It's Not About The Pus

To Dr. Sandra Lee. Heartfelt thanks for humanizing medicine and for inspiring along the way...

Several years ago, my daughter Emma introduced me to some videos on YouTube of a dermatologist from California who posted her sometimes shocking but always intriguing encounters with patients who suffered from a variety of dermatologic issues. Of all of these videos, it seemed like the ones which made Emma happiest to watch were the videos in which this doctor's treatment resulted in gallons of pus draining from some part of the patient's body.

Well, okay--Emma liked pus and blackheads. Well, pus and blackheads and massive lipomas (fat-based tumors). Well, pus and blackheads and massive lipomas and big hairy moles. Well...

You get the picture.

With some great finesse and skill, and with a good mix of humor and learning, Dr. Sandra Lee, better known as Dr. Pimple Popper, was able to help many embarrassed patients survive their dermatologic issues, all the while captivating my daughter's interest. "Eewww, gross," Emma said. "Let's watch it again!"

Suddenly, my job as an ER physician was boring. Stories of heart attacks, strokes, traumas, broken bones, asthma attacks, allergic reactions, even drunks vomiting on me at 3 am--none of them held any excitement compared to the ten-year old massive cyst that Dr. Lee excised from a women's scalp or the golf ball-sized lipoma she removed from the upper back of a man who hid it by wearing a draped shirt. Yes, it was intriguing even for me to watch. How was I going to compete with Dr. Lee popping juice out of everything she touched?

I lost my daughter to the wonders of Dr. Lee. "Dr. Pimple Popper is so great, Dad!"

Not only Emma, but soon my friends and family were asking if I did "the stuff that Dr. Pimple Popper does." They too couldn't seem to get enough of the various videos posted on YouTube. And like Emma, more pus equaled more entertainment. Pus that flew across the room--well, that created a giddiness that could not be contained.  

"Yes," I would answer, "sometimes I have to drain an abscess from someone's armpit or groin due to an ingrown hair. Sometimes I have to drain abscesses from wounds, too." For good measure, I added, "And sometimes I have to drain a thrombosed hemorrhoid." I know there are many more invasive procedures we perform in the ER that could be considered similar, but I couldn't think of them quickly enough. At least, I thought, I would get asked what "thrombosed" meant, right?

I was wrong. After finding out that most of my procedures were performed on problems smaller than the size of a tennis ball, my people lost interest.

As the last few years passed, I was happy to catch an occasional YouTube video of Dr. Pimple Popper. Dr. Lee's contagious personality and warm smile, combined with her intelligence and skills, helped her to create a spectacular vehicle, by use of videos, to share the fascinations of her profession. She was a natural at bringing some amazing stuff to eager viewers who were insatiable for her.

On a recent trip with friends to Toronto to celebrate the arrival of 2019, we had returned to our hotel rooms one afternoon to rest for a few hours after a very late previous night of fun. While channel-surfing, I was excited to rediscover Dr. Lee and learn of her new television show on TLC. Desperately needing a nap, I committed myself to just watching her for ten minutes, maybe fifteen at most.

Fifteen minutes turned into two hours. In the blink of an eye.

This time, though, watching Dr. Lee was a very different experience. Yes, all of the fascinating lumps and bumps and lesions that needed squeezed, drained and excised still existed. Yes, white and brown and green and black pus still oozed from the majority of her patients. Yes, many of her patients still found brilliant ways to hide their ailments for years, under wigs and baggy clothing or with caked-on makeup.

This time though, among all the hoopla, I was able to appreciate Dr. Lee's magnificent mannerisms, her empathy, her compassion--her realness, so to speak--in dealing with her patients. Recognizing these things initially, I believe, had gotten lost within all the other excitement. I was more focused on how fast she could duck away from some flying pus rather than her gentle approach to patient care.

For example, after a patient was kindly greeted by office staff and placed in an exam room, the real magic began. Dr. Lee would softly knock on the door of the treatment room before entering, wearing a smile and exuding warmth. As she approached the patient, hand extended in greeting, she would establish eye contact with the patient and introduce herself with a gentle and calm voice (sometimes simply by her first name). From there, if anyone else was in the room, she would turn her attention to them, making sure to introduce herself, repeating the process until she was acquainted with each person in the room. After introductions, she would sit down (yes, sit!!!) and begin her interview with the patient, involving the patient's company, learning everything she could about the reasons a patient was visiting her. Respect was given and received. Eventually, a wonderful level of comfort was achieved.

I could continue on with the importance of Dr. Lee's empathy and compassion while performing a detailed exam, explaining her findings of the exam, reviewing test results and options to treatment, and mapping out the future course of dealing with a patient's ailment, but it all seems rather obvious, right?

Or does it?

You would be surprised at the number of patients who go through the process of a medical encounter only to leave with confusion, frustration, or feeling worse than prior to their encounter. No introductions. Standing at bedside with arms folded, appearing disengaged and aggravated. Rushed conversation. No updates. Abbreviated result explanations and dispositions. This is the reality of an encounter for many patients.

Ugh.

Recently, a close friend of mine had to take his elderly mother to a rural ER twice, in a span of two weeks, for some serious and concerning symptoms. To hear him talk of the vast difference in the care they received, by the same facility but different treating teams, was upsetting. During the first encounter, introductions were made, respect was given, explanations were provided, and a detailed treatment plan was initiated. During the second visit, there were no introductions by either the physician or nursing team. His mother was dismissed or hushed each time she tried to explain her symptoms in some depth. They were made to feel like a nuisance. No rechecks were performed. They sat around for five hours wondering what was going on. Their questions brought no answers. "And Jim," he said, "only about five of the twenty rooms had patients in them." My buddy's family was truly disheartened and discouraged by the encounter.

Years ago, during my emergency medicine residency in Syracuse, we had a physician who gave lectures to us on the importance of empathy and compassion. Being young-guns in a big trauma center, Dr. Ruth's lectures were not nearly as exciting to my buddies and I as compared to lectures on how to drain an expanding epidural hematoma (a potentially fatal arterial brain bleed) or perform an emergency thoracotomy in a trauma patient (rapidly opening the chest between ribs to clamp a sheared aorta or contain bleeding from a punctured heart or lung, for example).

Yet, it was during residency when I truly realized the power and magnificence of empathy and compassion in medicine. Of respect and dignity. Of smiling and bringing into a patient's room good energy. Of sitting down if even but for a few minutes. Of introductions and eye contact to all in the room, not just the patient. Of a warm handshake. Of explaining findings of the exam, of the testing and procedures to be done and the ensuing results, and of a plan moving forward. Of rechecking the patient during their medical visit. Of properly closing the loop of their visit with a goodbye or good luck wish.

Of being human.

This was a crusade I took up while working with our residents as a core faculty advisor. I became Dr. Ruth, insisting on my residents bringing their very best to each patient encounter. While empathy and compassion and ease of conversation was inherent and easier for some residents, for others more time and work needed to be invested to improve this part of their patient encounters. An investment, I stressed, that was worth pursuing.

Yes, the ER gets busy. Crazy and insanely busy. I get it. I've witness it firsthand for 22 years as an ER attending physician. However, all of these things mentioned above take just a few extra minutes. Providing anything less is met with too many excuses. Occasionally, in the emergency setting, it truly is beyond our control that we simply can not provide more empathy or time to a patient (think about a car accident with four critical victims arriving at the same time). Otherwise, if it were me or my family or friend lying in that hospital cot as a patient, I would greatly appreciate those few extra minutes of kindness and compassion provided by the treating medical personnel.

What if it was you or your family member?

Returning to Dr. Lee's TV show, then, on that lazy afternoon in Toronto, I greatly appreciated her kind approach to each patient. Sure, she might have more time working in an office setting that is more predictable and controlled compared to my working environment in a big trauma center. Sure, she is being taped to splice together some great scenes and moments of the various care she provides. Sure, anyone might give a little more of themselves if they know they are being watched. However, Dr. Lee consistently demonstrated her excellent bedside manner with each patient encounter I watched. She excelled and inspired in a part of medicine that is often ignored and overlooked, all for the sake of moving more patients in and out and increasing the billing so more profits could be made.

I could have cared less about how much pus would fly out of her next abscess or where it would land. I was enthralled on simply watching a great doctor doing her job well, from every perspective.

I hope Emma was, too.

Thanks, Dr. Pimple Popper. It was never really about the pus...

As always, big thanks for reading. What are your thoughts and experiences?   

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I continue to be amazed with the amount of support and readership. My heartfelt appreciation to all...   

Going Down or Going Up

Anyone who is familiar with the medical field is well aware of the hierarchy that exists for the typical doctor in training. It starts in medical school, when you are a lowly first-year, and culminates after you finish residency, when you are a polished doctor, an attending, defining your own terms.

During the first year of my emergency medicine residency, we were assigned a rotation of five to seven weeks in a very demanding surgical sub-specialty service. Lucky me. Not only was I assigned this rotation during December and January, the holiday months, but my specific time was seven weeks with this service.

Heart transplants, bypass surgeries, lung resections, and much more--all at my lucky finger tips. The main reason for our involvement in this rotation, as ER residents in-training, was to learn how to perform a chest-tube insertion. Simply, it involves cutting through the skin of your mid-lateral ribcage, through the muscle and cartilage layers between two ribs, and accessing the lung space. You then insert a hollow tube into this lung space, which when hooked to a low-pressure vacuum, evacuates blood or air, or both. Either of these (usually from a trauma) can collapse the lungs and cause respiratory distress, which can lead to cardiac distress, so quickly inserting this tube can be life-saving. This procedure, known medically as a tube thoracostomy, is one of the "musts" that anyone entering the emergency medicine field must learn.

