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...   

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...

No Love For A Father

The nurse hung up the phone, shaking her head.

"I can't believe the nerve of some people," she said, clearly aggravated by the phone call. The phone call, she explained, was from a gentleman inquiring about where he should check-in when he brings his father to our ER in a few weeks.

"In a few weeks?" the nurse asked, making sure she heard right. She did.

The gentleman explained that they were moving their father from the West Coast back to our side of the country, to be closer to family, after the father's third wife recently died. The caller had heard that it would be a much quicker process for their father to get into an assisted-living facility if he came through the ER.

"Honestly, sir, that is not a reasonable expectation, unless your father is ill and needing treatment. We are an Emergency Department," she said, enunciating Emergency, "not a place to bring your healthy father for placement."

Her words fell on deaf ears. Around 1 a.m., almost two weeks to the day of that phone call, another one of our nurses walked into the nurses' station, looking incredulous.

"Get this," she said, "this family in Room 22 brought their father directly from the airport to our Emergency Room to have him placed in an assisted-living facility. And," she continued, "they're pissed that they had to wait three hours to get called back from the waiting room."

It was a busy night but, eventually, I was able to make my way to their room. Their story was somewhat familiar with me, but I wanted to learn more.

"Hello, folks," I said, introducing myself to the patient and his family, consisting of two sons and a daughter. All local folks. All dressed in sophisticated clothes and very well-kept. I tried not to be judgmental as I continued. "What brings you to our emergency room tonight?"

"How many times do we need to repeat this?" asked the one son, the obvious spokesman. And obviously obnoxious. "We need you guys to get Dad a place to live here in town."

"At this hour?" I asked, looking at my watch. "It's 2 a.m., I don't think that's going to happen, sir."

"Well," said the son, "we've been waiting since 10 p.m. It's not our fault that it's now 2."

"Even at 10, sir," I said, staring at the spokesman, "I doubt we would have been able to accommodate you." Turning my attention to the patient, I continued. "Sir, are you hurting anywhere? Do you have any injuries or health problems that seem worse to you tonight? Anything that warrants you coming to our ER?"

The patient shook his head no. It was obvious that this was not his planning. I looked back to the son and cocked my eye. He just shrugged his shoulders. After obtaining more history from the patient, I performed a thorough physical. It was stone-cold normal. Clearly, this patient was mentally and physically stable and the family was simply seeking a short-cut to finding a place for their father to live. Heck, he could even live on his own if he wanted to.

"So, just to clarify this," I said, looking at his three grown children, "you picked your father up at the airport and drove him straight to our ER, at this hour, to be placed in a living facility? Am I correct?"

They all nodded. "But all three of you live locally," I continued, "why aren't one of you opening your home to your father until you can get him into a local facility?"

"We were told by several people, including my family doctor," the son spoke, "that this was the easiest way to have Dad placed." Shame on that family doctor, I thought. "And if you can't get him in a place tonight," the son continued, "then just admit Dad until you can get him in somewhere."

It's hard to get a rise out of me, but these people were doing a darn good job. I took a deep breath and tried to clean up my thoughts of these people.

"Well," I said, looking between the patient and his ungrateful children, "unfortunately, your information is wrong. I'll call our case management team down to discuss the available options for your family, but your father has no medical emergency and I won't admit him for the reasons you want. What your father does have, though," I said, "are three children who live locally that could easily provide for him until an assisted-living facility is available."

The family just looked at me. And I stared right back, alternating between them. I wasn't going to blink first.

"Well, then," the spokesman said, "can you call the case manager down to talk to us?"

I walked out of the room, disappointed in this family's dynamics. I'm sure there was more history between this father and his three kids than I was aware of, but still...to pick-up your father from the airport and bring him right to the local ER to dump him off? I would be ashamed of myself. Why even bother bringing him back here to live if this is how it was going to be?

Our case management team came down and, sure enough, were unable to place this patient directly into an assisted-living facility. The soonest they could arrange for his placement was in three days. Three days? People waited months for placement into a facility, and this patient would be there in three days. I guess it was a good shortcut for this family, after all.

"Three days?" said the son, "what kind of system is this? We can't wait that long. Do we have any other options?" No other options, said case management. No other options, said the nurse. No other options, I said.

The patient got dressed while his family grimaced and glared in our hallway. I seriously think they entertained the idea of leaving quickly without their father, but I kept my eye on them. I was ready to chase them down if they tried such a thing. I knew, just from observation, that they weren't above such a thought.

