Tuesday, February 12, 2019

4, 3, 2, 1 And 90.

Everyone you meet is fighting a battle you know nothing about. 
Be kind.
Always.

One of the largest problems in our ER, it seems, is that there is a subset of patients who visit us on a routine basis. Commonly known as "the regulars," these familiar faces are sprinkled throughout our day between all our other patient visits. Whether it be for chronic pain, for chronic illness, for companionship, simply to have a place to hang out for a few hours, or to get some food, we are often inundated with these patients at the most inopportune times. Three trauma patients, four chest pain patients, two stroke patients, seven respiratory distress patients, three lacerations, two compound fractures, and five sick kids--and arriving between all of this organized commotion of providing good care are Johnny, Sally, and Herb, with a combined total of over two hundred visits between them.

It is a real problem in our ER. It is a real problem nationwide.

Of course, the most compassionate thing to do would be to sit down and spend some time with these patients. Human to human. Heart to heart. It seems like most of these patients simply exist in our society without participation. Unfortunately, though, this is not our reality. We just don't have the time among all the other serious happenings in our ER that require our attention. We can consult our case managers to evaluate options of living arrangements, of providing adult services, and  to spend a few extra minutes with these patients, but they too are often overwhelmed with what's required from them in our busy ER. Hopefully, between the attention given to them between myself, the nursing staff, our aides, and our case managers, their needs for that day's visit are met.

As an outsider without experiences in the ER, it might be hard to fathom this problem existing to such a degree. So imagine your sick child with a high fever and trouble breathing, your sick friend or family member who has chest pain or a facial droop with difficulty talking, or yourself after a car accident being brought to us because your leg is deformed with a bone sticking out, and you can easily understand what patients require more of our time and attention. Sadly, it is not Johnny, Sally, or Herb. You would want us, your treatment team, to be fully invested and immediately available to you or your loved one in such a dire time.

On the rare occasion that our ER is not busy and one of our regulars show up, though, I do like to take the time to sit down and learn a bit more about them. These moments when I have this opportunity, I am usually surprised at some of the things I learn from our regulars. Their stories are compelling--some of these patients experienced things that I never will, whether it be heartaches or triumphs. It is from these talks that I am usually the one leaving the encounter more enriched and appreciative. These folks are resilient and intelligent--some are quite the masters of storytelling and all of them have life stories that are intriguing.

On a recent shift, still busy but not overwhelming, I had the pleasure to treat Kevin, another one of our regulars, and spend a little more time with him than I would usually be afforded. In his mid-fifties, Kevin was homeless. He was frail and had unfortunately progressed to relying on a walker, due to a multitude of medical problems, for ambulation. His last visit to our ER was just three days prior. 

Walking into Room 22, then, it didn't surprise me to see Kevin sitting in his cot and his royal blue walker sitting in the room's corner. Several tan plastic bags (with a local market's emblem) occupied both his walker's seat as well as a maroon hospital chair. These bags contained all his life's belongings. His beat-up brown Carhartt jacket filled the second chair.

"Kevin," I said, entering the room after knocking on the metal frame and pulling aside the curtain, "it's good to see you this morning." Extending my hand to his, we shook as I took in his appearance. Kevin looked tired, wiped-out, skinnier and worse for the wear since the last time I had seen him. His full head of gray hair and beard were matted and unkempt. His blue eyes were dull. Nasal hairs met his upper lip. A patch of keratosis on his left temple was scaly and pale. His pointed nose and thin lips added sadness to his narrow, long face. His arms and legs were wiry and bony. He was frail.

Kevin looked intently at me, holding tightly a large cup of coffee in his left hand. "Hi Doc," he said, his voice hushed, as it was usually. "My stomach is upset and I feel like I have to puke." After speaking, he took a long drink of his coffee.

"Sorry to hear this, Kevin," I said. His ability to drink coffee, despite his complaints of nausea and stomach pain, was not lost on me.

After asking him a multitude of questions (diarrhea or constipation? fever? where is the pain? how long have you had it? constant or intermittent? ever have this pain before? etc.), it was clear from Kevin's nonspecific answers that he might have had other goals, rather than acute illness, for visiting our ER this day.