Simply put, though, this rotation sucked. I can't put it in any nicer terms. I was tired and worn-out, depressed and miserable, from all the hours and extreme demands of this rotation. A typical day started between 4 and 5 a.m. and finished, if you weren't on call, around 6 or 7 p.m. I was on call every third day, which meant I worked a 36 hour shift that day. Over Christmas, it got even worse--I was on call every other day. This was genuine, hellish, character-building training back in the days when strict rules and regulations were just evolving.

The hierarchy was never more evident to me than during this rotation. I was a lowly emergency medicine intern on service with several medical students below me and a fellow surgical intern beside me. Ahead, a second-year internal medicine resident, a fourth-year surgical resident, and a "fellow," a graduated surgical resident pursuing several additional training years in a surgical sub-specialty. And, of course, our attending, who varied day-to-day. Eight of us made up the team.

Did I mention that this was a hard rotation?

The funny thing about medicine, though, is that, as a resident, an intern, or medical student, there is much more to be learned from a rotation than just the medical knowledge and patient care. I constantly stress this to our emergency medicine residents. Be alert. Absorb everything about a patient and their case. Be compassionate. And watch those teaching you, extracting the best and worst of those experiences to add or avoid in their own practicing. I credit myself for being the doctor I am from emulating my favorites attendings just as much as from learning how not to behave or practice from certain individuals in the medical field.

From all my experiences during these seven weeks, one negative experience prominently stands out. Unfortunately, it doesn't involve a patient but rather the attending of our team. It was Christmas Day, around 11 a.m., and I was on-call. After finishing morning rounds, the departing on-call team, the attending, and our oncoming on-call team were collectively going down an elevator to the main-entrance lobby. Our attending that day was a fiftyish, hard-working, intelligent physician who, quite honestly, was always quite impressed with himself. His people skills, though, were extremely lacking.

Despite everyone being either depressed or exhausted, a lot of effort by others was going into kissing our attending's ass--laughing at his jokes, hanging on his every word, schmoozing left and right. Someone eventually asked him what the rest of his Christmas Day plans were.

"Well," he answered, "unfortunately, all my kids came home for the holidays."

"That's a bad thing?" I blurted out, surprised by his answer. I would have done anything, anything at all, to have spent the day with my wife and my family.

"Yes," the attending replied, surprised by my question, "very bad, actually."

"May I ask exactly why it's bad, sir?" I asked, ignoring the glare of my senior resident. I knew she wanted me to shut up, but that wasn't happening. "Is it too many people in the house? Too much commotion? Something like that?"

"Hardly," he replied, laughing to himself and shaking his head. "My family aggravates me and, quite frankly, I don't enjoy their company." He could have stopped there but didn't. "My wife and I have four kids, two married, no grandchildren. I would love some grandkids, but my kids are too damn selfish for that."

He got momentarily lost in his thoughts before speaking again. "Let me give you all a little piece of advice. This job we do--make it the priority in your life. Don't get distracted with a spouse and kids if you can help it. Trust me, they only get in the way." I waited for him to laugh, to finish out his joke of a statement. No laugh ever came, though.

His words had silenced the elevator and still, he continued. "Now I have to go home and play nice with my wife and kids. Trust me, that's a much harder job than this, any day. If I had my choice, I'd avoid all of them and stay here for the day." The elevator bell rang as he finished speaking, the doors quickly opening to let the departing on-call team and the attending out. No last holiday wishes from any of them.

If only the attending had remained silent and lost in his thoughts, I wouldn't have had to pity this man and his ridiculous words. "Have a nice fricking Christmas," I mumbled to no-one in particular.

Here I was, an intern-- a low-life medical scum barely clinging to the bottom of the totem pole--wishing for nothing other than to be surrounded by the ones I cherished on that Christmas Day. And here was the attending-- a worshipped doctor high on his pedestal--wishing for anything but to be surrounded by his family on Christmas Day. Clearly, he was letting his life be defined only by his successful professional accomplishments. And he seemed to be okay with that. He didn't seem to be affected by his failures as a husband. As a father. As a friend. As a man. He probably didn't see it, even.

How sad. How very, very sad.

Although I learned a lot during this rotation, none of my gained medical knowledge came close to the perspective I gained going down that hospital elevator on that Christmas day. I was shown a clear example of what I did not, nor would ever, become. No textbook could have taught me that.

Writing this post, I realize that I never found out how that Christmas day turned out for this attending. I wonder if there were any family arguments? Did anyone drink too much? And what emotion saturated the dining room while this family ate their holiday meal? Anger? Silence? Am I too hopeful and naive to think that maybe there was a little happiness? I picture extreme silence, barring the silverware clinking the plates, with everyone maintaining their robotic and detached manners. I hope I am wrong.

This attending gets full credit for teaching me something valuable during that rotation. Climbing up the hierarchy of medicine did not mean that I would have to sink down the hierarchy of family and friends. I would never sacrifice one for the other.

Best Christmas present I got that year, for sure.

As always, big thanks for reading. I hope you all have a great weekend. See you next week...

Heroes Among Us--Gigi

The world just lost another angel. A hero. An ordinary person with extraordinary kindness and love.

Do you ever stop to think how often through your typical day you pass by an angel or hero and simply don't know? Busy, busy, busy. We have things to do, errands to run, and phone calls to make. We keep strangers at arm's length. And the cost of this hurriedness is simply that we fail to share and learn about one another. Every face we encounter holds a history, a story to be told, and sometimes those stories are remarkable and breathtaking. The unfortunate thing is that we will never know if we don't take the time.

Enter Gigi. Someone who always took the time.

Gigi was an EKG technician at our hospital. Almost nine years ago, as I have touched on previously, my son was diagnosed with a rare malignancy that required him to be on chemotherapy for a year. He failed to stay in remission and had to undergo a second complete year of chemotherapy to achieve remission again. Since then, he has been in remission for five years and is an extremely well-adjusted, bright, athletically-gifted boy who makes my chest swell with pride. Through his experiences, I have learned much about life, about love, about compassion, and especially about embracing the daily moments that hold the simplistic joys that many feel come only with big life-events.

What I was learning at that time in my life, however, Gigi already knew. She was frequently called down to our ER to do EKGs on patients and she could be overheard in conversation with them, asking them frank, sincere questions about their health, their lives. She seemed to really care and enjoy her interactions with each new face.

I didn't really know Gigi, however, until one day when she approached me soon after my son's initial diagnosis.

"How is your son doing?" Her voice had startled me and I looked up from my chart to find this middle-aged woman with a soft perm, intense eyes, and a big smile talking to me.

"Pardon me?" I asked, surprised at her bluntness. Most people either tiptoed around me or asked me directly about my son. I appreciated the latter approach and Gigi did too, obviously.

"Your son. I just found out about him and I'm praying for him and your family I just wanted you to know."

She was a stranger and yet, looking into her eyes, she was my immediate friend. I couldn't break my gaze with her. I knew that she got me, that she understood. She looked beyond my face and forced smile to see the hurt and anxiety that I was carrying.

"I'm Gigi," she said, holding out her hand. I took it and introduced myself. And she really did want to know about my son. How was he was doing? What medicine he was on? How was he adjusting to having a mediport? She genuinely cared and her thoughtful questions reflected that caring.

After a few minutes of conversation, she had to go do a stat EKG and I had to return to my patients. But before we parted, she asked "Can I have a hug?" A hug from Gigi, I learned that day, held more compassion that a hundred Hallmark cards. It was genuine and heartfelt--not just a quick expected pat on the back.

Through the years since, we learned much about one another's family, yet every time I saw Gigi, her first question to me would be about my son. "How's that boy doing?" His return to good health brought many authentic smiles to her face.

About a year ago, in the midst of a crazy shift, Gigi approached me with some worry on her face.

"Doc," she said, never once calling me anything else despite my urging to use my first name, "I'm really worried." She proceeded to explain that she had some abdominal bloating and intermittent pains for months but was afraid to approach her doctor. She felt it would be bad news and didn't want to face it or ruin her husband's recent retirement.

"Gigi," I said, "let's get you in a room. I want to do an exam and run some tests."

"Oh, no," she said in true Gigi fashion, "I'm off tomorrow and these patients need you today. Let me come in tomorrow to see you and I'll bring my husband along. I'll do whatever you say, but tomorrow, okay?"

Of course, Gigi. The next day, as I knew she would, she did come in with her husband. He was just as I pictured Gigi's husband to be--kind, considerate, supportive, and worried. Gigi and I had never taken our friendship beyond the hospital's walls and it was my pleasure to match her husband's face to her loving stories about him.

Unfortunately, Gigi's workup did reveal some serious findings. She had cancer. Cancer that had aggressively spread beyond its primary site.

With this news, I approached her room with a heavy heart. And knowing me as well as she did, she knew the minute I walked in the room that I held heart-breaking news.

"Just tell me, Doc. Don't sugarcoat anything."

