "Rocket," I prepared Ms. Ilene for the next step. "Ms. Ilene, this is the most difficult step. I apologize beforehand if it causes you any discomfort while I insert this," I said, sweeping my hand toward the apparatus.

With the nurse standing on Ms. Ilene's right side, holding a suction-wand in her one hand and Ms. Ilene's hand with her other, I inserted the "Rocket" like a pro. It was a much easier procedure than I anticipated.

"Wow," Ms. Ilene said, "that slipped in easy."

What followed, then, were several more comments caught by the nurse that I was oblivious to. She caught me up to speed between her giggles, though, after-the-fact in the nursing station.
     "Doctor, you were really good at slipping it in."
     "Is it in far enough?" (I had assured her that I had inserted the device far enough).
     "I am glad it slipped in so easy."
     "That wasn't bad at all for my first time."
     "Wow, you inserted it deep!"
     "Thank you for being so gentle."

In-the-moment and focused on the next task at-hand of inflating the rocket, though, I still couldn't understand why the nurse was grinning.

With a ten cc syringe, then, I began to inflate the "Rocket." "Ms. Ilene," I warned, "you are going to feel the 'Rocket' start to get more firm. The firmer it gets, though, the better it will do it's job."

"Good," she said, "make it nice and hard. Whatever it takes."

Again, another chuckle from the nurse. I remained oblivious.

Slowly, I inflated the "Rocket." One cc. Two cc. Three, four, five, six ccs. "How are you doing, ma'am?" I asked, pausing to give Ms. Ilene a little respite.

"I definitely feel it getting firmer," Ms. Ilene answered. "Good, then," I answered, palpating her exterior nose, "just what we want. I would like to inflate it just a little bit more."

She agreed. I proceeded. Seven cc. Eight cc. "How is that?" I asked, palpating her nose again. I was happy with the progress of things.

"Well," Ms. Ilene said, "it definitely feels firm. It is uncomfortable, but if you need to make it harder, go ahead and do your thing."

I swore I heard the nurse chuckle again. What the heck? I looked at her and could see the smiling squint of her eyes resting above the top edge of her mask. I gave her a questioning look.

Nine cc. "There, Ms. Ilene," I said, palpating her nose and briefly looking into her nasal passage, happy with my findings. "I think that is all we need to do. I think this is going to work out well for you."

"Good," she replied. " That wasn't nearly as bad as I thought it would be."

"Feel here," I said, guiding her finger to her lateral edge of her left nose, "see how firm that feels--that is exactly what we want. This will do the job."

"Yes, that definitely is swollen and firm," she confirmed.

I assured her that she was the perfect patient and that everything about her packing went really smoothly. I thanked her for being brave. After cleaning up a bit, the nurse and I walked out of the room and into the nursing station.

"What was so funny?" I asked the nurse, who sat down in her seat and covered her face with her hands to muffle her laughs. She couldn't control the shaking of her shoulders.

"Are you kidding?!" she exclaimed finally, after catching her breath. "You seriously did not get how funny that conversation would have been to someone standing outside of her room?"

I seriously didn't. After being refreshed about the conversation, though,  I felt my face getting heated. I know I was turning red. And trust me, I am a hard one (no pun intended) to embarrass at this point in my career.

I dreaded going back into Ms. Ilene's room after being made aware of the conversation. Was she just as oblivious as I was as to how our conversation could have been interpreted by someone with wandering ears? However, after observing her for 30 minutes, I had no choice but to go back in to explain her blood results and my happiness with her vitals signs and end-result of the procedure. I requested for the nurse to accompany me, but she claimed she had an IV to start in another room. I knew, though, that there was no IV start and that she wanted me to face the situation on my own.

I slowly approached Ms. Ilene's room like a little kid about to face his parents for a well-deserved scolding. Slowly, I pulled her door open and slid her room's curtain to the side. I peered inside. I breathed a deep breath out. She was napping.

I touched her shoulder. "Ms. Ilene," I whispered. I shook her shoulder again. Slowly, she opened her eyes. She gazed around the room and took in her surroundings before fixing her eyes onto me. "Oh," she said, "it's you."

"How are you feeling?" I asked.

