Defining Emergency

Emergency, as per the all-knowing Webster, is defined as an unforeseen combination of circumstances or the resulting state that calls for immediate action. Furthermore, an emergency is also defined as an urgent need for assistance or relief.

These definitions sound pretty spot-on, right? When thinking about emergency room settings, even, one can easily correlate the words of Webster to what one would necessitate to be a situation requiring emergency medical treatment. A trauma. Broken bones. A heart attack. A stroke. A seizure. Respiratory distress. A cardiac arrest. The list goes on and on and on. When a critical illness or injury occurs, then, we should all be thankful that we live within a society where emergent, life-saving medical care is available.

Lately, though, it seems the system meant to provide this care is being bogged down by questionable decision-making. Instead of providing emergent care, it seems I spend at least half of my emergency room time now playing doctor to chronic illnesses. To pain control issues. To mildly elevated blood pressure readings. To months of nonspecific weaknesses and fatigue. To office appointments sent to the ER because "we are overbooked today." And our ER is not alone. I hear the frustration of my colleagues and see first-hand how overworked most of us who provide health care in the ER setting have become.

A month back, I was in the middle of a very busy shift. Several patients with chest pain (one requiring immediate catheterization), two patients with respiratory distress (one from skipping dialysis and one from a COPD exacerbation), and three patients from a motor vehicle collision presented almost simultaneously to our ER. Within minutes, all of these critical patients had been treated with efficient, appropriate life-saving care. The team on deserved kudos for doing their job well and making a difference in these patients' outcomes.

Walking back to the nursing station, then, I was surprised to find our secretary being berated by a gentleman in his thirties at the counter. His voice was loud and menacing. His face was pinched with anger. His fists were clenched by his side.

"Whoa," I said, walking up to him, standing between him and the secretary, "what seems to be the problem, sir?"

"We've been waiting two hours to be seen by a doctor!" he exclaimed. "What the hell is going on around here?"

Are you kidding? All he had to do was look for himself to find the organized commotion that was occurring in our ER setting. What followed was the briefest of conversations.

"Sir," I asked, "what brought you to our ER today?"
"My daughter's left ear is hurting her."
"For how long?" I asked.
"Two hours," he replied.

Two hours of ear pain? I get it--maybe he was worried about his daughter. I would be as well. But my daughter would also have gotten Tylenol and Advil and watched her daddy patiently wait for their turn to be treated once the dire situation had been explained. Better yet, we would have probably waited until the morning when a call could be placed to her personal physician.

I explained to him that we had multiple critical patients brought to us and we would be with his daughter as soon as possible. "We're all trying our best, sir," I added, "but you're going to need to be a little more patient."

The father stared me in the eye. I stared back. Finally, he blurted out what he had been thinking to say. "Well, then," he spoke, sarcasm dripping from his pathetic words, "try harder." It didn't end there, though. He continued. "This is bullshit waiting two hours to be seen."

Before I could respond, he turned his back and huffed himself back into Room 27 where, the nurse shared with me, his eleven year-old daughter comfortably sat watching TV. "And," the nurse added, "I had already explained to him why they were waiting to be seen."

After this, one of our regulars who had been to our ER over 200 times (since we started tracking in March of 2006) arrived via ambulance. Then a gentleman carrying a big bottle of Mountain Dew was escorted from his ambulance, by foot, into our ER because his main complaint was "I just want to take a nap and was too far from my apartment." Next, an asymptomatic patient with elevated blood pressure for three years, non-compliant with her medications for financial reasons (yes--I noticed the pack of cigarettes hanging from her purse), was sent to us from her family doctor to be cured on the spot. "Go right to the ER," she was told.

Can you appreciate the obviousness of the long waiting times in the emergency department? Although we all pride ourselves on providing expedient care, a four to six hour wait is sometimes the reality for some of our noncritical patients.

As if to hammer the point home, my last patient during my shift that night (I was working 5pm to 3am) was a sixteen year old female who had presented to our ER, via ambulance at 2am, with her mother.