"Maybe my belly hurts sometimes, Doc."
"I'm not sure how long I've felt this way."
"No, I didn't puke, but I thought I was going to yesterday."
"Sometimes I have a good shit in the morning. Sometimes I don't."
"This coffee helps my stomach, Doc. Can I have more?"
"Do you still have packs of crackers?"
"It's cold out there today."
"I might need to stay in the hospital for a few days, right?"

You could see the natural progression of his answers and what his intent was in coming to the ER.

 I performed a detailed exam and found him, despite his chronic medical issues, to be stable and well from an emergency perspective. Labs were drawn, a urine sample sent, an EKG performed. All his results were favorable. Kevin deserved this workup to make sure he was safe.

"Kevin," I asked, after finishing the interview and physical exam and reviewing his results, "is there anything else we can help you with today? It seems that your exam and results are okay today, so this is a good visit."

And this is where Kevin broke me and exposed the weaknesses of our system and my job. "So, Doc," he asked, his dull eyes fixing on mine, "you are going to just send me back into the world then?"

Ugh! What a question. "Yes, Kevin," I said, "we are going to have to send you back into the world."

"Why can't you admit me? Even for just tonight?" He took another swig of his coffee.

My hands were tied. I certainly couldn't admit him--the hospital isn't for this purpose. Yes, we could see what we could do about his safety. Yes, we could feed him. Yes, we could spend a few extra minutes with him this visit. In fact, Kevin's nurse, Nurse Pearl, was as invested in Kevin as much as I was. Even more. With her blond hair, calm voice, caring demeanor and big heart, Nurse Pearl was the perfect nurse to care for Kevin during his visit this day. She spent much of her free time with him--she cleaned him up, washed his face and even put hospital-issued socks on his feet. I commended her for her compassion to which she replied, "There's something about being clean and washing one's face that makes people feel human again."

Together, we formulated a plan. We agreed to try to find Kevin some food. She and I agreed to get our case management team involved to see what our options in helping Kevin might be on this day.

After five minutes, we reconvened in Kevin's room. He had already put on his Carhartt jacket and was packing his filled plastic bags into the small compartments on his walker. "Kevin," we said, proud of ourselves, "here are a few things we found to help you." And we spilled our contents in front of him.

Four breakfast bars.
Three juice boxes.
Two turkey sandwiches.

Kevin seemed quite grateful for this attention and supplies.

Nurse Pearl and I were on the same page. Handing out food in the ER under these circumstances can sometimes be quite conflicting among my co-workers. Some are of the belief that we shouldn't, as it might encourage more visits among these patients. Others, like Nurse Pearl and I, believe that these patients will be returning regardless of the food handouts. The root of this problem, to us, lies deeper. It seems too many of our patients are lacking support, proper care (including mental health issues), and safe environments during their hardest of times. The answer? I wish I had one... do you? Discussing this dilemma with my 89 year old father, though, was simplified to this. "Jimmy," he said, "you have to do the right thing--if you can help feed a person who's hungry, why wouldn't you?"

After the case management consultation, we were able to help place Kevin into a shelter.  In fact, Nurse Pearl went so far as to arrange a taxi to safely transfer Kevin to the shelter. Prior to leaving, Kevin could not contain his gratitude. "Thank you, sir." "Thank you, ma'am." Have a nice day." "This is really great." "I am really happy."

One community shelter.

All in all, it was a good day for Kevin. More importantly, if was a good day for Nurse Pearl, myself and our support team. We were reminded that empathy and compassion for one another must never be lost or forgotten during these privileged encounters.

Ninety minutes.

The amount of time Kevin was in our ER, reminding us of the the real reasons most of us chose to go into medicine.

Some things you just can't learn in a textbook. You learn it from your heart.

As always, big thanks for reading. What are your thoughts? It was wonderful to have the time to spend with Kevin, which isn't always the case in our extremely busy ER/trauma center. 

Feel free to forward or share this post.

Thanks to each of you for the overwhelming response to my return. Your comments on here as well as Facebook, email, and Instagram have been generous, kind, and inspiring... I am grateful.

Friday, February 8, 2019

To Care Or Not

I dedicate this to each of you who have cared for or are currently caring for an ill parent or family member. 

Recently, due to the stress that several of my dearest friends have been experiencing in caring for their elderly parents, I am even more appreciative and respectful of my privilege in caring for elderly patients who have attentive and loving adult children who accompany them to our ER.

