Little Big Man

We are all familiar with the saying "Actions speak louder than words." It is most often used to connote something favorable and positive. Unfortunately, this quote was the first thing that popped into my head while treating a recent patient.

I had been walking down the main ER hallway, another crazy shift in bloom, when one of my favorite nurses poked her head out of a room.

"Doctor K," Carla asked, "are you free to help me out with this patient?" I didn't even need to give her an answer. When Carla beckons, I come running. Plain and simple, she is that amazing.

I walked into Carla's room to find a patient lying in bed, hands to his face, crying out for his mother. Heartbreaking. His mother was kneeling beside him, whispering quietly in her son's ear. Tears were streaming down her face, too.

The patient was seven. A sweet, scared little boy named Eddie. Eddie had been rushed to our ER to be treated for burns to his face and body. From the doorway, I could see several small blisters with surrounding redness on his bare torso.

What were the circumstances that resulted in these burns? Apparently, Eddie did not come from a good socioeconomic situation and, as a result, lived in a crowded apartment with his mother and several other family members.

The day Eddie was brought to the ER had been an especially cold one. While his family sat watching TV in a room off of the kitchen, Eddie, hoping to be useful, went alone into the kitchen. He had decided that he would warm up the apartment. He grabbed a cigarette lighter and successfully persevered in his struggle to flick the lighter's flame. With his free hand, he turned the oven's dial to "ON." Ready to be a big man and provide heat for his family, he opened the door to the gas oven. Slowly, while holding his arm stiffly in front of him, he advanced the flame into the oven.

Whoosh! A sudden flash of flame was born and jumped out at Eddie, surprising him. He instinctively yelled out as he backed away from the heat. The pain and redness to his skin was immediate. The family called 911 and, after shutting the oven door, turned off the dial. Their quick thinking stopped any further flames from spreading. Eddie, with his mother accompanying him, was brought urgently to us.

I was able to determine that Eddie's burns were "minor." His airway and breathing were stable and his burns were either first degree (superficial, like a sunburn) or second degree (partial thickness, or to the layers just below the skin surface). When you are seven and in pain, though, any burn is considered "major" in my book. Suffice it to say, Eddie's burns were significant but not life-threatening.

While giving him pain medicine, some IV hydration, and soaking his wounds, we discussed Eddie's case with our regional burn unit. They requested we transfer him to their facility for overnight observation. I agreed wholeheartedly. He was a child in pain. He deserved to be treated cautiously, tenderly.

"Eddie," I asked, after we had made him comfortable, "what made you decide to light the oven this way?"

"Mama and Aunt Pammie do it all the time," Eddie said, shyly looking over at his mother. She was now sitting in a chair, beside his cot, stroking his hand.

"To cook?" I asked, rubbing this brave little kid's shoulder.

"No. We light it and keep the door open so we can stay warm." With the colder weather, it turns out, Eddie's family supplemented their apartment's warmth this way. Eddie, after seeing his mother and aunt light the oven several times, thought that he could do it, too. My heart broke a little, in that moment, looking at this thoughtful little boy who sustained burns because he was trying to help his family. He gave his mother a feeble, lopsided grin, the morphine adding to his charm.

"Baby, it's okay," the mother said, stroking his hand. "Aunt Pammie and I should have never done that." She turned to me and continued. "I'm not going to get in trouble, am I?" Although the question seemed self-serving, I was genuinely impressed with her concern for Eddie. She handled her little man with appropriate and abundant love. She even insisted on helping Carla with Eddie's treatment. I felt only good energy with her, discerning nothing suspicious. Eddie, it seemed to me, had a mother that truly loved him.

"No, you're not," I assured her, "but let me have our social worker talk to you about your living conditions and see if there is any available help for your family. Maybe have them come out and check the place out for you."

"Thank you," she said, "We could use some help trying to get the landlord to fix some of them windows."

So, as it turns out, Eddie's injuries were not a result of being negligent or careless. They stemmed from imitating the adults in his life, who were completely unaware of the lessons they were teaching him.

Eddie's situation got me to thinking in that deep, reflective way. How many times through the day do I, as a parent, verbalize to my children what I feel are essential life lessons when, in actuality, my witnessed actions carry more weight than any of my words. Actions that can be both good or bad. Conscious or instinctive. Helpful or harmful. Deliberate or unplanned.

Witnessed or unwitnessed by young eyes. My kids' eyes. Your kids' eyes.

