Underneath

A heartfelt appreciation to the readers who shared their personal stories, both devastating and hopeful, on my last post.  Your courage to share was felt and your words of wisdom were heard...thank you.

Walking into Room 33, my next patient, who had come to the ER complaining of cough and cold symptoms, seemed just as I had expected.  He appeared relaxed on his medical cot, lying back at 45 degrees, facing the room's door, his legs comfortably extended in front of him and his gown tied correctly behind him.  He was a few years shy of middle-age and appeared to be in good physical shape. His sandy blond hair, sprinkled with gray, framed his slightly weathered, apprehensive face.  Between coughs, he managed to give me a faint smile.

"Hello, Mr. Brown," I said, extending my gloved hand and introducing myself, "I'm Dr. Jim.  What can I do to help you in our ER today?"

He coughed before answering in raspy voice.  "I had a bad cold about two weeks ago.  It lasted about a week before going away."  Another cough.  "But now," he continued, after taking a deep breath, "it's back.  Back with a vengeance, actually." Yet another cough.  "I've had three miserable days of this stuff," he said, swirling his hand in front of his runny nose, reddened eyes, and dry lips, "and have tried every over-the counter medicine out there."  Cough.  "I just don't know what else to do."

As he spoke, my senses were acutely attuned to him.  I listened to see if he was speaking full sentences of five or six words or fragmented sentences of just a couple.  I listened for audible wheezing.  I watched to see if his diaphragm and intercostal rib muscles were struggling, under his gown, in their respiratory effort.  I noticed the skin coloring of his arms, the pink of his nails, his reddened, irritated nares, and the slight sheen to his forehead.  I listened closely to his cough, to observe if it was of a dry, hacking quality or a wet, congested effort; whether it came in short, interrupted bursts or was continuous and drawn-out.  I watched to see how quickly he recovered from these coughing spells.      

The patient probably thought that I, standing beside his cot with my stethoscope in hand and a smile on my face, was simply waiting for him to finish his coughing and complete his story.  And I was.  Of course, I was eager to learn of any other input he might share so that we could get him on the right road to recovery. What Mr. Brown didn't probably realize, though, is that as important as his providing a detailed history may be,  these obscure observational moments, wordless and symptom-producing, can provide just as much, if not more, information to a treating physician like myself.  I, for one, would much rather hear the cough than have a patient struggle in his description of it.  Penile discharges, though?  That's another story.

Back to Mr. Brown.  Even without doing my physical exam, I suspected he might be suffering from a community-acquired pneumonia.  "Sir," I said, touching his shoulder, "I'm going to perform a physical exam now."  He nodded his consent.  Starting with his head and taking my time, I closely looked in both of his ears (clear), his eyes (slightly bloodshot from his coughing spells), his nasal passages (angry red with significant turbinate swelling), and his throat (red, no exudates or swelling, mild anterior lymphadenopathy).  His tongue was dry and his breath smelled of neglect, like skipping a brushing.

Moving the exam along nice and smoothly, I next focused on his torso.  "Mr. Brown," I said, "we need to remove your gown so I can listen to your heart sounds and auscultate your lungs."  Trying to help, I untied his gown's back tie while he untied his neck.  Slowly, he pulled off his gown, somewhat hesitantly.  And after he did, I understood his reluctance.

His entire anterior torso, extending from his left shoulder to his chest to his abdomen, was a patchwork of skin-grafting.  Thin, transparent, papery patches of transposed skin were bordered by longitudinal, thickened keloid scars.  Some of the patches were less transparent and more natural-appearing, some of the scars less protruding and more flesh-colored, but it was obvious that multiple skin-grafts from multiple body sites had been a necessary, life-saving event at some point in Mr. Brown's life.

"I know, I know," he said, watching my eyes closely absorb the view of his torso.  "I never remember to mention these skin grafts.  Out of sight, out of mind, I guess."  He was almost too blase, leading me to believe that these physical scars walked hand-in-hand with his mental scars.