Although this may seem like it should be the standard, you would be surprised at just how many elderly patients present to our emergency department alone. At times, it is heart-breaking to hear their shared stories of being the lone survivor of their family, of being estranged from their children, or of having geographical factors contribute to their aloneness in presenting to me for care. So when an adult child is present, I make it a point to not only introduce myself to them, but also to thank them for being available for their parent. Including them in providing more history and in discussions about testing and treatment plans for their parent benefits not only their parent, but also myself and my team. I am grateful for their presence and input.

A few months back, however, I had both the pleasure and discomfort of witnessing two vastly different situations in how adult children interacted with their parents.

The first interaction came early in my day shift. I had just rounded the corner of one of our busier hallways near our noisy triage area to find a favorite aide leading a family from our waiting room down the hallway toward their assigned room. The family consisted of two middle-aged adults, a teen-aged boy, and an elderly woman who relied on a walker to ambulate. As the tech led this family, it became clear to me that the elderly woman was struggling, lagging behind the others. Noticing this, I stepped forward as the aide simultaneously stepped back to help this woman continue forward with less struggle. 

The woman, who was wearing a simple purple dress with white walking shoes, with messed shoulder-length grey hair, was quite appreciative for our efforts. She paused to look with her wrinkled face first at the aide, and then to me on her other side, rewarding me with a warm, generous smile. Even tired, she had a gleam in her eyes that conveyed her gratitude.

Sadly, the members of her family didn't want to be bothered. Asking the aide for their mother's room number, they continued down the hallway at their own rushed pace, walking into the opened door of Room 31, which was about 50 yards away. The aide and I glanced at one another, with a look of bewilderment, before continuing onward in guiding this patient. By the time we got to Room 31, the patient's family had already turned on the TV, both adults sitting in provided maroon chairs and the teen-age kid sitting on the edge of the bed. 

Ugh. The aide and I continued to lead the patient into the room. Together, after asking the teen-ager to get off the bed, the aide and I eased the patient onto a stepping stool before hoisting her into the bed. We sat the back up for her to be more comfortable. All the while, the three family members, who I learned later to be her son, her daughter, and grandson, focused all their attention onto a sporting event on the TV. 

You get the picture, right? Clearly, this was not to be another love story I would bear witness to and write about between an adult child and his parent (visit A Love Story). I am not naive enough to believe that all parents are perfect, and that some may have made mistakes or caused pain to a child--I am simply stating that as an outsider, this is a hard scenario for me to witness. 

I left the room as the aide was changing this patient into a gown. Later, she found me.

"Can you believe that family? I would never ignore my mother that way. They were so annoyed to be here and didn't even say a word to her!" The family bordered on making Lauren angry, and that wasn't a good thing. 

As I was not this patient's treating physician, I shared the story with my partner, who was treating the patient. His experience was disheartening. It seemed the family was completely uninvested in their mother's care, opting to ignore her while they watched TV before visiting the cafeteria to eat, returning only to act annoyed that they still had to wait for her results. After it was decided that this patient would be admitted, the family, instead of waiting for their mother's room number and assignment, left. Their mother would be transported to her admission room without any supportive family accompanying her.

Later in the shift, thankfully, I was privileged to witness an outpouring of love between a parent and her grown children during a visit.

Margie, my 72 year-old patient, was a beautiful spirit trapped in a failing body. Her short brown-dyed hair, her worried face, her clear eyes with underlying dark circles, her protruding cheekbones, and her thin frail body sat upright in her cot, covered in several warm blankets in attempts to help her chills and aches. Despite her fragility, she greeted me in sassy way.

"Well, hello there. Are you going to be my doctor today?" she asked as I entered her room

"I am, ma'am," I said, extending my hand to her. Her hand, cool and boney, felt fragile in my grip.

"Good then," she said, "let's get busy and figure out what is wrong with me."

Immediately, I liked Ms. Margie. She had a coy yet innocent way about her.

In the corner of her room sat her three adult children, two women and a man. All three were attractive and had their mother's clear eyes. They appeared nervous, of course, and I sensed that their mother's reason for being here was going to be a serious one.  I walked over to them and introduced myself to each of them, shaking their hands and learning their names. As customary, I thanked them for being in the ER with their mother.

"You do know how much you are loved, right Ms. Margie?" I said, starting the conversation. "You have not one, not two, but three children with you tonight. How wonderful and blessed are you. I don't see this much support too often."

