The Lonely Walker

They made a regal couple, the elderly man and woman sitting in Room 19. She was the patient, he the supportive husband. She sat in the treatment cot while he sat in a chair pulled near her bedside. Together, they greeted me with their warm smiles as I walked into their room.

They both had full heads of healthy, silvery hair that shimmered from the overhead fluorescent bulbs. Their eyes were intense and watchful, and their crescent lips, framing big, teethy welcoming smiles, stretched like thick, pink rubberbands across their lower faces. He was impeccably dressed in conservative, mid-season wear, including a green layering-sweater. She was in a threadbare hospital gown, clearly confident and stylish despite her outfit.

After introductions and the shake of our hands, I learned that they were both in their early eighties and had been married all of sixty years. Sixty years! Can you believe that? How amazing. I congratulated both of them on achieving such a milestone.

"I know where I'm going," she laughed, looking heavenward, "for putting up with him all of these years." He laughed harder at her words than she did.

This, ultimately, explained the matching walkers that were parked against the counter in Room 19. Who needed matching rings for a 60th anniversary present, anyway? I would think that I, too, would be more practical on my 60th anniversary. I noticed these walkers immediately upon entering the room. His and hers. Identical. Front wheels, back posts with thick rubber stoppers, and a right-sided hand brake on each. Greenish-blue in color. Her's had feminine clothing casually strewn over the front bar.

She was 82, to be exact. "He's a few years older than me," she jokingly added, dismissively nodding toward her husband, "I'll always be his spring chicken." By triage notes, she had presented with a two-week history of worsening abdominal pain "that came in waves," mainly to the right upper quadrant. "But right now," she told me, "it isn't so bad." It seemed to be associated with any intake of food.

She still had her gallbladder and my first three thoughts of the cause of her pain were gallbladder, gallbladder, and gallbladder. Of course, elderly women thoroughly enjoy stumping us in the medical field, so I also entertained other suspected reasons for her pain--an ileus (where the bowels are less efficient in moving air or material forward), a bowel obstruction (where the bowels kink on themselves and prevent any forward passage), referred pain from the heart or lungs, an atypical urine infection, or some form of peptic ulcer disease.

I questioned her further. She had no fever. No change in bowel movements. Some occasional nausea and bloating. Then, I asked her one last question, whose answer raised my suspicions beyond the normal concerns.

"Do you have a cancer history, Mrs. Brown?"

"Actually," she answered reflectively, "I do. I had breast cancer about a year ago." She looked over at her husband and smiled. "Remember those days, dear?" She explained that she had undergone chemotherapy following a right mastectomy.

Oh no, I thought to myself. Add metastatic cancer to that list. Unfortunately, I have seen several cases of elderly patients with a remote history of cancer who had presented with a recurrence of their cancer, abdominal pain being their only complaint. I could only hope Mrs. Brown wouldn't be in that category.

I did my exam on Mrs. Brown. Sure enough, she had significant abdominal pain to her right upper quadrant, but only if I was palpating deep in that area.

I explained my suspicions to her. We would need to test her urine, her blood, perform a chest x-ray, and finally, the most important of all the tests, perform a CT scan of her abdomen. That would effectively rule-out or rule-in my biggest concerns. Because we had just had a stroke patient and a trauma patient before her, I explained her workup may take a few hours time.

"Honey," she said to her husband, "go ahead out to the car and take a nap. I'll be all right in here. Dr. Jim," she added, winking at me, "will take good care of me."

Any other night, I would have worked hard to find an extra cot for Mr. Brown, but this night in the ER was crazy. I knew there were no available beds. "Go on, Mr. Brown," I said, "you have a few hours nap time ahead of you. I'll take good care of your wife."

I left the room and let Mr. and Mrs. Brown have a private moment. Minutes later, I saw Mr. Brown shuffling down our hallway toward the exit sign, guiding his lonely walker along the way.

Slowly, Mrs. Brown's results started to return. Her urine was clean. Her chest x-ray was unremarkable. Her blood work, however, returned with two concerns-a mild drop in her red blood cell and platelet counts and an elevation in three of her liver enzymes.