"May I ask what happened, Mr. Brown?"

"It happened when I was young, in elementary school.  Believe it or not, I had been playing with matches.  No, not on the playground," he chuckled here, "but in my backyard.  All I really remember is my shirt catching on fire, a lot of pain, the smell of my skin burning, and then my mother's screaming." He coughed a few times, his face mildly grimacing with the effort.

"I'm so sorry, sir," I said sincerely.  Imagine spending a large chunk of your childhood undergoing multiple reconstruction surgeries, missing school and losing friends, at a time when those things matter, in the process.  Being treated differently than the healthy kid standing next to you.  Not to mention the constant pain.  And feelings of lessened-worth.  Too many doctors appointments, no sports, lots of dressings.  I was letting my mind race in that brief minute.

I looked more closely at this patient.  Everything had seemed to change after seeing what was underneath his gown.  And now I understood his symptoms even better.

"Sir," I said, "do these scars restrict you when you need to take a really deep breath?"  He nodded "yes."  I continued.  "And do you get a lot of pain from these scars with your coughing spells?"  "Doc," the man smiled, "I think you get it.  It's been pretty hard with the colds this year, but these scars sure don't make recovering any easier." 

I did get it.  Because of his torso scars, his thorax, when stressed with illness, couldn't expand as easily as yours or mine. His fibrous scars and skin-grafting, lacking pliancy, prevented him from taking as full a breath as necessary.  Kind of similar to being wrapped and squeezed by an anaconda, I would imagine.  His work effort, thus, was increased.  And not exchanging air in the depths of his lungs, because of this momentous effort needed, would set him up to acquire pneumonia.

Not only this, but now I understood why he probably put a lot of effort and time into staying in decent physical shape.  "If I put on even ten pounds," he told me, rubbing the scar tissue around his umbilicus, "I start to hurt right here, from the outward pressure.  It seems any weight I gain goes right to my stomach, of course, and not my ass or legs.  Hell, I'd even take a double chin.  So I really have to be careful with my diet and exercise unless I want to have constant pain."  Talk about the pressure of eating right and hitting the gym.

Me?  I work out just so I will always look better than my brothers.  There is a lot of pressure being the best-looking boy in the family.  Clearly, he had better reasons than me to visit the gym.

After finishing Mr. Brown's exam, we got an x-ray, some baseline blood work, and an EKG.  His WBC count was slightly elevated, going hand-in-hand with a very early consolidated pneumonia viewed on x-ray.  We took no chances--he was placed on a strong antibiotic, given albuterol and atrovent nebulizer treatments and a machine to do the same at home, and, probably most important, he was given a strong cough syrup with hydrocodone to ease the stress that his cough was bringing.  He was quite appreciative upon his discharge, his cough lessened and his breathing a little easier.

"Thanks, Doc," he said, after he was dressed, "this was a good visit."

Meeting Mr. Brown initially, everything was just as I had expected.  Until we removed his gown.  And then, I saw what was underneath--the physical limitations of his body during a time of illness.  And underneath this, I was fortunate to learn of his hidden strengths and stoic fortitude that his life experiences taught him.  He seemed the better man for it.

I gave this some thought, about how much we all have in common with Mr. Brown.  How we show the world what we think they want to see.  But underneath, don't we all have something we are hiding, just like Mr. Brown?   Something that may even be limiting our full potential?  May it be physical.  May it be mental.  May it be both. More importantly, underneath, buried in doubts, don't we all have more good that we can give this world of ours?  If we just get over our fear of showing... What.  Lies.  Underneath.

Mr. Brown, thank you for trusting me to show me your underneath.  It made a difference.

As always, big thanks for reading.  I hope this finds you having a good week...