"I am a lucky lady," she said pensively. At that, one of the daughter's spoke up. "No, Dr. Jim, we're the lucky ones." I liked these children as much as I liked their mother.

As I interviewed Ms. Margie, it was refreshing to see how all three kids were involved in her life and knowledgeable about her symptoms. It seemed all three of them, each with their own family to attend to, took turns spending an unselfish amount of time with her. Several years prior, her husband and their father had passed. Ms. Margie, with her fierce independent streak, insisted on remaining at her home and the kids did everything possible to continue making her comfortable.

As I gathered information from Ms. Margie and her kids about her symptoms, I felt my concern for her well-being exponentially increase. She smoked although "I've really been trying to quit, Dr. Jim." She had several months of significant weight loss with increasing fatigue and weakness and, despite her children's urging, refused to see a doctor until several weeks prior to her visit with me. Finally, with her continued deterioration, she agreed to her children's requests to come to the ER for some workup.

Her workup was heart-breaking. Initially, her chest x-ray revealed a pretty large mass in her lung. While Ms. Margie was over in the radiology department getting both a CT of her chest and brain for further investigation of this mass, I stopped into her room to visit with her kids.

"Are you all doing okay?" I asked, opening up a chance for them to express their concerns.

And they did. "Is it cancer?" I answered that I was very suspicious of this, yes. "Is Mom going to die?" I told them that we had several bridges to cross to figure out exactly what it was and what we could do about their mother's results. "Should we share any bad results with Mom?" Yes, I said. I told them that most patients inherently have a feeling when something isn't right, and their mother was one of those patients who would not want any of the results sugar-coated.

They continued to ask questions, all rooted from a very deep, endless well of love for their mother.

Finally, one of the daughter's broke down and started crying. I walked over to her and gave her a hug. "I'm so sorry," I said, "but I think your mother, no matter what her results, is going to have the best support ever from you three." My compliment was sincere--Ms. Margie was blessed, no matter her results, to have these three children accompany her on this journey.

Unfortunately, Ms. Margie's results were devastating.  Lung cancer--a huge mass residing in the right middle lobe. Brain metastasis--multiple lesions sprinkled throughout. Bone metastasis--"cystic lesions" consistent with cancer in her vertebrae.

Damn it all.

I went into the room and sat on the edge of her bed, explaining Ms. Margie's results to her while her three children crowded around her, holding her hands and stroking her hair. Though brave faces were attempted, tears fell plentiful and freely. Mine included. We admitted Ms. Margie to the hospital to have a variety of consultations and begin her journey of fighting cancer.

Despite such different situations involving adult children accompanying their ill parent to the ER, the depth of emotions I felt, whether good or bad, ran deep. I felt such despair over what I witnessed regarding the mother with her walker being ignored by her family. I felt such despair for Ms. Margie and her kids, too. The difference, though, was that this despair for Ms. Margie was minimized by the amount of hope, by the infinite love, and by the sincere compassion that her children provided unabashedly to her. The power of their presence and investment in her well-being was magnificent.

Ms. Margie was transported to her admission room with her three caring kids beside her.

I get it. Some parents failed their children. And some didn't. And the ripples from these relationships travel far. I understand that some of these relationships have a reason to be strained and forced. With all of these factors, though, I'm a pretty damn privileged guy when I get to bear witness to the unselfishness and unabashed love an adult child has for their ill parent.

I love my job...

As always, big thanks for reading. Have a great weekend. To my dear friends and each of you who are involved and invested in your parent's care, my hat is off to you. Big kudos for your unselfishness and love. Please feel free to share your thoughts or experiences. 

Also, big thanks for the amazing support I received upon my return essay. It feels good to be back.

Tuesday, February 5, 2019

I Feel Things...

I'm  back! Thanks to the many people in my life for their support and encouragement upon my returning--you know who you are! Please feel free to repost, share my return, and visit my archive!

Well, well, well...hello my long, lost friends. I missed you!

It seems like a long, long time since I have written a post for my blog, StorytellERdoc, and I am excited, nervous and humbled to be reentering your lives while returning to my baby.