I pulled up my chair, grasped her hand, and explained all her results very thoroughly. She cried, her husband cried, and I cried. It simply wasn't fair. Hardworking, decent, compassionate, loving--none of these traits had protected Gigi from something bad. It was her right, I felt, to only have good things occur in her life. I was really affected by her results and through the rest of my shift, I heavily relied on my Naphcon A eye-drops. It was now my turn to pray for her and her family. We admitted Gigi to continue her workup of identifying her type of cancer, its location, and its staging.

Remarkably, my son and Gigi had never met and, encouraged by my wife and I, all three of our kids made Gigi get-well posters. The next day, Cole and I hand-delivered the posters to her. She was in her hospital bed, her husband sitting in the corner, when Cole and I arrived. We knocked and walked through her room door. After looking up at us, Gigi immediately reached out her hands for Cole, who instinctively walked to her bed and sat down beside her. Gigi wrapped him in her arms and my lucky son received the same exact hug that I had received nine years earlier. If it was possible, his hug was even more magnificent than mine had been.

Through her battle, Gigi never once lost her faith or let her beautiful spirit waver. We shared hospital visits, phone calls, and cards, which never seemed to be enough to satisfy this sender's aching soul. She was, as you would expect and hope, surrounded by loving family and friends throughout her ordeal. She braved multiple rounds of chemotherapy and radiation and, despite her body's failings at times, pushed forward in attempts to beat off her disease. "I'm not doing this for me," she said, "I'm doing this for my family."

Sadly, though, Gigi passed away before the holiday season began.

Gigi was never defined by fame or fortune, but rather by compassion, kindness, and love. She embraced humanity wholeheartedly and clearly enjoyed touching the lives of others. If she hadn't taken the time with me nine years prior, reaching out to me in a dark moment of my life, I would have missed having an angel here on earth as my friend.

Gigi, I thank you for taking the time.

As always, thank you for reading. We all have a Gigi or two in our lives, hopefully more--if you want to share a little about your Gigi, feel free to in the comments. Next post will be Wednesday, January 13.

The Family Room

It's in every emergency department.

Empty, it's just another shell of a sparsely decorated hospital room, lacking vibe and energy.

But when you fill it with nervous, hopeful family members awaiting news of their critically-ill family member, it is transformed into a room that can barely contain every possible extreme of human emotion.

It is The Family Room.

So, you ask, why is this room known as The Family Room?

This is the room where the families of the most extremely sick patients are placed while the medical team uses every available effort in their medical arsenal to save a life. It's a place for family to be alone, to comfort themselves in the face of adversity. These may be families of trauma victims, heart attack victims, stroke victims, or any other critical illness. Because the family room is usually situated on the edge of the department, it is usually quieter, more calming, and private. A far cry from the commotion that usually accompanies the room in which resuscitating a patient is happening.

Don't be fooled, though. This is no ordinary room. Physically, it may look like any other decorated hospital room, with a few extra vases and boxes of tissues thrown in, but that's where the similarities end. It is a room that demands and deserves respect. It is a room that I imagine as my friend, absorbing and buffeting and protecting all within it from the swirls of anger and the clouds of desperation. Sometimes, just sometimes, the mood is joyful. More often than not, however, this is a room where dreadful news is delivered to a family not prepared for such news.

Our own family room is just as I described above. It sits in the corner of our department, nestled between our waiting room on one side and the entrance hallway to our department on the other. It's painted beige and coral with a flowery border at the top--comfort colors, I guess. Short shag navy rug. Two of the corners hold lamps, usually lit for better ambiance. The furniture consists of two love seats and two wing-backed chairs, a couple in dark blue floral patterns, the other in pink and coral. Slightly better quality fabric and stuffing than the standard hospital furniture, but not by much.

How do I know these details? It's amazing the small things that I notice when I'm trying to blink back my own tears in sharing a family's misery. Sometimes I'm transported back to tenth grade when I counted Christmas tree ornaments on our church tree during my grandfather's funeral, all in the hopes of distracting my impending tears. 157 ornaments on the tree closest to the Virgin Mary.

I rarely deliver news alone to a family waiting. Either the ER social worker or the supervising nurse accompany me, sometimes both. I wear my long, official white coat to respect the gravity of the situation.

Imagine that moment right before walking into the family room with bad news. I hesitate at the door, take a deep breath, and remember that my words and support will be paramount to the family. I open the door, usually to be greeted by several anxious family members either pacing or sitting well beyond the edge of their chairs. After introductions of myself and my team, I ask them how they are each related to the patient.

Then, the hard part follows. I sit close to the spouse or family. Sometimes, I am offered a hand to hold and I eagerly take it. If the patient has already died, I make it a point to not linger and share the news almost immediately. It is important to be blunt but heartfelt, using the words "dead," "expired," and "we did everything we could." It has been shown that a family needs to hear several variations of the word "dead" so that the news sinks through their despair. Reassurances are given that everything possible was done.

If the patient is still alive, I review with the family everything being done to save their loved one. I explain any prehospital treatment, what we are currently doing for the patient in the ER, and give the family a brief opportunity to ask questions. We sometimes need to review the patient's living will or DNR status and to what level efforts should be pursued. Family members may even be invited to witness the resuscitation.

Through all of this, I don't lose eye contact. I focus on each person in the room, letting my eyes say something different from my words. "I'm so sorry" is the most simple and heartfelt offering.

As an ER doctor, I have a protective shell around me that I can usually maintain. But in the family room, I am different. It is not rare for me to leave with tears in my eyes, and that does not shame me. It is my privilege and blessing, really, to accompany a family through some of their darkest moments. I appreciate their acceptance of my presence during their misery. Who am I to bear witness to their profound loss?

I have been told by several staff members that my greatest gift is how I interact in that family room. But, for whatever I bring to that room, it is but a feather compared to the weight I carry away from it each and every time I meet another family.

I am humbled by this part of my job. And respectful of the family room's role in our ER.


Thank you, as always, for reading. I am grateful...may your week go well. Next post will be Wednesday, December 23.

Meeting Candy

It was early morning, 4 a.m., the first time I met Candy. I had been on the job for about a year. Not having any idea what I was walking into, I slid Candy's curtain to the side to enter her treatment room. What I walked into was better than a shot of espresso.

Candy was running her fingers through her nurse's long blond hair.

"Honey, what I could do with your hair if you let me," she was saying to Mo, who was being an awfully good sport about it. I'm not sure I could let some stranger caress my scalp and hair in this manner.

"Yeah, yeah. Thanks, Candy," Mo answered, "that's what you told me last time, too."

So, Mo already knew Candy. I later learned that everyone who works in our ER knew Candy.

Candy, as it turns out, is a transgender male-to-female. These terms can be confusing, but transgender simply means that a person is living cross-gendered without sexual reassignment surgery.

Candy was known for handing out brutally honest fashion advice to our staff during her treatment time. I was only too happy to watch her interaction with Mo play out.

"Yes, honey," Candy continued as she held tight to Mo's hair, "you need to cut it a little shorter, get some highlights, and have it frame your face better."

"Um, okay, thanks Candy. I'll get right on that," Mo answered, still the good sport. "You do remember, though, that it's four in the morning, right? I'm sure not getting gussied up for an overnight shift."

"Ugghhh," Candy continued, ignoring Mo's defense, "and your split ends! Girlfriend, how could you? Go get me some scissors and I'll take care of this mess right now."

Mo extracted herself and her hair from Candy's grip. And then noticed me standing by the entrance.

"Oh, Candy, look who we have here! One of our doctors is waiting to see you." I do believe that Mo had just thrown me under the bus!

I stepped forward with my hand extended and introduced myself to Candy, feeling her eyes bore into my every fiber.

"Well, well, well," she said thoughtfully, "what do we have here?"

Nope. I'm first. Let me describe Candy to you. First, her outfit. She was in a white with black polka-dot mini-skirt with white tights, humongous red heels capping the ends of her lower extremities. Her shirt was sheer, white and black zebra-striped, hanging loosely over her skirt. She had a five o'clock shadow, a prominent Adam's apple, and thin scraggly hair that hung limply to her shoulders. Her makeup was very loud, despite the facial contusions and abrasions from the assault that brought her to us this night. She was sitting upright comfortably in her cot, one leg bent under her thin frame.

Okay, now your turn, Candy.

"Hair, good. Body, good. Nice eyes. Nice lips. Wow, look at those cheekbones!" Yes, I was really liking this Candy character, but made a mental note to myself that I should probably check her vision on this visit. Mo, who I thought was leaving the room, decided to hover to see what advice I would be receiving. She was leaning against the wall, arms crossed, smirking at me, thoroughly enjoying me being in the hot seat. She must have known it was going to get ugly soon.

"Wait. Oh yes," Candy exclaimed, pointing at my mouth, "look at that tooth!"

Shoot. I can't believe she narrowed in on my tooth. I think I have pretty nice teeth, barring one slightly off-colored one on my right upper front. And even this tooth isn't so bad. I had gotten knocked in the mouth playing basketball a few years ago, resulting in this tooth turning slightly off-white. My dentist had thought it would die and I would ultimately need to get it pulled, posted, and replaced. However, the darn thing didn't die off completely, and now I was stuck with a half-living tooth. Kind of like tooth purgatory.

Eventually, I knew I would have to get the tooth addressed, but it didn't bother me, and you had to look really hard to see it. At least I thought so. Thanks, Candy, for looking hard.

"Yeah, sugar," Candy continued, Mo now in a full-bloom smile, "get that thing taken care of, would you? Jesus H. Christ! Why would you walk around looking like that?"

How can you not smile? I started laughing, but Candy was just getting warmed up.