Two-fers And More

Anyone who has worked in an emergency department is well aware of the term "two-fer." It is a term that seems to be accompanied by dread and a discouraging shake of the head. Unfortunately, though, it is a reality that comes with our jobs. And as much as we'd like to run from a two-fer, we have all learned that it is better to just suck-it-up and deal with the situation.

Two-fer. See, just thinking about it, I can feel my heart rate picking up.

So, as the name implies, we are not dealing with a single patient. Nope. A two-fer typically means that there are at least two patients from one family that wish to be seen. For example, a mother with some URI symptoms may decide to be seen by a physician as long as she is checking-in her sick toddler, he with a fever and some ear tugging. Maybe it's the elderly couple who have both decided that their diarrhea is from eating out at a local buffet house. "I knew I shouldn't have eaten the rice, Edgar. It didn't look right." Maybe, even, it's twin pelvic exams for the college roommates who do everything together.

Surprisingly, though, I think patient number two does not typically plan on being seen but, instead, makes the split-decision to be treated once they arrive at the ER. And why not, really? They are already here. If their family or friend is going to be treated, they may as well get "checked-out, too."

If it were only two patients, maybe it still wouldn't be such a big deal. But guess what? Yep, you guessed it. Sometimes there is a "three-fer" signed in. Sometimes, even, a "four-fer" and a "five-fer." A general rule is that the more people that sign in from the same family, the less sick they really are. And because of that, they usually get sent to our express track. Don't you think, for one minute even, that I don't appreciate immensely that provider taking one for the team.

A few years back, one of my favorite physician assistants, a compassionate free-spirit named Patty (imagine Carole King dancing wildly at Woodstock), was assigned to my supervision. And it was during this shift that Patty set a new record. In my book, anyway.

Guess how many she saw from one family? Five? Nope. Six? Nope. Drum roll, please...Patty saw seven patients from the same family. Is "seven-fer" the right term here? I don't honestly know.

Can you even imagine walking into one treatment room and finding seven patients, though, waiting to be seen? I can't, although Patty seemed to take it all with a grain of salt. "I may as well just buckle-up and get this family taken care of, Jim," she replied when I called her to ask if she needed any help. And tell her that I thought she was a god. "They all seem to have the sniffles," she added, "I'll be okay."

It turns out that two adult-cousins, mothers in their twenties, each brought in two of their kids to be seen for cough and cold symptoms of a day's duration. While checking in their kids, the two adults decided that they, too, wanted to be "checked out." Heck yeah, why not? So let's count. One mommy plus two kids equals three. Plus, one mommy and two more kids. Three plus three equals six. Not seven.

Oh, but while this family was in triage, one of the young mother's decided to run back home and get her third child, an infant, who "was just starting to get a runny nose, too." So, while she was away, the other mother took charge of four unruly, poorly-behaved kids. We could hear them, three halls over in our acute ER, causing a ruckus. Wouldn't you think that if they were sick enough to come to the ER, they would be somewhat fatigued or a little wiped-out?

This, my friend, is how Patty ended up with seven patients in one room. While mom number two was away, mom number one was placed in one treatment room with the four waiting kids. The door was shut after a few minutes, by nursing, because of their disrupting behavior, until Patty went in to perform her exam. Pardon me, I mean exams.

Happily, Patty reported that there was no significant concerns or illnesses in the room. An ear infection here. A strep throat there. Otherwise, normal cough and cold symptoms presumed to be viral.

"Patty," I had to ask, "is this a record for you?"

She didn't even flinch. "Hell, yeah, Jim," she said, chuckling, "and I hope I never have to top it."

I was eager to see how she approached so many patients. Maybe she saw one or two patients at a time and then stepped out to fill out the medical charts. That's how I would do it, I think. To avoid all that confusion.

"Nope," Patty said, shaking her head and pulling out a ratty 8 1/2" x 11" paper, "all of my notes are right here." As the mothers had talked, she had taken notes on each patient and then immediately performed their exam. "If I had stepped out of that room, even one time," she added, "I don't think I would have ever gone back in." When she was done, she stepped out of the room and formally filled out each patient chart, their discharge instructions, and their prescriptions, if needed.