What started as a small adventure and challenge from my writing group, with my first posting on November 19, 2009, turned into quite an amazing ride throughout the literary and social media world. The number of friends I met was staggering. I received recognition and awards. I won prizes. I was interviewed and contacted for my opinions. I got over a million hits. All of these things, though, were secondary to my intent. I simply wanted to pull you into my world, through my words, to focus on obscure life and ER moments that possessed a level of rawness and realness that connected you and I as fellow human beings. I wanted my words to be a reminder that choosing empathy and compassion over cynicism and sarcasm was possible.

On this journey, I posted 150 essays about life, patient encounters, and magnificent small moments--writings that to this day I can still read and feel the array of emotions I poured into my words. These writings made my heart swell, my eyes tear, and my smile broaden. They still do. My last post, on March 16, 2015, was not a planned exit from writing for my blog but, unfortunately, life happens and I needed to take some time to gather the bits of myself that became brittle and crumbled over the years. I had life lessons I needed to absorb. I had experiences I needed to process. I had to refocus my energy and passions and love onto the things and people that deserved my attention.

I am human and I have flaws. My life isn't perfect. Not even close. Now, though, it's in a much better place, thanks to a lot of internal work and introspection. I have more clarity.

I am back and stronger than ever. Personally, I look forward to sharing with you my journey. I hope to entwine my life experiences into my writings. Professionally, I still smile when I go to work, which is all I really need to say about that, right? The emergency department where I have worked for 22 years as an ER physician is busier than it's ever been. We are treating everything from devastating traumas to irritating hang nails. Among the 90,000 patients that we treat yearly, you can imagine the numerous interactions and situations that exist, simply waiting to be witnessed and observed.

I hope to be that witness, that observer. I hope to bring to you, through my storytelling, a perspective that is unique and intriguing in the way it unfolds the the human spirit with the laughter, the tears, the triumphs, and the pain of an encounter. Some stories will be personal, some will be professional, but all of them will be heartfelt.

In many ways, I am still the same person you got to know through my essays over the past few years. If you revisit these essays (visit the archive or try Gigi or The Witness), you will still capture my essence. As before, I still love my three amazing kids and my big forestry family. I still miss hearing my mother's voice. I still wear my heart on my sleeve. I still love my diverse friends and music and books and the gym and laughing and a good meal and sleeping in. I still love the privileges of my job--I continue to meet, accompany and treat some pretty amazing and memorable patients and their families during their stressful ER journeys.

In other ways, though, I have changed immensely. These changes will be revealed slowly, with time.

At this very moment, as I sit here in front of my computer screen, I am very nervous but grateful for the chance to enter your life with my stories. I offer my warmest thanks for your patience and time as I begin to expose my layers to you, once again.

While recently deciding to pursue this journey again, I signed into my ignored email account and was surprised to find many unopened emails from the past few years. They were wonderful, supportive, and encouraging. Some correspondences took the time to share their personal experiences and connections to my essays, and these emails made my decision to return even easier.

Let me share..."I don't remember what prompted it, but I ended up over at your blog the other day. What I thought would be a quick trip is turning into a multi-day journey back through all of the posts I read years ago. Once again, I was amazed at your gifted storytelling, your attention to detail and the way they're all seamlessly woven throughout, and the gentle, inspirational way you share with us readers perspectives we will otherwise never be able to see. Katie"

Again..."Thanks for the beautiful stories and insight from the physician's perspective. Please keep the stories coming. I look forward to each and every one. Thanks for sharing your experiences with us. They touch our hearts and many times make us smile and feel uplifted if only for but a while. Shirley"

And again..."Yours is not the first ER blog that I've read but there is an obvious difference. You don't seem to have the customary judgmental bitterness. I've been thinking about it and what makes you different from another doctor. I think part of it is that you are not afraid to feel things. Most of us spend our whole lives trying to get away from the bad/uncomfortable feelings. After a break up you stay busy and party with friends to avoid those feelings of sadness, etc. I think many ER doctors have shut themselves off from the feelings of their patients. Their goal is to become immune to the suffering by reason of self-preservation. You, on the other hand, seem to see that it's ok to be sad about something sad. You are not afraid to experience your feelings but you also don't live in them, either. I think this is why you've kept your humanity. Anyways, thank you very much for your writing. Jennifer"

So all my mumblings above come down to this...

I feel things...

I hope I can make you feel things, too...

Until next time...

As always, big thanks for reading. To all my faithful readers--hello, friends! Thank you for returning. To my new friends, thank you for giving me a chance. I look forward to sharing this incredible new journey with all of you!

Jim