"Honey, can you spell manicure? Because you need one bad. Look at those bitten-up nails!"

I looked down at my hands, appreciating my nails, actually thinking that they looked pretty good to me. Now, though, I was feeling the need to apologize. "I'm sorry, Candy, I can't help it."

"Well, help it. You're a doctor, right? There's no reason you shouldn't be getting yourself some manicures (she said it like "man-neeeee-cures") and pedicures." She shuddered and continued. "I can only imagine what your feet look like!"

"Do you want to see them, Candy?" I asked, now enjoying this immensely. I had on hospital clogs, it would be easy to accommodate her.

"Ugghhh," she said, "find somebody else with a foot fetish. That ain't me, honey."

Ouch! She was tough. Clinton and Stacey from "What Not To Wear" held nothing on Candy.

Well, I'm happy to say that Candy turned out alright that night. Just some bumps and bruises. Interestingly, she had been working a corner in one of our less-desirable neighborhoods and had been picked up by four college boys for her services (this was her version). Less than a mile later, when they found out her true gender, they assaulted her and threw her out of their barely stopped car.

I'd like to think it wasn't her gender that bothered them as much as her fashion critiques. Can you even imagine? "Honey," she'd start out as she bent to get into the car, "what's up with all those pimples on your face? And you," she'd continue, looking at another one, "what's up with that greasy haircut you're sporting?" Yep, out the door she went.

I've seen Candy in the ER a few more times since then and always enjoy her wisdom and our conversations. Most recently, I was out to a dinner party at a local restaurant that was having a simultaneous gathering of transgender/transsexual localites. As my party followed the waitress to our table, we passed the gathering and there was Candy, sitting at a table with three other members, laughing and smiling and being quite animated.

Her hair is still scraggly. My tooth still isn't fixed.

You go, Candy!

Thanks for reading, as always, and have a great weekend. Next post will be Monday, December 21.

Please Make Her Comfortable

During a recent shift, I was witness to a family's struggle and courage in facing their mother's illness.

Their mother, age 96, had broken her hip a week prior. Because of significant health and social issues, the family and patient concurred with the orthopedic team that it wouldn't be wise to operate.

The patient was sent to a local rehabilitation facility. Prior to the transfer, the patient and her family had discussed at length a living will and to what degree heroics were to be performed in the event of a medical emergency. They opted for no intervention whatsoever--no CPR, no medical testing, no antibiotics, no intubation, no resuscitation efforts. Basically, they wanted only comfort measures for pain and anxiety relief.

A very difficult decision, of course.

Within a week of being transferred to the rehabilitation facility, unfortunately, the patient started to have a cough. Soon after, she began to have a harder time breathing.

The facility, despite their best efforts, eventually sent the patient to our ER when it was discovered that she had very low oxygenation levels. They were not equipped for this.

I walked into this patient's room and after introducing myself to her and meeting her family, consisting of two sons, a daughter, and a daughter-in-law, I began to sort out what I could do to help this patient and her family.

On exam, this patient was obviously struggling and appeared to have pneumonia. She had a fever and very low oxygen levels. When I listened to her lungs with my stethoscope, she had classic findings for infection. She was starting to get very fatigued and was not as mentally alert as her family knew her to be.

Normally, with a patient in this situation, we are very aggressive. She would have been intubated and received three, sometimes four, antibiotics intravenously. She would have gotten a very thorough workup that would have included x-rays, blood work, and possibly a CT scan of her chest to make sure she didn't have a blood clot in her lungs, a possible consequence of her hip fracture.

However, upon review of the patient's paperwork sent from the rehab facility and the family's personal request at her bedside, we did none of this. We respected their wishes and this patient's living will.

I did order this patient some low doses of morphine and valium which made her more comfortable. The family was quite appreciative. Although the patient was critically ill, she was not yet near her end. After another discussion with the family, we came to a mutual decision to admit their mother to the hospital and continue her comfort care. The family was uncomfortable taking the patient home with her hip fracture. I called their family doctor and he graciously came in and handled the admission.

During the admission, I was stopped by the daughter in the hallway. She was very tearful, as any of us would be, and second-guessing their family decision of no heroics.

"Mom lead an amazing life. I know it's time...but this is so hard to watch. I feel like we should be doing something more."

I put my arm around her. "God Bless your family," I said.

"Well," she sighed, "this is how Mom wanted it, so I guess we have to respect her decision."

I nodded at her words. I have several times witnessed these decisions reversed, but it seemed that this family was not going to follow that route.

The daughter, though, still needed to reconcile the decision with her anguish.

"What would you do?" she asked me suddenly.

Her question caught me off-guard. It was a question that I couldn't possibly answer for her. Her family's decision was made after weighing many specific circumstances, circumstances that I knew nothing about. So no, I couldn't give her a direct answer.

I explained this to her. "But," I continued, "does the rest of your family still support this decision?"

"Yes," she said, "and I think I do, too."

I decided to open up to her. I shared with her how several years ago, my beautiful mother, after courageously fighting and beating back leukemia for several years, decided that it was time to stop. It had been an extremely difficult decision, fully supported by my father, my six siblings, and myself. Because Mom knew. And despite all the setbacks, her faith had never wavered and her spirit had remained unconquerable. She had fought the fight and had benefited from that fight. But, unfortunately, her disease had come back with a vengeance. After several failed attempts to reenter remission, she chose to stop all further treatments and go home to spend her remaining days enveloped in our love.

"So, yes," I said, "it was very hard to watch. But it was the right thing for Mom and our family."

Now, the daughter nodded at my words. After a moment or two, she spoke. "Mom did have an amazing life, but yes, it is time."

I squeezed her hand in support and she leaned in and gave me a hug.

"Thank you," she said as we parted.

No, I thought to myself as I walked away remembering my mother's beautiful spirit, thank you.

What Do I Know?

One of the hardest parts of being a physician is that people expect you to know everything about everything. And I have to be brutally honest here. That ain't me. But, thanks to a great residency and medical school, I do know my medicine.

Heck, though, I'll be the first to admit that I've never known much about plumbing. Or electrical work. Or car engines. Or how to cut an onion without crying. Or rectal foreign bodies.

Whoa, back up! What did I just say?

Yes, you heard me right. Rectal foreign bodies. As in having something in your behind that shouldn't be there. If you need to squat over a mirror to look, then chances are something is wrong back there. Seriously wrong.

So, imagine my surprise when, in my first year of residency, I discovered that our hospital's ER, being centrally located among several prisons, got it's fair share of rectal foreign bodies.

"Wait a second, people," I wanted to scream out, "I didn't sign up for this part of the job!" As long as I was making a list, I didn't sign up to do internal pelvic exams on eighty year-old ladies with blue hair, either. Unfortunately, though, in the ER you simply don't have a choice. Besides, I was a first-year resident. That's about as low as you go on the medical totem pole. Who would have listened to my concerns?

I remember well my first "something's stuck back there" patient. One of my favorite teaching physicians, Dr. Z., held a chart out for me. "Hey, K.," he said, "there's a patient in Room 12 I'd like you to see." Looking back now, I should have known his snicker was not all that innocent.

I walked into the room to find a regular Joe sitting on his cot, his feet and legs dangling off the side, looking a little uncomfortable.

Hmmm, not a prisoner. So far, so good.

"Hello, sir. I'm Dr. K. What can I do to help you today?"

"Well," the patient stammered, "I had an accident."

"What kind of accident?"

"Well," he started, his eyeballs almost rolling up into his brain to recite his rehearsed story, "I was at the gym and after working out, I got a shower. After I was done, I walked back to my locker wrapped in a towel and as I went to sit down on the bench, the guy next to me put his hairspray bottle down and I sat on it. It was an accident."

I promise you, he did not even crack a smile. It's amazing how distracting ass pain can be, I guess. Even as a first-year resident, I knew a good story when I heard one. The storyteller in me wanted more.

"So," I said, "did the bottle scratch your skin? Leave you with a bruise? What happened to it?" I, in some twisted way, wanted to hear him admit to me that as we were talking, a Clairol hairspray bottle was still missing.

He looked at me incredulously. "Look," he said, "you're new here, right?"

"Actually, yes, I am. Why?"

"Because, I've been...," he blew out an exasperated breath before continuing, "let's just say that this isn't the first time this happened to me." That explains Dr. Z.'s smile. And what gym has multiple hairspray bottle accidents in their men's locker room?

It turns out this guy had several "accidents" in his past that brought him to the ER. And, of course, they didn't really happen at the gym. He was a local celebrity of sorts. It was my privilege to finally meet someone famous, although a few years prior, I had met Cyndi Lauper. That should count, right?

I listened to the patient's heart and lungs with my stethoscope for way too long, hoping against hope that my shift would end before I had to do the rectal exam. No such luck. After feeling his abdomen, it was time "to look back there." I stepped out of the room to bring Dr. Z. in with me. After all, he was my teaching physician for the shift (plus, he dragged me into this case).

Dr. Z. walked in. "So, Joe, I see you met Dr. K., one of our new residents. He treating you okay?"

Great, Dr. Z. and Joe were buddies. "Yeah," Joe said, eyeing me up, "he'll do."

This is where my learning curve took off.