Time spent? One hour. Which, when you think about it, is a good average. Seven patients an hour. Us ER docs typically average two to three patients an hour, although our patients may be a bit sicker. Nonetheless, Patty kicked ass. And I told her so.

"Yeah, well thanks, I guess," Patty said, wondering if I was teasing her or being serious. Maybe a bit of both, actually.

News of Patty's heroics travelled fast through our ER and, for the next week, she was looked at with nothing less that pure adoration. Honestly, I think she soaked all the glory and attention right-up. Who wouldn't. Some even nicknamed her "Seven."

As much as a team player that I am, though, I was very glad that it was Patty who stepped up to the plate to see this family. And not me. I think Patty single-handedly saved me from becoming a befuddled bobble-head.

Suddenly, a two-fer doesn't sound all that bad anymore...

As always, big thanks for reading. I hope everyone is having a great week. See you Friday, June 18.

My Spinning Head

My head is spinning. Seriously spinning.

Let me see. A combined twelve years of elementary school and high school. Four years of college. Four years of medical school. One year of internship. And three years of residency. Oh yeah, don't forget about the thirteen years of "life" I've had since all of this formal schooling and training has finished.

Yet, for all of this experience and hard work, I felt abandoned. Confused. Wayward. Standing in the middle of a store aisle. I ended up looking to my left, ready to plead for a stranger's help. I looked to my right, hopeful that some angelic vision enveloped in a bright, shining aura would proclaim the answer to my question. And I looked ahead of me, acutely aware of all of my options.

Which cough and cold medicine should I buy?

You might laugh but, seriously, how does the common person do this? Here I am, with all of this medical knowledge and ER experience in my back pocket, and even I can't make a decision to what I should buy in this endless cough and cold medicine aisle.

It started out simple enough. Traveling down the fourteen hours to Hilton Head these past few days, staying in a hotel room halfway through the trip, lots of car time with some lingering kid-coughs, closed continuous car circulating air, and, before I could blink, my wife has a runny nose, sinus congestion, and headache. And is feeling rundown. And is achy everywhere. And has a sore throat. And a fever, "well, maybe I don't have a fever but I feel warm." I'm sure it was brewing before we left but, unfortunately, presented itself at the start of our vacation.

The thing is, my wife never gets sick. Seriously. She takes her vitamins, she exercises, she eats her vegetables, and not from a can, mind you (that would be me and my love-affair with young, tender peas). She consistently partakes in all the things that I only do on a sporadic basis. But, here we are, on vacation, and she's the one whose ass is dragging. I would take one for the team, in a heartbeat, if I could spare her this misery. But, I have to admit, for once, it's nice to not be the adult in the house getting the kids' spill-off illnesses.

She's not a complainer (of the two of us, that would be me), so when she asked me if there were any medications she could take to feel better, I knew she was not feeling well.

We went out as a family to WalMart to buy her some medication for her symptoms. The irony of it--driving fourteen hours to go to a store that exists five minutes from our home--was not lost on me. But to our credit, we did try the local grocery store first.

I walked into the store, very clear about what kind of medicines she needed to get back on track. How hard could this be, really? She and the kids grabbed a cart to fill-up on our needed supplies for a week of condo-living. I searched out the pharmacy section. "I'll meet up with you in a few minutes," I had said. On hindsight, a stupid statement.

I found the cough and cold medication aisle quickly. I started picking up the boxes to read the active ingredients. Cough suppressant? Cough expectorant? Nasal decongestant? Antihistamine? After sorting through all of those options, then, I had to decide if I wanted acetaminophen (Tylenol) or ibuprofen (Motrin or Advil). Okay Jim, I comforted myself, just take your time and start over.