Eddie ended up recovering quite nicely from his injuries and his family was very appreciative for his treatment and good outcome. They could not, however, have been nearly as appreciative as I was of the important lesson they reminded me.

Thank you, Eddie, the little big man. It's not everyday I get a life-lesson from a seven year-old.

As always, thanks for reading. Next posting will be Wednesday, February 3. Thanks for your votes and support in the Medgadget Weblog Awards...much appreciated.

Shirley's Tumbler

I wish there was more reason and less rhyme in the ER.

For example, I might sign on to see a gentleman with urinary symptoms who ends up having an abdominal aortic aneurysm. Likewise, I might sign on to see an elderly woman with twenty medical problems who ultimately has nothing but some loneliness issues. Hug, please!

So when I signed on to treat a recently-retired man with back pain, chronic by history but exacerbated by recently lifting some grocery bags, I assumed it would be an easy, clear-cut case. "Me lift heavy bag, me back go 'crunch,' me try Tylenol but it no work, me come to ER." See how easy that can be? Wrong!

I walked into his room to introduce myself. I found a pleasant, mildly-distressed, sophisticated gentleman lying in his cot. In the corner chair, an equally sophisticated woman sat on edge. She introduced herself as his wife.

"Sir," I said after introductions, getting to the point, "I understand you hurt your back."

"Yes, he did," the woman jumped in. "It was stupid, really. He forgot to tell the grocery cashier not to put as many things in each bag. You know how they like to load those bags up when you ask for paper inside of plastic."

"Thank you, maam," I said, redirecting my questions and attention back to her husband. "And sir, did you have any trauma or falls or direct blows to your back recently."

Again, the woman answered. "No, he didn't." She waved her hand as if to dismiss his symptoms. "He does this all the time." She directed her attention from me back to her husband. "I warned you before you went shopping today, Leonard, not to let her do that." Leonard glared at his wife. I understood how he felt.

"Do you have any chest pain, shortness of breath, or abdominal pain, sir?" I asked.

I heard her grating voice again and, I must admit, I cringed. "No, he doesn't. But he has a trip planned to Vegas tomorrow and I want you to tell him he can't go, not in this condition. How the hell is he going to sit on a plane for three hours?" She looked at him and shook her head. "Stupid, I tell you."

"Well, maam," I said with restraint, "let me finish asking him some questions, do an exam, and then I'll be able to make that determination. And," I added, "I would like your husband to answer my questions from now on. When we are done, I'll give you a chance to share any more information that you feel is necessary."

From the look I got from her, I do believe she thought I had asked her for one of her lungs. That would be meaningless, though--she could still survive. Give me both of them, maam.

I looked from her to her husband, who was now glaring at his wife. And what do you know? The guy had a husky, deep, authoritative voice. "Shirley, just shut the hell up. You're embarrassing me. I don't know why you had to bring me here and I don't know why you just can't sit there and be quiet."

Uh, oh. I could smell the danger in their dynamics.

"Sir, I continued, trying to shortcut an argument, "let's get back to my questions. Do you have any traveling pain, numbness, or tingling or is the pain just sitting in your lower back?"

"Just right here, doctor," he said politely, placing his hand over his lower back region. "No where else." Well, I'll be damned--this guy finally got to answer a question! Sweet, golden silence emanated from the corner.

"Do you have any urinary symptoms at all? Burning? Going more frequently? Anything out of the ordi..."

I was interrupted by his wife. "No," she said, "Leonard doesn't have any problems pissing."

Okay, I had had enough now. "Maam," I said, giving her my undivided attention, "I appreciate you trying to help, but I am going to ask you to leave the room if you interrupt your husband and I one more time. You can't possibly know first-hand how he is urinating and, unless he can't talk, I want to know directly from him. Is that clear?" I got a huff and a dismissive look from Shirley, right before she turned her attention upward to a room corner--her way to let me know I was now going to be ignored. "Thank you," I said, refusing to be baited.

Leonard and I were able to finish reviewing his history without any further interruptions. I asked Shirley if she would like to add anything else, and she looked back from the room's corner to Leonard. "Oh, what? Now what I have to say is important? No thank you!" Poor Leonard--my heart went out to him, kind of the way your heart goes out to that baby wart hog that the lionesses trap in Africa.

