Tuesday, February 12, 2019

4, 3, 2, 1 And 90.

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

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.


Beth Nelsen said...

So much of what we do in medicine isn't medical. I hope my residents get this by the time they're done. It's easy to diagnose and treat; the art is in the management. We can only help our patients once we take the time to listen and empathize with them. This is where I draw my strength from, and it's what brings me joy in medicine. I'm lucky to work in a place where this is the expectation and not the exception. Thank you for sharing your story.

Katie Axelson said...

Woof. This is such a hard thing. I'll be honest, the regulars wear me down--both the honest ones and the dishonest ones. Especially when even the honest ones they try to manipulate me to go way above and beyond protocol because of the "inconvenience" this was to them. I don't have turkey sandwiches to give out. I wish I could connect them with mental health services or additional resources. But in addition to a tight clock and a pocket full of exit excuses, I do also have a listening ear and basic counseling training. Part of me says "If we don't help, who will?" The other part of me says, "They're taking advantage of the system and keeping me from those in true need." Except they too have waited their turn for time with me. So the real question becomes: how can I love them well in this moment without my loving them well taking away from loving the others well? Like you, some days I can linger. Some days I can only provide a place a sit that doesn't disrupt our traffic flow, a clean bathroom, and free wifi. Some days that has to be enough. And some days it can't be enough. Kill them with kindness... even if I only have 5 minutes.

Melissa H said...

You are amazing... reading this I felt as if I was in that room with you and Kevin. Just to think- ten+ years ago I was in those rooms working with you and watching in awe of your professional and caring demeanor you displayed... no matter who the patient was. Thank you for being you. Thank you for sharing.

Lydia said...

So easy to forget that without those who just even listen , life becomes a different painting. It only takes a single, gentle stroke of the brush to touch a lonely soul. Thank you for that reminder

jimbo26 said...

The only thing I can say - thank you to both of you and the help from others .

Unknown said...

What patient's representative does?I saw one once to the ER. Why not do a follow up with those patients and reader them appropriately where they will get the other real help they need. Because, I know, resources are out there. So, use them!

G-31 Toastmasters said...

I work in an elementary school. I am sad to say that many Regulars start being Regulars even as early as Kindergarten. The school nurse has to say things like "I have seen you four times already today, Kevin. You are fine. Go back to class. Bus is at 3." How sad is that? The need for extra TLC runs deep in some.

Unknown said...

As a ER Registration Clerk, i try to help the Nurses daily..."what can I do for you, non medical?" I also have 2 adult childrenn who battle addiction. (Thank God both are sober). I just found your stories recently, due to the Misspoken Senator.
You hit the nail on the head.
Thank you.

Unknown said...

Thank you for this blog, you are so right about everything. Being in EMS I see it all the time, I spend less time with them, I often wish I could do more to change their situations or help guide them. I am now involved with Mobile Integgrated Health which we hope to address those "regulars" and help them with resources to hopefully better their situations and self manage their healthcare