I decided a different approach--let's go with the proclamations on the front of the box. Cold Multi-Symptom (regular or severe), Sinus Congestion, Headache and Sinus, Cough and Headache, Sore Throat and Cough, Sore Throat, Cough, and Sinus...you get the picture. If nothing else, I appreciated the selling of every single variable you could squeeze out of the common cold.

So picture it, you are at the store shopping and you see a guy scratching his head, rubbing his chin, pacing back and forth, picking up a box off the shelf just to replace it back in seconds, and that would be me. With all of my infinite medical wisdom.

I finally sorted through all of these options before realizing, "Wait, she'll need both a daytime and a nighttime medication." I sure didn't want my wife to get tired in the daytime during our time at Hilton Head, right? Possibly risk sleepwalking through our vacation? So, guess what? She'd need the nighttime version, too. Unfortunately, though, the daytime formula I had decided on didn't have an alternate nighttime version (it's usually just an addition of some form of antihistamine). So what did I do? Well, of course, I started over.

The minutes dragged, the active ingredients blurred, and the box-front symptoms united to form one big blob of an illness. Finally, after much frustration, I picked out what I thought was the best option for my wife's illness.

"Daddy," I heard my youngest call, just as I was wrapping up my choice. Looking down the aisle, I saw my smiling family approach me. "What took you so long?"

I held up the boxes I chose for my wife to see. I must have looked like the village idiot, extreme pride radiating from my pathetic face, eagerly anticipating my wife's approval of the two $2.68 boxes of miracles. Please, please, I remember thinking, tell me how good I did.

What she asked next was like fingernails on my brain's chalkboard. "What about the liquid, Jim? How's that?" I think I stomped my feet, my mind screaming "No, no, no" while my voice remained silent. "Or," she continued, walking down the aisle, scanning the options, "maybe I'll just do gel-caps." She looked at several boxes quickly, scanning each's front and back in just short of ten seconds. "Yeah," she said, "I think these will do." She had found a combo-box of both daytime and nighttime medication with, evidently, just the right active ingredients to treat her symptoms.

I think I'll just place this whole experience in the "knows too much," category, thank you very much. I might just be giving myself too much credit, though, on that one.

Now, if you don't mind, I have to go take a couple Tylenol for my headache. Or maybe Motrin. Oops, I mean Aleve...

As usual, big thanks for reading. Next post follows on Wednesday, March 17. Hope everyone is well...see you then...

ER Tupperware

I am only going to warn you once, so please pay attention. Beware of any patient carrying Tupperware or Gladware in the ER. Chances are slim at best that they are carrying food in those containers. What is in them, then? Oh, my friend, I could write a book on what people have brought us using those containers.

It happened again to me last night in the middle of my overnight shift. I should have known better, but I must have been tired.

A very nice elderly woman, a retired government worker, presented to the ER for complaints of two days of coughing with phlegm production. She had no fever, no difficulty breathing, no difficulty speaking, stable vital signs, and no change in her daily routine. She just thought that she needed "checked out" at 5 a.m. while a snowstorm raged outside our ER doors. She came by ambulance.

"I've had the cough for a few days, doctor, and wanted to make sure it wasn't pneumonia. I never had it but heard it can get pretty bad."

"Well, maam, do you feel bad?" I asked, trying to get to the root of her buried complaint. Sometimes you have to dig and dig and dig to find that complaint and, still, all you're left with is an empty hole.

"Oh no, not at all. I feel great." Her words were followed by a sweet, innocent, old lady smile.

Hmmm, I thought, scratching my chin after performing a perfect exam. 5 a.m. Raging snowstorm. Feels great. What oh what should I do.

I sent her to x-ray for a quick two-view of her chest that, of course, came back negative.