I walked into her room to find this patient and her mother both lying in the cot, laughing while watching TV, the patient in no obvious distress. I introduced myself to them before I started asking questions. "What can I do to help you tonight? What brought you to our emergency room?"

The girl looked at her mother and started giggling, my first sign that she would survive whatever her ailment may be.

"Well," she said shyly, "I've had some burning when I pee for about a week. And," she added, not done "I have something gross leaking from down there (she swept her hand towards her pelvis as she spoke)." Upon further questioning, I learned that she had been diagnosed with a yeast infection from her family doctor one month ago but failed to get her prescription filled. I also learned that she was sexually active with not one, but two partners. Unprotected.

I was disheartened. "What made you come to the ER at 2am when these symptoms have been going on for over a week?" I asked, hoping there was some rhyme or reason to her seeking out emergent care at this time. There wasn't. Her answer to my question--"Why not?" I didn't even approach her on why she came in by ambulance. Some things are better not known, I guess, especially at 2am.

I'm not sure this is the system that was imagined when emergency departments started gaining favor in our society. Don't get me wrong, though. I, like all of my colleagues, are 100% committed to providing respectful and appropriate care to anyone who shows up in our department, whether it be a critical, life-threatening illness or a chronic "nuisance," so to speak.

I can only hope that people will be patient and understanding as we all cope with the evolving changes that seem to be occurring with our health care system. And my hat is off to all the medical folks who work hard, day after day, treating our fellow mankind as best we can within this currently accepted system. Because, even as bogged down as we can sometimes become, what an awesome privilege we have in meeting and greeting and treating our fellow kind. Of helping them out in their time of need.

Salute!!!

As always, big thanks for reading. I wish a blessed holiday season to each and every one of you...

The Pit Stop

I walked up to the closed door and paused , exhaling a deep breath weighted with disappointment, trying to clear my thoughts for the conversation about to come. My clenched fist was briefly suspended, mid-air, ready to knock. Beyond the door, I could hear muffled conversation and movement.

A calm, pretty woman stood beside me. An emergency department case manager. She held a notebook and pen, ready to jot down any useful information that might be shared with us by the room's occupants.

I turned to the case manager. "Are you ready, Cindy?" I asked, making sure she was prepared for the gravity of this unfortunate situation. She nodded "yes," confident in her skills during such adversity.

I turned back to face the beige, chipped door of the family room and knocked lightly. The noises of conversation and movement suddenly ceased, and I could easily imagine the stillness and anticipation that pervaded the room.

I rotated the door handle, gently pushing the door forward before stepping into the room. The air and energy of the room were stale and suffocating, especially after leaving the hallway atmosphere of chaos. My eyes darted quickly, taking in the whole of the room. On the couch, two elderly people, a man and a woman, sat on either side of a middle-aged woman, their hands linked in unity. The two corner chairs were filled with a middle-aged man in one, a college-aged boy in the other. All five people focused intensely on our arrival, their dilated eyes wary for the news I was about to bring them.

Before sharing my news, I briefly introduced both myself and Cindy and learned that this room contained the patient's wife, his in-laws, his brother, and his son. After shaking hands, I deliberately continued to hold on to the wife's hand while her father rubbed her back.

"It's not good, is it?" the wife asked me. I shook my head "no" to her question before saying the word out loud. "No," I reiterated, "it's not good. Despite all of our attempts, we can't seem to get your husband's heart beating again."

I had left Room 17 for the family room with a dismal feeling. The woman's husband, in his late 50's, had collapsed at work and, despite being intubated, having immediate CPR and being given all the appropriate life-saving medications by our prehospital team, still had not responded to any medical interventions. He had arrived at our facility ten minutes earlier, thirty minutes after his collapse. After several attempts of high-Joule defibrillations and multiple escalating doses of medications, our team remained unsuccessful in our resuscitation attempts. I had left his room with the patient in asystole, a malignant situation where the heart was not making any electrical signals to stimulate itself to beat. It was not looking good.