"Okay, Joe," Dr. Z. said, "you know the routine." Dr. Z. had Joe get on all fours on his cot (yes, my mouth was gaping open, too) and, after several layers of gloves, we inspected Joe's backside poking out of his gown. No scratches. No bruises. Then we tried to manually (unfortunately, "manually" meant using my fingers, not Dr. Z.'s) grasp and remove the hair spray bottle. Although I could feel the bottom of the bottle, I was unsuccessful.

I was filled with shame from my failed attempt. I had wanted this story to have an ending where I saved the day, where all the nurses would cheer for me, a measly first-year resident, and my unlimited brilliance as I walked out of Joe's room holding up the Clairol bottle like it was some sort of treasure trophy.

Dr. Z. tried his best to cheer me up. "It's okay, K. Really. This is what residency is for--to learn how to successfully pull a hair spray bottle from a patient's ass. There'll be more." Funny guy, that Dr. Z.

We sent Joe to x-ray. Abdominal films revealed to us that, just as Joe had said, there was a stuck hair spray bottle. Just beyond our reach. I blacked out Joe's name on the x-ray and made myself a copy to frame and hang over our fireplace, but my wife refused. "Don't you even think of taking down our wedding picture!" Sometimes I wish she could be a better sport about this stuff.

Unfortunately for Joe, the bottle would have to be removed in the OR. We tried one last hurrah by using a special rectal speculum and graspers, but no such luck. Yep, Joe was heading to the OR.

While under anesthesia and completely relaxed, the GI team was able to use a scope to retrieve the missing bottle from Joe's backside. I can only hope that they got the round of applause that I had dreamed about.

I often wondered what Joe told his family and friends about his hospital visits. I mean, really, what if one of them wanted to send flowers? What do you write on that card? Please let me know if you have an idea about that--I'm blanking out.

I still don't know much about plumbing or electrical work or peeling an onion without crying. However, I'm proud to say that so many years later, I know all I need to know about rectal foreign bodies.


Thanks for reading...and enjoy your day. The next post will be Wednesday, December 16.

The MoooooER

Imagine your phone ringing. You scurry around your house, rushing to locate the handset.

You finally find it.

"Hello," you say, winded, "how may I help you?"

There's a pause.

"Hello," you repeat, "is anyone there?"

Suddenly, without warning, you get your answer.

"MMMOOOOOOOO!"

That above scenario, my friends, would be me calling you.

After my first year of residency, my wife had called me at work, quite excited, telling me she had found an amazing house for us to rent during my last two years of training.

Say what? I was surprised and didn't know we were "looking" to move from our very comfortable, two-bedroom condo just ten minutes from my hospital.

"Trust me," she reassured me, "you are going to love it."

And she was right. I did love it. Leave it to my wife to find such a great place.

The new house was about 35 minutes from the hospital, almost all country driving. It was built by Farmer Ed, an old-timer who we grew to love as family, smack in the middle of his cow and corn pastures. Farmer Ed had built this house for his planned retirement in a few years and wanted to rent it out until then. It sat comfortably on the top of a beautiful mountain range, alongside a curvy, country road where neighbors waved as you passed by. The views were endless and the sunsets spectacular. A small, friendly town sat just a few miles away.

It was not uncommon for us to wake at the break of dawn in our new house, cows milling around our bedroom window, talking to us in their language. Many a times I had dreams interrupted by Bessie's moo. Sometimes, even, it felt like Bessie and her gang were having some fun with us, staging their own version of The Sound of Music. Hey, Moo Trapp Family, go back to your hills in Austria and let me sleep!

Ashamed of myself, I must admit that I rolled over a time or two in my dreams to snuggle up to Bessie and her warm, engorged udder. "Moo," I whispered seductively in her ear. "Moo moo," she answered back, blinking her big eyes and batting her long lashes flirtatiously at me.

Okay, I just made that up. Sorry.

Anyway, my wife loves to speed walk and sometimes, on days when I was home, I would go with her. I always struggled to stay alongside her, but the country scenery and surrounding beauty did much to distract me and make the walks more tolerable and even fun.

One day, as we passed a pasture of grazing cows, on a whim, I stopped and inhaled a deep breath. Plugging my nose, from the back of my throat I forced the air out, emitting a low, guttural "moo."

"Hey," my wife said, "that was pretty good."

And you know what? It was good. I knew because the cows had stopped their grazing to look up.

I took another deep breath and mooed again. And another. And yes, another.

The cows started mooing and began walking collectively toward us. I got a little nervous, the barbed-wire fence the only thing separating my wife and me from eighty misled cows. I didn't want a mutiny on our hands. My wife, however, found this all to be quite funny.

With a little practice, I soon had the "moo" down pat. It sounded good. Heck, I'm going to forget about being humble--it was excellent!

I started mooing all the time, I think to the point where family and friends began avoiding me. I mooed on the phone, I mooed at work, I mooed at home, I mooed at parties. That would have been me who, standing alone in the corner with my drink, mooing, you carefully avoided.

I was a hit, however, with the young kids. I would get calls from our family's and friends' children to moo. Over the phone line, I'm told, my moo sounds even better. On hindsight, though, I think their parents just said this to keep me from coming over and doing it in person.

The biggest place where my moo was a hit? Easy answer--our pediatric ER.

Where I trained in residency, we had a Pediatric ER and it was here where I perfected my moo. If a child wasn't critically ill, I would have three strategies to make the visit easier: 1) Hand out stickers, 2) Hand out a popsicle, or 3) Moo. Let's face it, anyone could do strategies one or two, but three? Sorry folks, I owned that one all to myself. And truly, it was a hit. A smile usually appeared by my second moo.

So, I mooed my last two years in residency and brought my moo with me when we moooved here.

The other day, one of our residents brought his devilish, happy, handsome two-year-old son to visit our ER. He was so darn cute already, but I knew a way to make his cute factor fly through the ceiling.

I took a deep breath and plugged my nose.

"MMMOOOOOOOO!"

At first his reaction was usual--a look of bewilderment. By the second moo, however, I had him.

"Moo," I said. "Again," he said. "Moo," I repeated. "Moo-cow," he said, clapping his hands. "Moo," I said one last time. He laughed out loud and flailed his giddy arms and legs.

As I walked away, I felt like, once again, my moo had made me the cat's meow. I was all that!

Unfortunately, three patients were peering out of their rooms, wondering why there was something mooing in the ER hallways.

"It's okay, folks," I said, "go on back in your rooms, please."

At the nurse's station, I overheard one of our newer secretaries on the phone. "Yeah," she said, "some idiot is out in the hallway mooing-can you believe that?"

I almost bent over to moo in her ear from behind, but I restrained myself. Instead, I went to my telephone and called home.

"Hello," my youngest daughter answered, "how may I help you?"

A pause.

"Hello?" she repeated.

I took a deep breath and let it out.

"MMMOOOOOOOO!!!"

"Oh, hi Dad," she said nonchalantly. Then I heard her yell, "Mom, it's for you. It's Dad and he's mooing again."

I could have sworn I heard my wife's faint response. "Tell him I'm not home."


As always, thanks for reading...next post will be Monday, December 14. Have a safe and enjoyable weekend...

No Second Chances

In residency, I was fortunate to train at a university hospital that had a burn center, one of approximately 125 centers in the U.S. As a result, we treated victims of all types of burns. While some burns were minor, many were quite significant, requiring months of both physical and psychological treatment. Death was the result of the worst of these burns.

I was working a twelve-hour shift when an ambulance called in. They were bringing us an elderly woman from her nearby residence. She had been drinking and had fallen asleep while smoking a cigarette. A fire ensued. Both her nightgown and couch had been extremely flammable, resulting in very serious burns to her body.

"It's bad, Doc," the paramedic said, ending his call.

Within minutes, the ambulance arrived. Our trauma team was activated and between the ER and trauma teams, we were ready to treat this patient.

Remarkably, this patient came in talking and not in much pain, which was worrisome. "I want to go home!" she said emphatically, obviously intoxicated.

Her injuries were profound. The skin on her arms, her legs, and her torso, both front and back, was either charred or translucent gray, indicative of full thickness burns. She had minor redness and blistering to her face and anterior neck. Her hair and eyebrows were singed.

It's daunting to see a patient so badly burned and not in significant pain. Very disturbing. The smell of her burnt skin and hair permeated the ER.

If I may, I'll briefly explain burns. They are classified by the type and by the depth of burn. Types include electrical, contact, steam, gas burns, thermal, etc. This patient sustained thermal fire burns. Unfortunately, she also sustained secondary contact burns, where the couch and her nightgown melted into her skin. Depths of burns are classified into three categories: superficial (or first-degree) burns, partial thickness (or second-degree) burns, and full thickness (or third degree) burns. Superficial and partial thickness burns, which this patient had on her face and neck, result in pain. Full thickness burns, the worst of burns, extend through the skin and soft tissue beneath it, burning, among other things, nerve endings. Thus, the reason this patient wasn't in extreme pain.

This was bad news. She had partial and full-thickness burns to at least 70% of her body (a morbid percentage). She was going to die from these burns.

Another grim fact was that most of her burns were circumferential, meaning that they completely circled, or wrapped around, her torso and extremities. With serious burns, there is significant swelling and edema. Circumferential burns, in essence, are a tourniquet, preventing the skin from expanding and compensating for this edema. With increasing pressure from the edema, the deep blood vessels are compromised and blood flow is diminished, initially to the extremities and ultimately to the vital organs.

I knew we only had minutes to talk to her and explain the gravity of her injuries. She was in disbelief. I explained that her injuries were-life threatening and how the swelling from her burns would quickly advance to her throat and close her airway.