"I feel really well, Doctor," she answered. She paused before continuing. "I really want to thank you again for being so gentle about everything."

Ugh! I looked closely at her but could not see any hints of her being coy. She appeared to mean this very innocently. Darn the nurse for tainting such a nice encounter!

Gladly, I discharged Ms. Ilene from our department to followup with our ENT services in 48 hours since she would still be in town visiting her friend. I also advised that it would be okay for her to take an antihistamine for a few days if, in fact, an allergy to the cat was the main cause.

Later on, while rethinking this encounter, I realized that there are probably many moments in the emergency department, due to the highly personal nature of things, that could be interpreted as something more than the innocent interaction it really is. Thankfully, though, we carry on through these moments and keep them at the professional level they deserve to be. Well, most of the time...

 Soon after, unfortunately, word associations began to process in my mind.

Nosebleed. Source. Allergy. Cat. Kindergarten teacher. ABCs. Reading. Dr. Seuss. The Cat In The Hat....Hmmmm, I wondered if Dr. Seuss ever had any innocent moments that could have been interpreted by an outsider as something coy or devious or silly. Did these moments happen everywhere in our lives or were these moments of innuendos predominant in the emergency department and the medical field?

I found my answer while perusing lists of Dr. Seuss's books to confirm that the emergency department is not isolated by such silliness. And there, within the lists, I found my answer.

The name of Dr. Seuss' book, the greatest of all childhood authors, that made me smile at the silliness of it all? Drum roll please...

There's A Wocket In My Pocket.

Enough said. I am on my way to the library right now to check it out.

As always, big thanks for reading. I hope this silly and embellished humor starts your week off right. It feels good to be writing again...         

Monday, March 9, 2015

Where To Look

Big thanks to my many encouraging is with you in mind that I have returned with another post.

I walked into Room 30 to find two eager sets of eyes awaiting me. One set belonged to a young man, late-twenties, muscular and imposing, sitting in a chair in the corner of the room. His eyes were hazel brown, big and inviting, relieved at seeing my entry into their sheltered world. The other set of eyes, darker brown and magnified by her gold-stemmed glasses, belonged to my patient, a woman in her early-sixties. She sat  upright in her treatment cot, knees drawn up to her chest and covered by the thin hospital-issued bed sheet.

Clearly, I had interrupted a conversation between them. Upon my entrance into their treatment room, they gave me the respect and gift of silence, a pause in which I would be able to introduce myself. As many of my fellow coworkers would confirm, this does not often happen. Rather, it is not unusual for us providers to walk into a treatment room only to wait for a patient to finish a cell phone conversation (while holding up an index finger indicating they are almost done), finish the last gulp of a bottle of soda or swallow the crumbled remains of a bag of chips. Worse yet, a patient sometimes will keep on talking to someone else in the room and behave as if we haven't even entered.

I liked this woman and man already.

Extending my hand, I introduced myself first to my patient, Ms. Loretta. "Hello, ma'am, my name is Dr. Jim and I will be taking care of you today." Turning to the man sitting in the corner of the room, I repeated myself. They were both gracious in their return greetings and I learned that the young man was her son, John.

Ms. Lorettta appeared calm, composed, and quiet as she sat in her cot. She was of short stature and delicate frame. She looked tired, her graying hair wiry and thin and a few days beyond its last washing. Her face was wrinkled. Her eyes, broody and intent, watched me closely as I leaned against the wall and asked her question after question regarding her reasons to visit our emergency department. Occasionally, she looked towards her son to supplement her answer, to clarify something she couldn't quite find the right words to describe. Each time her son was successful in filling in the blanks.

She had come to our department with several weeks of increasing abdominal pain. A diagnosis of kidney (renal) cancer several years earlier had led this patient to having several bouts of chemotherapy and the subsequent great news of achieving remission. Her complacent face, after learning her history, spoke to me--the more she shared her new symptoms with me, the more I realized that she had an inherent sense that something bad was happening in her abdomen again.

I did, too.