For the next several minutes, I explained to the family, with earnest, what our medical team was doing in attempts to resuscitate their loved one. After I finished, the wife stood from the couch and dropped to her knees, half in prayer and half in disbelief. "Please, Gary," she wailed in a desperate voice, "don't leave me yet. I want to talk to you one last time."

After helping her back to her feet, I offered her to come to Gary's room with me to be with him during our resuscitation efforts. She accepted.

The patient's wife, Cindy and I walked back to Room 17. As we neared it, I explained the focused commotion she would witness when we walked into the room--three nurses, several techs, a senior resident physician, a pharmacist, a respiratory therapist, and several others all scurrying in their efforts to help her husband, who would be lying on his cot in the middle of all of this activity.

I pulled back the curtain to the room and walked in, surprised to see that CPR was not currently in progress. I introduced Gary's wife to the team and guided her to Gary's side before seeking out my chief resident as to what transpired in the last few minutes. It seemed that right before we had entered the room, Gary 's heart rhythm had switched from asystole to ventricular tachycardia, another life-threatening rhythm. However, this rhythm responded to our team's electrical shock and Gary, still unresponsive, now had a faint pulse accompanied by a normal sinus rhythm. After being down for forty plus minutes, this was nothing short of a miracle. A well-timed miracle corresponding to his wife, on her knees in the family room, pleading with him to hold on.

We encouraged her to talk as much as she wanted to her husband.

And so she did. With tears brimming her reddened eyes, she remained near her husband's left ear, continuously whispering her hushed encouragements and pleas while stroking his hair. Soon after, her son and the patient's brother also were escorted in to be with the patient. Their expressions of disbelief as they walked into the room were heart-breaking.

We called the cardiology team who, after arriving at this patient's bedside in minutes, prepared to take him to the cath lab. Unfortunately, his outlook was tenuous. I was skeptical, after 45 minutes of resuscitation, if Gary would have a positive outcome. Even if he survived, there was no predicting how mentally capable he would be after such a long time in cardiac arrest. If not to survive, why else would he be hanging on?

Suddenly, I thought back to Gary's wife dropping to her knees, begging for a last chance to talk with her husband. I thought of Gary and how, out-of-the-blue, he suddenly regained a faint pulse after multiple failed previous aggressive attempts to jump-start his heart. I looked at his wife, his brother and his son currently holding Gary's hands and whispering their loving words into his ear.

Was this the reason?

I was searching for some sense in this nonsensical situation. Possibly, I realized, I might have been over-analyzing the whole situation, trying to understand how Gary could possibly still be alive. Quite frankly, though, after 45 minutes without a pulse, Gary should not have been successfully resuscitated. Was the whole reason of Gary's lingering due to something beyond our control--the fates cooperating to let his wife and family have several more minutes with him? For proper goodbyes? Or was it because his body really was responding to all of our heroic measures and would heal itself with our modern interventions?

I was eager to know how our efforts would be interpreted by fate. Watching Gary being wheeled down the hallway, from Room 17 to the cardiac cath lab, with his family by his side, I was hopeful that there might be just a sliver of a chance at his full recovery. If not, though, just seeing his family have the opportunity to be with him, to speak to him, to accompany him so he wouldn't be alone during his passage, was enough of an explanation for me.

I got my answer when I returned for my scheduled shift the next day.

Although Gary had still been alive at the end of my previous shift, he never regained consciousness. Per Cindy, he peacefully passed soon after, in the evening, surrounded by his loving family.

He had hung on for all the right reasons...

As always, big thanks for reading. I wish much peace for Gary's family. I also hope this finds you all well. See you again later this week...

A Mother's Cry

It happened again last week. Among the hustle and bustle of a crazy shift. A pre-hospital radio call from an ambulance team that nobody ever wants to receive.

"We're bringing you a child in cardiac arrest."

Noooooooo. Word traveled quickly through our staff, and the mood immediately got very somber as everyone prepared the resuscitation room for this child. We could only pray that the child being brought to us would respond to our life-saving measures.