I entered her room to explain her results to her. And also to share that she was now second in line to go over for her CT scan. She was, however, napping. I softly strolled up to her lone walker to check it out more closely. It was spiffy. I've only seen aluminum and black walkers before, and was wondering if this was a custom paint job.

"I never wanted that thing," Mrs. Brown said, my back to her, startling me. I turned around. She had awakened. "Edgar needed one. I was afraid he was going to fall. But you know men...he insisted that he didn't need one. The only way I got him to finally accept using one was if I got one, too."

I nodded. "They sure look nice," I said. "Thank you," she said, "they are identical. We call them "the twins." If I had to use a walker I didn't really need, then at least I was going to pick out a color that suited me."

I smiled before remembering the business at hand. Slowly, I explained to Mrs. Brown what I had meant to explain when I first revisited her room. After finishing, I assured her that I would be back the minute her CT results returned.

An hour later, I walked, heavy-hearted, back into Mrs. Brown's room, accompanied by her nurse. Mr. Brown had returned, his silvery hair now somewhat mussed up from his successful nap. The greenish-blue walkers, side by side again, seemed to present a fortified protective wall. I held her CT report in my hand.

"Good news or bad news?" she asked, as Mr. Brown leaned forward from his seat and grabbed her hand. I looked them both in their eyes.

"Not good," I said. I went on to explain that Mrs. Brown's liver, via CT, appeared abnormal. Not only did she have multiple liver lesions suspicious for metastatic disease, but she also had a solid liver mass that was partially obstructing her small bowels. As I spoke, I appreciated the tightening grip Mr. Brown's hand took to Mrs. Brown's.

We all took a deep exhalation when I finished my explanation. "Well," Mrs. Brown said, "I guess that how she goes, then." She looked over at the two walkers, side-by-side. "I guess I won't be needing that thing much longer, Edgar." Her eyes grew glassy, and I was surprised that she had focused her attention, after such devastating news, on the walker. After spending a few more minutes with them, I stepped out to arrange for Mrs. Brown's admission.

Rare or not, I still strongly believe in the power of prayer, sometimes if even to make me feel a little better about things. I'll admit, though, that there are times when my prayers take on a very different, even bizarre, angle. The night I treated Mrs. Brown, I'm sure, my prayers were along that path. Although, to me, they were quite simple and clear.

I prayed that those walkers would sit side-by-side for another 60 years.

As always, big thanks for reading. To the amazing commenters from my Wednesday post, thank you, thank you. Too kind. Next post will be Monday, May 24. See you then...

Pretty Gassy

I walked into the central nursing station to find the chart for Room 34, my next patient, and was greeted by Nurse Laurie.

"Dr Jim," she said, handing me the chart as a wave of smile splashed across her face, "I see you signed up to treat my new patient. Good luck. You're going to love this one."

Ugh. A statement like that can be a double-edged sword. And at 2:00 a.m., I could only hope that Laurie meant it in a good way. But, truth be told, her smile scared me a little.

I walked down the hallway, lightly knocked on the partially-opened door to the room, and entered. Lying in the cot, passed out, was a 22 y.o. college student. Beyond the room's dim lighting and this patient's evident sloppiness, I could still appreciate that this was a beautiful young woman.

She could have been a beauty queen. Or an actress. Or a model. Maybe she was a hero among us--a loving granddaughter who visited her grandmother every day in a nursing home or a big sister who watched closely over her younger siblings while she was growing up. Maybe she was that daughter who gave her daddy his laugh-lines.

Maybe. But right then and there, in our ER, she was just another drunk college student. Her hair was mussed up, some grass mixed within her blond, tangled curls. Her lipstick was disheveled and thick. Her mascara had bravely abandoned her lashes, streaking down to visit her jawbone. Her clothes were in a disarray of tucks and untucks. She was a drunken mess.

I turned on the room's overhead fluorescent lights before walking to the right side of the cot. I raised my voice. "Hey, Tiffany," I said, "it's time to wake up and talk to me."