After she returned from radiology, I repeated a brief exam, still stable, and explained the results of her negative chest x-ray to her. She nodded her head in agreement with my words and after I was done speaking, she stood up, went to her room's counter, and pulled her Samsonite purse from it. She carried the purse back to her cot and sat back down, opening it. She pulled out her wallet, two books, a rosary, a red Jolly Rancher, and a paper-clipped bundle of papers before finding what she was looking for.

"Oh, yes dear, here it is."

I watched her with excitement, wondering what she was going to pull out to show me.

Slowly, she began pulling her hand from her bag. Was she going to show me a winning lottery ticket, a rare signature from Abraham Lincoln, or heck, maybe even some banana-flavored Laffy Taffy?

I held my breath. As her hand lingered in the purse, teasing me, my tension mounted. Finally, she pulled out the object.

Nooooooooooooooo! I wanted to scream. And run fast.

She held up a blue-tinted disposable plastic Tupperware container for me.

The best defense is a good offense, of course, so I didn't waste any time. "Is that a snack, maam? Did you bring some leftovers to eat in our ER tonight while you were waiting?"

"Oh no, doctor, I think you really need to see what I've been coughing up." She tapped the lid as she spoke. How could I refuse this little old lady's request? I couldn't.

I stepped forward as she peeled the lid off the container. There better be a gold nugget in there, I thought to myself. But no, not even close.

"See," she said, "isn't that just awful?"

I peered hard into the container to see what she was seeing. I couldn't see anything awful, just a string of clear spittle beautifully draping the inside walls of the container, like garland around the front door. Her partial upper plate sat smack on the bottom, a small puddle dispersed around its edges.

"Oh, there you are," the woman said, snatching up the wet partial and plopping it into her mouth. I made a silent plea with God. Please, dear God who is all kind and good, if you can get me out of this room in the next minute, I will shovel my neighbor's driveway. Or shave my head. Or never make another bowel movement joke again.

Now the woman held her breath in anticipation of my exam of her spittle.

"Oh yes, maam," I spoke, choosing my words carefully, "I see what you mean. That's some mighty clear phlegm you got there. Isn't that something how it sticks to the sides like that?"

"Yeah," she nodded, somewhat panicked, "tell me about it. Does that mean something? Is it bad when it sticks to the sides? Am I going to be alright?"

I answered her. "Yes, maam, you are going to be alright. Spittle clinging to the side doesn't mean anything more to us than usual spittle. And more good news. Everything about your visit looks okay--nothing we need to worry about or treat with antibiotics. Just work hard to keep bringing up that extra spit and if you get a fever or worsening symptoms, you can always come back for a recheck."

She seemed happy enough with that. But I knew one more question was coming my way.

"Um, doctor," she spoke, holding out her container, "do you want to keep this and send it to lab or something?"

Well, heck yeah, I thought to myself. I would like to keep your container and send it to lab, maam--if it were April Fool's Day. But otherwise, no, I don't feel any overwhelming urge to keep your container.

"Do you want me to throw it out?" I asked, reaching for it.

She pulled the container back towards her. "Oh no," she said, emphatically, "I'll take this home and reuse it."

I may have swallowed back a little phlegm of my own, thinking of what she would store in there next. A piece of lasagna? Leftover baked beans? Pennies from 1982? Jelly packets from a restaurant? Tomorrow morning's bowel movement? You know, the constipated one that she could slice like a stick of pepperoni?

I wonder if this is what Tupperware and Gladware had in mind when they marketed these useful containers.

The kind woman packed up her container and put it back in her Samsonite. She repacked her other things, too, which made me kind of sad. I had been eyeing up that Jolly Rancher.

"Well then, maam. You take care of yourself, okay? And again, always feel free to come back or visit your family doctor if you need to."

She reached out and shook my hand. "God Bless You, Doctor."

What a sweetie-pie, yes? After helping her out of her room, I looked down at my watch. More than five minutes had passed since my plea-bargain with God. There would be no extra shoveling for me when I got home that morning.

As always, thank you for reading. Next post will be Wednesday, January 6. Stay warm...