"I'll do whatever you need if you can just call my daughter," she said, the morbid news settling in. "And can I have a smoke? I'm nervous."

No smoke, but my attending gave me permission to quickly call her daughter. The nurse ran and got a portable phone and I dialed the out-of-town daughter's number. A woman picked-up. Thankfully. It was her daughter. The patient told me to "tell my daughter everything," so I did.

I quickly introduced myself. "Maam," I said, "I'm sorry to call you with this news, but I'm standing at your mother's bedside in the emergency room. She's been involved in a serious burn accident and her injuries are life-threatening. She asked that I call you."

"Will she be okay? Was she drinking?" the daughter asked hurriedly.

I stepped away from the patient and lowered my voice. "Well, yes, it appears she has been drinking. And I'll be honest with you, maam, she's probably going to die from her injuries. She insisted we call you before we place a breathing tube in her airway to protect it from her burns and swelling. She'll be hooked to a ventilator after that."

"Oh, no," the daughter said, hesitating before speaking again. "I haven't spoken to my mother in years. We're estranged."

How damn heartbreaking. "Do you have any other family?" I asked. "No, it's just me. I'm an only child, like my mother. My father died when I was young. We were never in touch with his family."

It's so profoundly sad how many cases emotionally play out this way.

I moved on. "Can you talk to her? Again, she asked us to call you. If there are any words needed to be said, now would be the time to say them." The daughter lived five hours away and it was doubtful she would make it in time to see her mother.

I heard the daughter sobbing as I walked back to the patient's bedside. "Here's your daughter," I said to the patient, placing the phone to her ear.

All around this patient, it was organized chaos. She was receiving excellent medical care--attention to her burns, aggressive IV fluid hydration, and pain medicine. Preparations to intubate her were underway.

We, however, were in our own bubble. I was only interested in one thing--allowing this conversation between mother and daughter to occur. I stood by her cot, near her head, holding the phone as close as I could. I turned my head away, in essence to give her some privacy.

The patient sobbed. "I'm so sorry, baby." "I know, I know." "I love you, too." "I'll see you when you get here."

How sad to summarize all your regrets and feelings into a thirty second conversation.

This patient had been in our ER less than five minutes, tops, but by the time we hung up from her daughter, she was already getting stridorous, a sign that her airway was compromised. We needed to intubate her. I repeated our concerns and she agreed. Her eyes searched mine and she whispered, "It's bad, huh?" "Yes, maam. I'm so sorry, but your injuries are very bad."

We sedated her with adequate medications and successfully intubated her.

After the intubation, as expected, her swelling and edema worsened. Ultimately, this restricted her breathing and compromised her blood flow. Her vital signs became unstable. Before transferring her to the Burn Unit, the trauma team performed escharotomies. These are linear lengthwise incisions through the skin and soft tissue, along the lateral sides of the patient's extremities and torso. This procedure helped to relieve the increasing pressure from the swelling. Despite this, she continued to decompensate.

I learned a lesson that day. Yes, she received excellent and necessary medical treatment. But making that phone call, well, in the end, it was that phone call that was probably the most important thing we offered this patient in her hour of need.

Sadly, she would not be a miracle patient. And there would be no further reconciliation. Her daughter arrived just hours after this patient had passed.


As always, thanks for reading...the next post will be Friday, December, 11. It will be lighthearted.

Grim Google

I walked into one of our big trauma rooms to see a medical patient who had been placed there because of overflow.

After introducing myself to the patient and his very pregnant companion, I asked him what brought him to our ER.

His chief complaint was as big as the room.

"Doctor, I'm dying of colon cancer."

His exact words. And as he spoke, his words were accompanied by his companion's eye-rolling.

I think now is a good time to describe the patient. He was 25. Yes, 25. He looked very nervous but otherwise normal appearing, short brown hair, 6'0", 220 lbs. Pure muscle. I think he ate a side of beef for lunch every day.

"Why do you think that?" I asked, suspicious I might already know. "Do you have a family history of colon cancer?"

"Well, no. I don't think anyone in my family ever had it--until now. But," he hesitated, choking back his emotions, "every time I go to the bathroom, you know, from behind, I see blood in the toilet and on the tissue."

"Bright red?" I asked. "Yeah," he replied.

What twisted human nature compels each of us to look in the toilet when we are done using it? I am reminded, though, of reading that if you put just one ml of blood in a toilet bowl, most people would overestimate how much blood they were actually seeing. I doubt this patient was an exception.

His concern for his health was very real. And although he was not your average demographics for a colon cancer patient, he still warranted a thorough physical exam and blood work.

"So, every time you have a bowel movement, you see blood?"

"Yes, sir, for the last two days."

"Any pain?" I asked.

"Not, really," he replied, "just a little itching and discomfort."

"Have you ever been constipated?"

"Well, yeah, I have," he answered.

"And obviously, you work out a lot. Do you do a lot of sit-ups? Crunches? Core workout?"

"Yeah, how did you know?" Don't give me too much credit--like I said, the patient was pure muscle. A four-pack wasn't a far stretch of the imagination. However, the abdominal strain and pressure from those exercises could be a contributing factor to his problem.

My next question surprised him. "Do you have internet access?"

"What?" he asked, glancing at his companion.

"Well, did you 'Google' your symptoms?" I asked with sincerity.

His female companion jumped in and answered for him. "Yeah, he did. Yesterday. And since then that's all I've heard about--'I'm dying,' 'I'm not gonna see my kid be born,' 'Why me?'."

On a roll, she took a deep breath and continued. "I have to be honest. I'm 37 weeks pregnant and I have to listen to him whine? I don't think so--it should be the other way around, right? Just tell him he's okay, Doctor, and we'll get out of here."

She finished speaking, looked at the patient, and gave him another dismissive eye-roll.

I loved it. I was going to ask her to give me an eye-rolling lesson when we were done. Twenty times a day, easy, I could be using that talent. And who knows, maybe for extra credit, she could teach me to bob my head, hold up my defiant index finger, and drawl out, all with a little attitude, "Mmmm hmmmm". High-pitched, of course.

After finishing the patient's history, we moved on to his exam. I reviewed the patient's vital signs with him--all good. I performed a very thorough physical exam--all good. This included a pain-free abdominal exam. I reviewed the patient's blood work results as ordered from triage--all good. Again, this included a normal CBC (no signs of anemia). I saved the best for last.

"I'm going to need to do a rectal exam to see exactly what's going on."

This was the moment when I knew this patient seriously did think he was dying. He had no objections to a rectal exam. There are very few reasons that a 25 y.o. male wouldn't object to a medical rectal exam. Very few. So his willingness for this exam spoke volumes of how ill he thought he was.

I performed the exam. And, I'm happy to report, it was in his favor--no blood, no pain (a touch of discomfort, at most), and no unusual findings.

Well, except for one. He had two small, inflamed hemorrhoids that were the most likely source of his bleeding.

Ugh! More near-death hemorrhoids! God's joke on the human race, they are.

I explained in detail to this patient what hemorrhoids are. I explained that we treat them with sitz baths, suppositories ("you mean I gotta put one up my ass?"), creams, and stool softeners. If his symptoms continued, I explained, his family doctor may change treatment, order a colonoscopy or CT scan, or have him see a colo-rectal specialist.

"An ass doctor?" he asked. "They really exist?" Oh yes, Virginia, there is a Santa Clause. And to you, buddy, yes--ass doctors do exist. They're the ones wearing heavy cologne along with plastic face shields and cover-up procedure gowns.

During this conversation, out of the corner of my eye, I saw this patient's girlfriend trying to hold back her smile and failing miserably. And yes, she was rolling her eyes at him. Again.

I liked her. And I liked this patient. In all seriousness, his worries could have been any of ours.

Finally, after my best reassurances that he was not dying of colon cancer, the patient finally relaxed and joked a little about "his new little buddies down there." I actually think he was going to name them.

I pulled out a blank sheet of paper and wrote on it. H.E.M.O.R.R.H.O.I.D.S.

I handed it to him.

"What's this?" he asked, taking the note and reading it aloud.

"Your next Google search," I answered, smiling.

His companion laughed out loud and rolled her eyes. Again. Only this time, they were directed at me.


After the recent news report of how people are bypassing their doctors and relying on search engines to make self-diagnoses of their symptoms, I decided to flip that coin. Thanks for reading, as always. Next post will be Wednesday, December 9.

The Half-Load Predicament

My family does a lot of swimming in the summer, both recreational and competitive. And because of the amount of time we spend at the pool, we go through a lot of swimsuits.

This summer, while at a local department store, my wife took the girls and went looking for some extra suits while my son and I searched out swim trunks in the men's department.

While my son was looking at the boy's rack, I thumbed through the available men's options. I passed right by the tiny Speedos rack, since I'm neither European nor obese, and found a rack of board shorts, my favorites.

The designs were current and hip and I just knew I was going to look 20 again at the poolside.

Finding a pair I really liked, I peeked at the tag to confirm the size was the same as what the hanger read.

What I saw next was nothing less than disgusting. And hysterical. I could not believe what I was looking at.

There, inside the swim trunks I had planned on purchasing, was half a load of crap clinging to the inseam!

Obviously, someone had tried these trunks on underwearless, which is gross enough. But to actually leave this mess and put the shorts back? I was incredulous. It either had to be a teenager playing a vile prank or someone who simply failed to hold their wet fart. Either way, I couldn't even imagine what their crack looked like if this is how the shorts turned out.