She stirred slightly, moving her head away from my noxious voice and the overhead lighting. "Tiffany," I said, now rubbing her shoulder, "you need to wake up and tell me what brought you here tonight." I padded my khaki's pockets to see if I had any weekend ammonia capsules left. I didn't.

She stirred a little more, this time opening her eyes and focusing on me. I smiled at her. "Where am I?" she mumbled, trying to absorb her surroundings.

Before I could answer her, though, she brought her right hand up to her mouth. I thought she might be ready to vomit or have dry heaves, but she didn't. She simply belched. Big time. It was disgusting and, yet, thoroughly impressive. And as if to let me know that it was no fluke, she belched again. After the second belch, an inebriated giggle and grin escaped her.

Laurie walked in, the smile still frozen on her face. "I thought you could use some help," she said. Yeah, I thought, help me pencil in the eyebrows that this patient just smoked off of my face.

I had read Laurie's nursing notes on this patient but, since the patient wasn't capable to answer my questions, I had Laurie, who had been privy to the prehospital report, fill in all the blanks for me. It seems that this patient, at a local tavern, had just helped a friend celebrate a birthday by downing several shots. After leaving the bar, she simply laid down on a nearby lawn to "go to sleep." Her friends, worried for her, had called 911. She was transported to our ER.

Tiffany's exam, performed with Laurie present, was benign. Well, except for her obvious intoxication. Her vital signs were stable, she had no evidence of trauma, and all parts of her systemic exam were within the normal limits of my expectations. With enough prompting, she was able to talk to Laurie and I in a slurred voice, confirming that she had been out to the bars with friends that night, drinking just "a little bit." She pinched her thumb and index finger. "Just a little," she repeated. She giggled, as if she thought she were successfully fooling us. Upon pressing her, however, she remained amnestic to lying down on the grassy ground.

While Laurie and I got her more comfortably situated, Tiffany closed her eyes to continue her nap.

And that's when the shit hit the fan. No pun intended.

Without warning, while she was napping comfortably, Tiffany let out a long, muffled, fluttering fart. Seriously. It caused both Laurie and I to jump back. Again, like her belch, it was disgusting and, yet, thoroughly impressive. And within seconds, from the stench, I suddenly wished that I could lay claims to such bragging rights as this patient. Someone, please, call the producers of "America's Got Talent."

Laurie looked at me, her gaping mouth mirroring my own. "Oh no, she didn't just do that." I nodded yes, trying to stifle my amusement, as Laurie continued . "That's just gross. If she shits herself, I'm not changing her."

I knew better. If this patient needed cleaned and wiped up, I had every confidence that Laurie would indeed do the right thing. Maybe, to rebel, she would wipe back to front, but still, she would do it.

So, imagine it. This beautiful inebriated girl, all dolled up and resting comfortably in her cot, letting one rip. So unladylike. So disgusting. And yet, so impressive (have I said this already?). Trust me, in Tiffany's case, it was not "what's on the inside" that counted. Thanks to her sharing her insides with Laurie and I, we could confidently say that her outside was probably the better bargain.

Well, Miss Tiffany didn't stop there. Before we left the room, round two occurred. And, while a family from a nearby patient room waited in the hallway while their mother got her EKG done in privacy, Tiffany decided to rip round three. Rounds four and five happened, fortunately, while Tiffany was over in the radiology department getting a head CT. Rounds six, seven, and eight, though, occurred after she returned back to Room 34, much to the dismay of Laurie and all of the central station nurses. Despite her room being located about fifteen away, Tiffany still managed to make quite an impression on all of them.

Because it was a quiet night, we were able to keep Tiffany in her ER room and observe her frequently. Well, the nurses did. After reviewing her normal CT, I was content in just getting updated reports about her from Laurie. Who am I to come between Laurie and her excellent patient care?

Finally, after about three or so hours, Tiffany sobered up enough to walk our hallways and go to the bathroom on her own accord. She walked out of the bathroom shaking her head. "I look like shit."