I have three kids of my own, and I shudder to think where a man could have gone wrong to get this kind of treatment from his own children. Did he spoil them? Did he wrong them so significantly that their refusal to take him in was justified? Or were his kids so caught up in their own lives that they had little time left for their father?

Regardless, the patient went to live with the spokesman son for three days. Three long days, per the son. I could only imagine, though, just how long those days would be for a father who felt no love from his family.

As always, thanks for reading. The next post will be Friday, February 5. Until then, if you haven't yet voted, go to Medgadget Medical Weblog Awards and vote for StorytellERdoc in both of his nominated categories. Your support and votes are appreciated! Big thanks!

Not A Hussie

The way our ER is designed, one of the patient treatment rooms, Room 15, sits directly across from a physician work station, a place where we can sit to do our charting, catch up on computer work, use a telephone, and review computerized radiographs.

We have several similar stations throughout the ER, but this one is unique because of the direct view it shares with Room 15. Despite our best efforts to keep the curtain drawn and the sliding glass door closed to this room, there are many moments when a patient and their family can "people-watch" us in the midst of a shift. I actually feel like someone might toss me some peanuts if I clap my hands and dance for them.

It works the other way, too. A screaming dementia patient can ebb away at your last thread of sanity in the middle of a crazy shift. The smell from a patient with a lower GI bleed can give you dry heaves, and the lingering apple-scented spray used to cover the smell only makes things worse. Even the conversations that are overheard, from critiques of the physical characteristics of our nursing and physician staff to the sharing of in-depth personal confessions and secrets, are enough to make one wish for an instant cement-block wall. Graffiti optional.

During one recent shift, because of the noise emanating from Room 15, I was quite happy not to be sitting at this particular station. One of my partners was, however, and I needed to talk to him.

As I walked down the hallway towards the station, the screaming and ruckus only intensified. I found the physician and connecting nursing station bare of any warm bodies and suddenly, I was worried about the happenings in Room 15.

I walked quickly into the room to see if I could be of any help. What I found was one of our recently-hired graduate nurses, Michelle, at the bedside of an elderly woman who obviously suffered from dementia. The patient was aimlessly yelling and aggressively trying to climb out of her bed. Michelle was struggling to get the patient back into her cot and despite her best efforts, this 100 lb. frail little lady was succeeding and now standing at the foot of her bed, all in the blink of an eye.

"Michelle," I asked, walking to the patient's other side as I spoke, "where is everybody? What can I do to help?"

"I think the patient in Room 18 crumped and everybody ran in to help" she answered. "Can you help me get Mrs. K. back into her bed?"

"Of course," I said, thinking this would probably be the easiest thing I would be asked to do during this shift.

Together, we tried to coax Mrs. K. back into her cot. Unsuccessfully. Mrs. K. had other ideas, I suspect, of taking a self-tour of our ER. It seems for every step back we convinced her to take, she took two forward. And she was a strong woman! Why does it seem that the more frail a patient appears, the bigger their can of whoop-ass? She was whooping us, no doubt about it. Heck, I thought, she wasn't even my patient!

Finally, I had had enough. Michelle and I were simply not going to win this battle. I work out often and although this woman's spirit was big, she did just weigh 100 lbs. So with that, I bent over, scooped up Mrs. K. in my arms, and easily placed her back in her bed. Problem solved. In fact, I suspect Mrs. K. enjoyed the ride. As soon as we got her back in bed, fluffed her pillow, and covered her with a warm blanket, she started napping, her outburst a thing of the past.

Guess what, though? After I picked up Mrs. K., I found my right arm, the arm I used to scoop her up, soaking wet.

"Michelle," I asked, "what do you think this is from?"

"Ughh, gross," she said, staring at my drenched arm. "Maybe she had an accident."

Do you think? I looked at my arm and my mind went rampant imagining what the wet was from. The best I could hope for was that it was something yellow. You gotta love Mrs. K. She showed me who was boss after all.

I went to our sink and scrubbed my arms with disinfectant soap. Twice. Three times. When I was done, I smothered myself in antimicrobial gel. That should take care of the juicing I just received.

Wrong. Soon after I returned back to my patients, I discovered a rash starting on my right arm. Only my right. The one that had the wet stuff on it. I looked at it and wondered, as you would, what the hell???

It was definitely a urticaric rash, better known as hives. What could Mrs. K. possibly have given me? Had she been a promiscuous hussie in her youth? Did her urine contain uranium? Was I allergic to recycled apple juice? I was cursing myself for being a good Samaritan. Was getting a rash on my arm worth this?

Of course it was. I would have helped Mrs. K. and Michelle again in an instant.