Leonard's exam was consistent with a lumbar strain or, simply, a pulled back. I explained my findings to both Leonard and his wife and also explained that, with his history and age, I wanted to obtain both a urinalysis and some basic lumbar x-rays to make sure he didn't compress a vertebrae. I also had the nurse give him a pain shot to get him more comfortable. A big, big shot. He deserved it.

"Yeah, yeah, yeah," Shirley said impatiently, "but what about telling him he can't go to Vegas in the morning." Fingernails on a chalkboard, I tell you.

What I had to say next to Leonard, however, hurt me more than I'd care to admit. I took a deep breath. "Leonard," I said, putting my hand on his shoulder, trying not to gag on my words, "your wife is right." There, I got it out. "A fresh strain on your back is not going to let you enjoy this trip and, in fact, may hamper your healing to the point where you might do some worsening damage."

Leonard wore a look of extreme dejection. Who could blame him, really. This trip to Vegas was with "the guys" but, more importantly, without Shirley. I was proud of Leonard, actually, for holding back the tears I knew would be coming if this were my situation. I tried to imagine it--me, my big crocodile tears, and a box of tissues, hiding from Shirley in our house attic.

I finally left their room. Honestly, I was exhausted. Leonard's case was quite simple and the amount of energy I used in his room was unexpectedly huge. No rhyme or reason. I needed coffee, stat. I debated calling the grocery store to speak to the cashier. "WTF?" I was going to say, reminding her to put only one canned good in each bag. Really, though, you and I both know she was innocent, an easy target for my frustrations. I was above that, wasn't I?

Well, Shirley stepped out of the treatment room soon after I did. After his nurse, Natalie, gave him his pain shot, I explained to her how frustrated I had been from the interactions with Leonard's wife. "Did you get frustrated, too?" I asked Natalie.

"Yes, but it's about to get better soon," she said, knowing something I didn't.

I went in and checked on Leonard a short time later and, thankfully, he was alone and his pain was much improved. His tests had come back favorable and I explained these results to him.

"Thank you, doctor," he said, "and hey, I'm sorry for my wife's behavior. I don't know why she always has to be such a nag." Don't worry, I assured him, it was all good. I appreciated his acknowledgement, though.

After observing Leonard for about an hour, I went in to check on him and plan a discharge. And guess who was back? Yep, Shirley was, sitting in the corner chair, drinking from a big tumbler.

I reviewed Leonard's results with her and she didn't interrupt me once. Nada. She seemed genuinely pleased and happy with his results and treatment. "Thank you, doctor" she said, once I had finished. I staggered from her unexpected words and, thankfully, the wall behind me supported my sway. Of course I'm embellishing, but she did throw me for a loop. I wished Leonard the best, though, and after advising him of his treatment plan, left his room shaking my head.

"What happened in there?" I asked Natalie. "Why is she so calm and pleasant now?"

Natalie laughed at me. "Did you see her big tumbler?" I nodded yes. "Well, it's not water that's in there." Initially, I was puzzled at what Natalie was getting at but then, suddenly, lightening struck me and things became very clear. And sad.

"Alcohol?" I asked. "Of course," she said.

It seems Shirley and Leonard and their marriage were well-known to our ER staff, barring me, and several of their previous arguments had been quite memorable. Shirley's "tumbler run" was just as famous as those arguments. And necessary, Natalie assured me. "Otherwise," she said, "I think we'd have to get security involved. Possibly the police. Those two can go at it like you wouldn't believe."

I slowly nodded my head, not really sure what to make of Natalie's words or Shirley's tumbler. That tumbler was able to do the impossible--drown out Shirley's abrasiveness. Although my sympathies had always been there for Leonard, I now felt some creeping forward for Shirley.

"They were pretty tame today," Natalie continued, interrupting my thoughts, her smirk evident, "they must have liked you."

"Listen, Natalie, can you do me two favors?" She nodded and I continued. "One, get a social worker in there to discuss counseling options, both for their marriage and Shirley's drinking problem." Natalie nodded. "And two," I continued, "get someone to drive them home."

Natalie touched base with me a few minutes later. "All done," she said. "Their daughter Lisa and her husband are reluctantly coming to pick them up. And Shirley and Leonard kicked the social worker out of their room--they didn't have 'any God-damn problems, for Christ's sake.'"

Shirley and Leonard, my best to you. And a personal plea. The next time you come together to our ER, if I'm working, bring me a tumbler, too. For Christ's sake, I'll need it...

Enjoy your weekend. As always, thanks for reading. Next post will be on Monday, January 25.