I think we all bit our tongues over that easy set-up.

Prior to being discharged, I checked on Tiffany for one last, final exam. She checked out well.

"I'm sorry about bothering you last night, sir," she said, chalking up a point for her apology but losing it just as fast by calling me sir. "Sir" equals "old man" when I hear it spoken to me. "I hope I didn't do anything to embarrass myself," she added.

"Oh, no," I assured her, lying through my teeth, "you were perfectly behaved. Not a problem at all." I wanted to be honest with her, but I knew that the truth would have completely embarrassed her. What purpose would that have served? She had been the guiding foghorn on our dark, murky, overnight shift and would never know.

She smiled then, completely unaware of how awe-inspiring her performance had been. I wished I could have given her a standing ovation. Instead, I extended my hand to her and we shook. "Good luck to you, Tiffany." Yeah, I thought to myself, good luck in your pursuit of the 2010 Miss Flatulence title. You're a shoe-in. "Thank you, sir," she responded, gathering her possessions and folding her discharge instructions into her jean pocket.

Pretty and gassy. Pretty gassy.

A pretty vulgar combination, if you ask me.

Isn't a little Monday morning bathroom humor better than a strong cup of coffee? LOL As always, big thanks for reading. See you mid-week...

"Yoo-Hoo"

As I sat down at my computer station to finish the chart on a patient I had just treated, I heard something quite interesting. A voice, smooth and mellow, was calling out.

"Yoo-hoo."

It was an older woman's voice. I was immediately taken back to when I was a child, in my grandparent's house, standing beneath a small, cottage-shaped clock that hung on the wall. With a new hour approaching, I held my breath, staring up at the clock, its small pendulum swinging beneath, clicking a constant, relaxed beat. Eventually, the clock chimed, a little trap door opened, and a small bird popped out and chirped it's greeting.

"Coo-coo. Coo-coo. Coo-coo." Three times, like clock-work (no pun intended). Standing outside of my memory looking-in, I saw the little boy in his summer shorts, his tanned face framed with shaggy brown hair, smiling as he looked up expectantly at the wooden bird that never failed to mark a new hour.

"Yoo-hoo. Yoo-hoo." The woman's voice snapped me back to the present.

I got up from my chair and followed the yoo-hooing until I was standing at the bedside of an elderly woman with matted soft-grey hair and empty hazel eyes. She clearly had dementia. She looked quite comfortable, though, and was mumbling something to herself between the yoo-hoos.

"Do you need help with something, maam?" I asked, straightening her sheets and tucking her in. "What can I get you?"

"Help me!" the patient screamed, "I need help."

This patient's nurse walked in just then, a younger nurse that I enjoyed working with. She was compassionate, knowledgeable, and hard-working. And apparently, at that moment, frustrated.

"Is everything all right in here, Victoria?" I asked, ready to help.

"Everything's fine. Mrs. Pello has Alzheimer's and was sent by the nursing home because the nurse there thought she was acting 'more demented' today." Victoria gave me a knowing glance. We both recognized the bullshit excuse by the nurse who sent in Mrs. Pello, trying to make her own shift easier. At our expense, of course.

"Anything wrong?" I asked. "You need me to see her?"

"Dr. P. picked up on her. We're just going to get some baseline tests and a CT scan of her head. If it's all good, she'll be heading back soon enough."

"Yoo-hoo," Mrs. Pello called out, yet again.

"On second thought," Victoria said, laughing, "if you can get her to stop yelling 'yoo-hoo' every five minutes, I would appreciate it."

"I kind of like it," I said. "It reminds me of a coo-coo clock my grandparents had when I was a kid. She sounds just like the little bird that popped..."

I was interrupted by Mrs. Pello. "Help me! I need help!" Her sudden outburst had caught Victoria and I both by surprise. Then, without pausing, Mrs. Pello continued. "Yoo-hoo. Yoo-hoo."

"Just wait," Victoria warned me, both of us chuckling, "you might like it now, but after a few hours of this, I'm not so sure."