Nurses ran to get the intubation and IV trays, pharmacists ran to get the resuscitation cart with all the emergent medications, techs ran to get the EKG and ultrasound machines, and respiratory therapists ran to get a ventilator. Two of us physicians were working with a slew of residents, and we all reviewed our mental checklists and tried to enter our objective frames of mind. Organized frenzy.

My partner requested to be the lead physician during the resuscitation. Being young and recently-trained, he wants to save the world. We all want to save the world, I guess, but for now we'd focus our energy on saving this child. I assured him that I would stay in the room and help with the resuscitation efforts.

The ambulance arrived. With a sad nod of his head, a trusted paramedic gave answer to our searching faces. No response. Yet. We all caught our breath as our hearts plummeted.

We transferred this child to our hospital cot. We emergently intubated this child, checked for any pulses, and continued CPR when we found none. IVs were hard to establish, so I started an intraosseous line by sticking a needle into this child's left tibia. Aggressive fluids were given. Medications were administered. Ventilations were forced into uncooperative lungs.

Efforts continued. My partner followed the life-saving protocols but didn't get any response from this child. Prayers were whispered. Seconds were watched as they ticked on the clock. Slowly, as slow as any time had ever passed, a heartbreaking realization permeated the room. We might not succeed.

My partner ran to the family room to discuss options with this child's parents, while I continued to follow all the resuscitation protocols. We had nearly maximized all of our medications. And still...nothing. CPR was continued, ventilations were continued, more medications and hydration were given.

My partner returned to the treatment room. He looked at me expectantly, and I shook my head "no." My partner shared his conversation with me. Dad was still at work, and Mom was in the family room with our social workers, waiting for family to arrive. She had been invited back to watch the resuscitation efforts, but declined. Her child had been through this once before, because of chronic, ongoing medical problems, and had survived. Surely, she thought, her child could survive again.

After almost an hour of failed heroics, with absolutely no response to any of our interventions, we confirmed what we were most afraid of. There were no palpable pulses. There was no cardiac activity, confirmed on monitor and with our bedside ultrasound. There were no spontaneous respirations. There were no signs of life from this child.

There would be no miracle.

My partner asked if anyone in the room objected to his prounouncing this child's death. Nobody objected, since we had all been involved in trying to save this child's life. We knew the efforts that had been put forth were monumental. No attempt had been spared by our team to bring this child back. Unfortunately, and for unexplained reasons, the fates held different plans. My partner announced the time of death.

I requested a nurse to clip some of this patient's hair for the family. I crossed myself after my silent prayer. I fought my tears. Hell, we all fought our tears. I consoled my partner, who, like me, has three young kids of his own. Slowly, a wave of profound sadness and nothingness swept across us. What good are any of us if we can't save a child's life? My partner went out to the family room to deliver the awful news.

Then, time stood still. From two hallways away, I heard the haunting sound. A sound that I knew was coming. A sound that is played over and over in my mind for days after an event like this. A sound of profound anguish. A sound of utter disbelief. A sound of infinite pain.

A mother's cry.

Slowly, as we all knew would happen, the mournful wails of crying crescendoed, and our emergency department came to a stand-still as Mom was escorted through our halls into her little child's room.

Despite our best attempts at maintaining our objectivity, and despite the fact that there were many more patients waiting to be treated, our ER staff cried collectively and gave consoling hugs to one another. We are mothers. We are fathers. We are brothers and sisters. We are sons and daughters. We are friends. We are human. And, we were broken.

Dad arrived just minutes after Mom was escorted to the room, and the cries of desperation were repeated. This time, husky and deep. Slowly, though, his cries softened and dissipated, until there was but one lone cry that began again. Higher-pitched. Guttural. Primitive. Emanating from the womb. A cry that conveyed the raw anguish and helplessness that only such a profound loss as losing your child could bring.

God Bless this mother. God Bless this father. God Bless this child. And may God Bless and watch over this family. And all of us.

If only life were filled with just happy moments...As always, thanks for reading. Next post will be either Friday, February 19, or Monday, February 22. See you then...