Since my kids have fantastic senses of humor, I decided to have a little fun. "Hey," I called to my eleven year-old son, "can you come here?"

He came up to me as I stood in front of the trunks. "Yeah, Dad?"

"I really like these trunks but I can't read the size on the tag. Can you?"

"Sure." My son grabbed the clean waistband and pulled it back to read the tag. "Dad, it says thirty...OH MY GOSH!" He had spotted the mess.

He released his grip on the waistband and could barely get his words out. "There's...there's a load of...of...it's brown...OH MY GOSH! GROSS!"

I sometimes wish my humor wasn't so twisted from working in the ER, but there you go. I could hardly keep a straight face.

"Look, Dad, I'm not kidding!" I took a look to appease him. "Well," I said reflectively, fingers on chin, "I don't think that should be there."

"We have to go tell Mom and the girls!" he exclaimed, running away from me before I could stop him.

I followed him to the girls section, where he was already in the middle of the story by the time I arrived. My wife and daughters looked incredulous. In unison, when he finished, they exclaimed "NO WAY!"

My wife and girls looked at me to confirm the story. "Really?" they asked. "Really," I said.

As my son rushed off with the girls to show them this remarkable find, my wife asked me again. "This is for real?"

"Yes," I said again, "no lie. I promise. And it's disgusting."

She caught me off-guard with her next question. "Aren't you going to take them up to the front counter?"

What? I didn't even think of that. I wasn't the one who took a dump in some new board shorts in the dressing room. And, I didn't ask for this to happen. Why should I have to take them up to the front?

"Because," my wife said, "that's the right thing to do. You don't want someone buying them and taking them home, do you?" Ugh, sometimes her reasonable thinking annoyed me. "Besides," she continued, "what if someone throws them in their cart and they have food or, even worse, a toddler playing in the cart. Then what?"

I pictured a little child, blond spiral curls, pulling those board shorts playfully over her head.

Nope, it still wasn't enough for me.

"Listen," I pleaded with my wife, "if I take them to the front counter, they'll think I did it. Who's going to believe that I 'just found them on the rack?' They'll be laughing at me the minute I walk away. Security will probably follow me on hidden cameras the rest of this shopping visit."

I could only imagine. "Hey, Nancy," the security guard would yell to the lady I handed the shorts to, "there's 'the shitter' looking at tennis balls in the sporting section. Why isn't he in the toilet paper aisle?" Then they would burst into fits of laughter, all at my expense.

No, I wasn't handing the swim trunks in. No way, no how.

My wife and I walked over to the men's section to find our kids playfully pushing one another close to the stained shorts.

"Hey, kids," my wife admonished, "be careful! And don't touch them! I don't want you getting someone else's poop on yourself!" Yes, I thought, but it's okay to have your own poop on you? Since she was somewhat annoyed with me, however, I decided not to question her on that point.

She hesitantly stepped towards the shorts and peeled back the waistband. The kids and I held our breath. "Well," she said, cracking a smile at the absurdity, "that sure is something, isn't it?"

Um, yeah, it is something. Something disgusting. Something filthy. Something funny. Something hysterical. Something unexpected. Something unbelievable. Yeah, it was something alright.

"Are you going to take them to the front? Or am I going to have to?" she asked.

I held my ground. "I can't, hon'. Seriously. I just can't do it."

She huffed. "Well, whatever then." I expected her to keep her threat and grab the shorts and take them up to the front herself, but she didn't.

She grabbed the cart handle and pushed it away from the rotten, stinking shorts. "Come on, kids. Let's get out of here and get some cookies." They had earned that much. As long as they washed their hands first.

"Wait," I challenged, "I thought if I didn't take these to the front, you were."

"I changed my mind. Let's go." Good--maybe she was seeing the light of my way.

I walked away from those shorts with a heavy heart. Why I felt so responsible for a load of feces that wasn't mine, I don't know. Darn that deviant culprit for making me feel guilty for his defecation.

On our way out, my eyes searched for anyone close to having a 33w. Or a shuffle to their walk. Or brown-stained pants. No one...

Driving home, I ended up calling in the problem anonymously from my cell phone. Okay, not really. But I do wish I had thought of that at the time. It's just that, for being a level-headed guy, I was a bit flustered.

When we share this story with friends, family, and coworkers (and trust me, we got a lot of mileage out of this one), they seem to be split on what they would have done. Do you know what you would have done?

One of my coworkers, Bill, said it best. "That sure was a shitty predicament."

Yeah, you think?


My next post, an ER story, will be Monday, December 7. I assure you that my kids are very happy and well-adjusted and carry no ill-effects from this shopping trip. Thanks, as always, for reading and have a great weekend.

Big Stuff, Big Words

I have become quite good at reading people within the first few minutes of meeting them. It comes with the job, actually. Thirty patients (and their families) a shift and rest assured, after 16 years in the ER, I have been exposed to many different personalities. I am a poker player of sorts, keeping my personal feelings hidden behind my smile while I measure up the alpha male, the needy daughter, and the nosy neighbor, all begging for more attention than the actual patient.

With all the family dynamics swirling around a patient's room, it is important for me to swiftly figure out the who, what, when, where and how so that I can attend to the patient's illness. You would be amazed how just one person can affect the entire ER experience, either positively or negatively.

And in Room 12, that one person happened to be a father of two boy, ages 10 and 12.

I walked into the room to find the ten year-old boy lying on the treatment cot, his forearm bent in the shape of an "L", obviously broken. The nurse was starting an IV to give him some morphine. Sitting in the corner of the room was this patient's twelve year-old brother, his face tear-stained and agonized, looking as hurt if not more than his younger brother. Pacing nervously alongside the patient's cot was their father.

Nothing really too much out of the ordinary.

Except the tension in the room was explosive. Something wasn't adding up.

And then Dad opened his mouth to speak to the son in the corner and it all made sense.

"I hope you're happy, damn it. Just look at your brother's arm. What the hell is wrong with you?"

Whoa, back up here. As the nurse was starting the IV, she looked up in the middle of Dad's rant to give me "the look," a warning that all was not good in this room. I interrupted Dad to introduce myself.

Dad bit his tongue during the introduction, but as soon as I asked what happened, Dad jumped right back in where he left off.

"He's always causing problems...pain in my ass...doesn't care about anyone but himself..."

His rant against his older son continued and the more he spoke, the more his son's shoulders shook from silent sobbing. The younger son with the broken arm sat silent, his pained expression speaking volumes.

The story played out that the two brothers were in the front yard playing soccer. Soon after, bored from kicking the ball, they started tackling one another. It was then that the older brother tackled his younger brother and, in the midst of the tackle, broke his younger brother's arm.

An accident, pure and simple. I could see it, the nurse could see it, and I know as you read this you see it.

Dad didn't see it. And I was finding it difficult to give him some benefit of doubt during his family's stressful crisis.

After several more hurtful insults, I had had enough.

"Come outside into the hallway with me, Dad. We need to talk."

In the hallway, Dad tried to start all over again with how his older son was a "problem child" and always created conflict in their family, but I halted him. Rarely have I met a "problem child" that didn't have a "problem adult" in his life.

I took a deep breath, not wanting to be anything but professional during this conversation. Deep down, though, my insides were screaming. I wanted to grab this guy and shake him, make him take an outside look at what he was doing to his older son.

"Listen, sir, I understand you're upset. But you have the power to make this a better experience for both of your sons right now. As things stand, your words are only making the situation worse."

"But damn it, he's got..."

I stopped him. "I've heard you already. And so has the nurse. And so have both of your sons. What I am asking of you is to go back in the room, find something nice to say to your older son, and then sit on the cot with your younger son and help him get through this visit. I don't want any more negative talk from you while we help your family, okay?"

I stared at him and he was silent. "Okay?" I asked again, more loudly.

He shook his head yes.

We walked back into the room. I looked at Dad. He was ready to talk to the son in the corner.

"See," the father said, "now you got me in trouble. I hope you're happy with yourself."

I was shocked. And angry. And frustrated with this man who, I felt, was clearly not appreciating the blessings of having children.

He looked at my face and, for once, I failed to hide my emotions. He did not say another word while we fixed his son's fracture.

After successfully reducing the broken arm, we sent the younger son to X-Ray for post-reduction films. We had Dad accompany him. I hung back with the older son.

Over popsicles, we got better acquainted. He shared that his dad said "a lot of mean things" to him. Words "that hurt sometimes." He assured me, though, that this was the extent of his father's unkindness. "He treats me okay most of the time," he added.

"You know this isn't your fault, right?"

He thought I meant his brother's broken arm. "But it is. I shouldn't have tackled him so hard."

"No, but that's not your fault, either. Things like this happen between brothers. I'm talking about the angry words you hear from your dad. Some parents love their kids very much but just don't know how to pick the right words to tell them."

He nodded while he looked down at his sneakers. I continued. "I have no doubt that you are a good son and brother." We talked a few more minutes that culminated with a smile from him.

Dad had calmed down before his son was discharged. Prior to leaving, I had an instinct that he wanted to say something to me--something apologetic, by his expression. But he didn't. A part of me, though, could only hope that he had looked in the mirror and didn't like what he had seen.

The nurse planned to arrange follow-up with this family.

Sometimes, despite our best efforts and resources in the ER, life and fate will continue to play out the way they were destined to.

Darn it all.