Well, little did I know at the time, but Victoria had hit the nail right on the head. Mrs. Pello's loud "yoo-hoo" was methodical and rhythmic, an audio alarm that was set to go off every five minutes, interrupting our workday. Unfortunately, her door had to be left open so that the nurses in their station could keep a close eye on her. And the risks of sedating her outweighed the benefits. So her yoo-hooing would just have to be accepted for a few hours.

Soon after meeting Mrs. Pello, a middle-aged man, who had collapsed at home, was brought into our ER and placed in the room next door. His right side was completely flaccid (no muscle strength) and he had a facial droop. An obvious stroke. A stroke alert was called and we emergently intubated this gentleman, hooked him up to a ventilator, and aggressively treated his escalating blood pressure. This patient was critical.

And then, suddenly, in the midst of treating this crisis, there it was. "Yoo-hoo. Yoo-hoo." It was clear and resounding. Everyone who was involved in treating our stroke patient did a quick pause. "Yoo-hoo." Mrs. Pello had added another one for good measure.

"Come on, people, back to work," I said, reminding them of our task at hand.

"What the hell was that?" the neurologist and neurosurgeon asked me, intrigued. "You really don't want to know," I said, grinning. My ER team, including Victoria, was shaking their heads, obviously trying to stifle their laughs. Swiftly, we transferred the stroke patient to the OR for emergent surgery after his CT scan revealed a large hemorrhagic stroke--blood on the brain.

Unfortunately, treating the stroke patient delayed Mrs. Pello's own head CT and she continued to sit in her room, waiting. "Yoo-hoo." Yep, about every five minutes.

At another point, as a family passed by Mrs. Pello's room while being escorted to their treatment room, she started screaming out "Help me! I need help." The family's eyes widened from fright. The staff, immune to the cries, didn't even budge to help, which I'm sure thoroughly impressed this family. They had to have thought of high-tailing it and heading to another ER. Someplace where the doctors and nurses cared.

Eventually, though, Mrs. Pello went over to the radiology department for her head CT. We all cheered, looking forward to a few minutes of silence. Unfortunately, not even five minutes had passed before we got an urgent call from the CT tech. "Can someone come over right away? Mrs. Pello is screaming for help." Oops, someone forgot to warn the tech of Mrs. Pello's outbursts.

She returned from her CT scan and, thankfully, all of her workup was normal. She had been in our emergency department for approximately four hours. Well, not approximately. More like exactly! Even those of us not involved in her care were celebrating her finished work-up and immediate plans to be transferred back to her nursing home. However, due to several ongoing emergencies, it would be one more hour of waiting until the ambulance service arrived to take her back. "Yoo-hoo."

Even though I wasn't treating her, I couldn't help but go into Mrs. Pello's room several more times to make sure she was comfortable. You see, not only did her "yoo-hoo" trigger a wonderful childhood memory of that coo-coo clock, but Mrs. Pello herself reminded me of my grandmother, an amazing and fiercely-independent woman who also was stricken with dementia.

Victoria was dead-on right. After five hours of "yoo-hoos," Mrs. Pello's voice had lost most of its charm and smooth, mellow tones. Now, her cries were simply annoying. Our staff gave her a wonderful farewell, lining up in the hallway to witness her be escorted by the ambulance team back to her nursing home. I think they were just making sure that there would be no screw-ups--that Mrs. Pello was actually leaving. Do not pass go. Do not collect $200. Just get the heck out!

Me? Well, of course, I was missing Mrs. Pello and her "yoo-hoos" five minutes after she was discharged. It was too quiet! And truth be told, I don't think I was alone. I think we all were suffering from yoo-hoo withdrawal.

So, I took a deep breath, calmed my fears, made my voice smooth and mellow, and did it.

"Yoo-hoo."

Update: One week later...
Good news...you can hardly see my black-eye anymore. I just wish someone had warned me that Victoria knew karate!

As always, a big thanks for reading. The next post will be Monday, February 15. Happy Valentine's Day to all of you...

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