Her son, sitting in the corner quietly unless spoken to, appeared much more anxious than his mother. Whereas she seemed resigned to some bad news arriving in her near future, he seemed to be using his energy to avoid any possible realizations of something bad occurring. His intimidating square face, thick neck, and inflated muscles--all those hours spent at the gym to make him stronger--would be of no use to his mother in what the fates might dictate to her. He fidgeted with his hands and feet. He occasionally diverted his gaze from his mother and I to the corners of the room. He seemed to want to rewind the hands of time to a few weeks prior when his mother was symptom-free of any pain and he could keep looking to a pollyanna future with his mother being an integral part of it.

Her physical exam was concerning for the abdominal pain she complained of. She had some distension which gave her belly the appearance of holding a helium balloon within it. Her pain was diffuse, all over, and I could make her right upper quadrant be the main source of this pain when I palpated a steady pressure downward toward her liver.

We did the workup--blood and urine testing with IV-contrast CT imaging of her abdomen. Sadly, the CT scan returned showing what the patient and I had feared--the cancer was back. She had multiple metastatic lesions in her liver and the collection of some ascites, fluid build up around the organs within the abdomen.


I walked into Room 30 with a heavy heart. Not only did I feel for this patient and her son, but I closely identified with the heartbreak associated with the news I was about to deliver to them. It was just eight short years ago that I had been sitting in a corner chair of a hospital room with my mother as the patient. She had been battling leukemia and, after coming out of remission, had a battery of tests that had led to the moment when her oncologist walked into her hospital room to share the devastating news with her and me--her leukemia was more spiteful than ever and was remaining refractory to all of our attempts to fight it. I remembered the pain I felt. I remembered the complacency of my mother upon hearing the news. She had inherently known and sensed this would be her outcome. I remembered the wishing and hoping that my father and six siblings (who all rotated their visits due to living several hours away) had been with us at that very moment to divide the pain of my mother's news.

Who am I fooling? The pain of such devastating news as this isn't divided among us--the pain multiplies. Then multiplies again. And keeps exponentially growing until we all learn the appropriate ways to diminish the power it holds over us.

Entering the room, then, I wasn't surprised to see Ms. Loretta sitting quietly in her cot with John now sitting at her feet, holding her hands within his massive mitts.

Without my saying a word, Ms. Loretta knew. "It's back, isn't it." It was more of a statement rather than a question. I nodded to her. "Yes," I said, "it's back."

She asked me questions about her tests. How was her blood work? How bad was the CT scan? Did she have much time? Did she have options? John remained quiet, his eyes focused only upon his mother.

I kept answering her questions to the best of my abilities, but refused to answer the "how much time do I have" question. I assured her that we would admit her to the hospital and get the oncology specialists involved immediately to provide some guidance to the questions she was asking.

All the while, as Ms. Loretta and I were talking, I couldn't help but steal glances at her son. He was me. Just eight short years ago. Sitting with his mother. Holding her hands. Processing bad news. Staring at his hero and wishing with all of his heart that he could absorb her hurt.

He sat quietly, his anxious movements calmed with the news that he was desperately hoping to avoid. He continued to grip his mother's hands in his. His eyes remained fixed onto his mother's face. I knew exactly what he was doing--he was etching her image, her heartbreak, her attempts to be strong at this very moment, into a memory that would remain with him until the end of his days.

Eyes watching eyes watching eyes. Her expectant eyes on me. My sympathetic eyes glancing between her and him. His loving eyes on her.

Sometimes, our eyes are rewarded with the beautiful imagery they seek. Sometimes our eyes are the recorders of specific moments of our lives that we may or may not wish to remember, memories of splendor and memories of squalor. Sometimes our eyes are the conduit of the emotions of our heart and soul. Sometimes our eyes are our best friends. And sometimes our eyes are our worst enemies...

As Henry David Thoreau said, "Could a greater miracle take place than for us to look through each other's eyes for an instant?"

In this moment with Ms. Loretta and John, I appreciated the miracle of my memory from eight years ago simply by looking through their eyes for but an instant. An instant that I wish I could have protected them from.

Thank you, Ms. Loretta and John, for this instant...may you both be rewarded for letting me be present in your moment of painful tenderness.

As always, big thanks for reading. This essay is dedicated to a whole new group of readers who have contacted me or encouraged me to keep on keeping on with my essays. Please feel free to share your "instants" with us...