Next post will be Friday, December 4. See you then...and hats off to the caring nurse who provided more than just good medical care for this family.

Cheetos and Painkillers

We pretty much went paperless in our ER several years ago. In paper's place, I now have a computer that lists all of the patients in the ER, their complaints, their vital signs, and their medical histories.

All at my disposal with the click of a mouse. Yes, mine is a powerful finger!

The nurses enter most of this medical information in triage or at a bedside computer in the patient's room. Occasionally, they will enter little tidbits of information that are quite funny. I live for these innocent commentaries.

"Patient's toupee keeps shifting on his head."
"Patient had smelly flatus during interview." (Is there any other kind?)
"Patient refused to put on gown but did adjust her halter top."
"Patient getting long lingering hugs from her 'brother'."
"Patient did not wash his hands after showing me his hernia."
"Patient used to smoke but quit three hours ago."
"Patient is constipated and tried to disimpact himself in our bathroom."

Yes, it's these little subtle comments that sometime tell me the most about a patient. And sometime warn me to shake the patient's hand with a glove on when I introduce myself!

So, after clicking to treat the patient in Room 29, directly across the hall from the nurses' station, I scanned the computer screen for the patient's information.

She was 24, complaining of abdominal pain for three days, and had no entertaining nursing comments charted. Another serious, legitimate patient.

Wrong.

As I walked into the room, I was surprised to find a young woman sitting comfortably on the bed, just finishing a small bag of Cheetos. In the corner of the room, accompanying her, was her husband, his hands dipped into a small bag of Doritos. Both had orange fingers. They must have been snacking for a while.

Now, if you had significant enough abdominal pain that brought you to the ER, don't you think you would pass on the Cheetos? I know I would. And trust me--nothing comes between me and my Cheetos!

I introduced myself to the patient and her husband but skipped my customary handshake. I didn't want orange fingers, too.

"What brings you here today, maam?"

The patient mumbled something that I couldn't understand.

"I'm sorry, can you say that again?"

The patient held up her finger to me, her way of telling me to wait. She nimbly jumped from the bed, went to the counter in the room, picked up a 20 oz. Pepsi that was nearly full, and proceeded to chug it down to within an inch of the bottom. As she put the Pepsi back down, I noticed that there was a second, though empty, bag of Cheetos sitting on the counter.

She spoke a little more clearly now, thanks to the Pepsi washout, although I could still see the orange crumbs clinging to her chin and orange saliva building up in the creases of her lips.

"You're the doctor, right?" I nodded yes to her question. She grabbed her left abdomen. "Oh," she started moaning, "oh my God! Help me, Doctor! My stomach hurts so bad." I think I actually saw her suppress a smile.

She was serious. Seriously a bad actress. She could have at least practiced in front of a mirror.

And maam, I'm so sorry, but Julia Roberts just called. She wants her Oscar back.

I asked this patient some specific, in-depth questions and got only the sketchiest of responses.

"Well," I said, after finishing my interview and performing a stone-cold normal physical exam, "I'm happy to say that you have a good exam. And your blood and urine work that the nurse ordered in triage came back normal, too."

"What?" she shrieked. "You mean to tell me I just waited four hours to have you tell me I'm okay?"

"Maam," I gently pointed out, "your vital signs are good, your exam is unremarkable, and frankly, you ate two bags of Cheetos and chugged a 20 oz. Pepsi. I think whatever was hurting your belly is already passing you by."

She looked very unhappy while she nervously glanced over to the corner at her husband.

"Umm," she said, "I need some pain pills."

"Pardon me?" I asked.

Now, I am a very compassionate doctor and rarely hesitate to provide pain relief with strong medications when needed. In fact, I sometimes get teased by our nurses for being a "candy man." So I promise you, I was not taking this patient's complaints lightly. It's just that between her complaints, her actions, her exam and her test results, my suspicions of her having a serious illness were so low that all she was going to get from me was Tylenol.

"Tried that. It doesn't work."

"Well, I'm sorry. You won't be getting any pain medication with your visit today."

She eyed me, I eyed her, she eyed her husband, he eyed me, I eyed him.

I was eyed out.

"You sure I can't have any pain pills? Just a couple. I'm hurting so bad." She was now holding the other side of her belly, not remembering it was the left side that was hurting before.

And then, in the midst of her drama, she did something unexpected and glorious.

She burped.

A big, nasty, bullfrog burp.

I think after that, she knew it was over. I shook my head no to her request, wished her good luck, and advised her to return if she got a fever or her symptoms worsened or changed.

"Yeah, whatever," she mumbled as she easily jumped up from the bed to get dressed.

I went back to my computer screen to get her discharge instructions ready and noticed that she had another page that I hadn't scrolled down on.

There, on page two, sat my warning from her nurse.

"Patient's 19th visit this year."

Maybe she just likes the Cheetos from our waiting room vending machine.


I hope everyone had a great Thanksgiving weekend. Thanks for reading. Next post will be Wednesday, December 2. See you then.

Pass The Clicker

In the spirit of this Thanksgiving holiday, a humorous peek into my home life...

I'm a typical guy who, if given the chance, will sit on my leather sofa with TV remote in hand and slowly meld into the cushion, oblivious to the fact that I am watching for the third time the same episode of "Trading Spaces" or that I may not have changed my underwear in two days. With this in mind, my wife and I made a decision about four years ago to cancel all but our most basic cable channels.

Who am I kidding! If I'm going to be honest here, she made the decision. I had no say. I still get teary-eyed thinking back to that awful day.

To complicate matters, the cable company screwed up our cancellation. Yes, they lowered our bill from $50 to $16, but they kept forgetting to reduce our cable plan to the basic package. As a result, we continued to get all the big package channels. All for the fantastic price of $16! Can you imagine how frustrating it was for me to hear my wife call the cable company ten times, requesting them to come and "fix the problem."

I saw no problem. We were getting a hundred channels for $16. Where's the problem?

"The problem is that it's dishonest," she replied.

I think her honesty may be the death of me.

Now, though, with the kids growing older and outgrowing PBS (our only kid-friendly channel among our huge selection of 12 channels), we were faced with another dilemma. What could they watch? We were stuck between "SpongeBob SquarePants" and "CSI." There was no gray zone of good television for our kids.

Low and behold, we discovered our favorite television series on DVD. We made trips to Walmart, Target, and Best Buy and were frequent visitors on Amazon.com. We snatched up "Little House on the Prairie," "The Waltons," "Happy Days," "Laverne and Shirley," "Leave It To Beaver," "Gilligan's Island," and "The Brady Bunch." There's more, but these were the shows that made the biggest impact.

Our kids were in heaven. If they liked Season 1 of something, we moved on to Season 2. And Season 3. And Season 4. I'm going to be honest here--I thoroughly enjoyed revisiting these classics. Probably more than the kids.

I discovered that I did not attain much personal growth traveling from my childhood into adulthood. I still liked Mary more than Laura. I rooted for Jan over Marcia, Marcia, Marcia. Laverne made me laugh, but Shirley held my heart in her hand. Did I really think Richie Cunningham was cool? And Mary Ann versus Ginger? Let me tell you, if you put your hair in pigtails and wear a red-checkered shirt and tie the bottom in a knot around your waist, I'll eat the scraps from your plate.

Mrs. Cleaver remained my fantasy mother. Just once I wanted to wake up and find my own mother, awesome though she was, serving me breakfast in full makeup and an evening gown! I remember Mom rolling her eyes when I asked her to play along with me on that. Nope, it didn't happen.

And how could I not mention Eddie Haskell, my idol? I got tired of my friends and family mentioning that I was his twin, but he did teach me that good manners and sincere politeness could take you far. Thank you very much. And by the way, did I mention how nice you look today?

I could not let this moment pass without mentioning how much I still love Grandma Walton. Not for the physical reasons, mind you, but just for the fact that I had never known someone who was so moody and sour. It was a new experience to watch such a crotchety character. I was so thankful she wasn't my grandma. I can only imagine what kind of mood Grandma Walton would be in the first time her bladder didn't hold out. Can you even imagine her shrilling voice? "John Boy, get over here right now and change my diaper!" Ugh. Keep writing, John Boy, and get yourself out of that house. Because up on those mountains, my friend, you wash the diapers by hand. In the cold creek.

The biggest hit for my kids, though, was and still is "I Love Lucy." Although I didn't see this one coming, my wife did. My daughters, 13 and 8, love everything about Lucy. And my son, 11, cheers right along with the girls. The candy factory line, the grape-stomping, the vitameatavegamin commercial--you know what I'm talking about. We all have our favorites--are you thinking of yours right now? Just hearing my kids gut-busting laughter from a show that is 50+ years old is a miracle in and of itself. It's hard to believe, but the episodes only seem to have gotten funnier.

We recently traveled to Hilton Head and instead of playing music overhead in the car, my wife and I listened to the episodes that the kids were watching. Better than music, I tell you, better than music.

And I know what you are thinking--NO, we are not pathetic!

I think a visit to Lucy's museum in her hometown of Jamestown, N.Y. is going to happen someday soon. I just need someone to promise me that it won't be a bust.

Okay, so maybe that's a little pathetic. But they just might have a picture of Lucy in pigtails wearing a red-checkered tied-at-the-waist shirt. Then who's going to have the last laugh?

Now, pass me my clicker. Peter's just about to say "Porkchops...and applesauce."


Thanks for reading...next post will be Monday, November 30.