I went and washed my arms again. Twice. Three times. Then I took 50 mg of Benadryl and changed into a long-sleeved shirt.

I obsessively kept checking my arms. And after about fifteen minutes, I noticed something that made me feel a lot better. Made me smile, actually.

My left arm was getting a rash on it, too.

Why would I possibly be happy to be getting the rash on my left arm, too? Easy. If the rash were only on my right arm, then that unknown wet stuff would have been the source. But...if both of my arms were afflicted with the rash, then it obviously had to be from either the soap or antimicrobial gel I used. My left arm never had anything wet on it.

Washing my arms six times and smothering them with gel twice had gotten to me. Mrs. K., thankfully, had nothing to do with my affliction after all. And sure enough, after about an hour, the rash started going away. On both arms. Shame be gone.

Mrs. K., I owe you an apology. I didn't really think you were a promiscuous hussie in your youth. I promise. In fact, I really enjoyed meeting you as you reminded me of my grandmother. And wherever you are, I hope you are well and still showing the world your indomitable spirit!

Just not in Room 15.

As always, thanks for reading. Next post will be Monday, January 11th. Have a great weekend.

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...

All Bound Up

After much holiday nostalgia, a silly, absurd, self-deprecating story.

Recently at work, I got myself into serious trouble. I mean big time. Trouble with a capitol "T". Trouble that almost made me a patient in our ER.

On that fateful day, I arrived for my 7 a.m. shift. After taking patient sign-outs from the overnight ER doc, while I was getting my computer workstation ready, I noticed a pink emesis basin sitting in the station. These bins double well as serving bowls, so I was eager to see what the overnight snack was. I peered inside to find that it contained about fifty pieces of banana- flavored Laffy Taffy. Supposedly, the night shift had snacked on a full bin of Laffy Taffy, leaving only the yellow-wrapped ones behind.

What? Are you kidding me? Who in their right mind doesn't go for the banana-flavored taffy first? Is apple or cherry or grape really that much better than banana? I don't think so, my friend.

Well, banana taffy and I, we're like an old married couple. I guiltily unwrapped what I swore would be my one and only piece at about 7:15 a.m., thinking that the rest could wait until at least after lunch. After proclaiming my undying love to the yellow gooey stuff, I plopped it in my mouth. Do you think I could savor it, roll it around on my tongue a little bit, enjoy it? Oh no, not moi. I chomped into it three times and swallowed it whole. Okay, just one more piece. I'll savor this one, I told myself.

That was wishful thinking. By 11 a.m., the bin was empty, my fingers were stained yellow (despite multiple washings), and my stomach was lurching at anyone who approached me. How do you possibly tell your stomach to remember its manners? Mine was blatantly rude, speaking out at every opportunity. I know I ate most of the candy, but I swear I didn't eat all of it. Did I?

One glance around the ER and I found my answer. At the far end of the nurses' station, sitting on a small stool in front of her computer, sat one of the new nurses. She wore a grimaced look and was rubbing her belly as she tried to concentrate on her screen. My partner in crime. I wanted to go up to her and tease her, but I am not a stupid man. Those nurses stick together and I knew that whatever I threw at her would come back tenfold to me. So, hard as it was, I let the moment pass and just shrugged off our conjoined misery.

Well, the following week was a long one. And not just for me, but for those around me. I was miserable. Completely and utterly unbearable. From my end (pun intended), the misery stemmed from the intermittent cramping, the spasms, and the constant rumbling that I could not conquer. For those around me, I'm sure, their misery was mostly from their pained ears--ears that bore the brunt of my constant complaining. I swear, after the third day, I didn't have one friend willing to say more than "Hello" to me before turning around and high-tailing it out of there. I couldn't blame them--I'd be the same way.

After a few more days, my wife got involved. "What's wrong with you?" she teased. "Take care of this already. You are a doctor, you know."

Yeah, yeah, I know. I also know that I should not have eaten forty to fifty pieces of Laffy Taffy (did I mention that it was banana-flavored?) in one sitting, but I did anyway. I refused to let the words "Fleets Enema" be mentioned in my presence.

I would like to take this opportunity to thank the kind, elderly woman, a complete stranger, who heard me out in the cereal aisle at Wegman's while I searched for some Rice Chex. "Um," I confessed to her bewildered face, "my name is Jim, and well, I haven't had a BM for almost a week."

Of course that didn't really happen, despite my wild imagination willing it to. I really did walk up and down the cereal aisle three times, though, begging for an angel of mercy to come and put me out of my misery. If not an angel of mercy, at least someone wearing a Depends diaper who could point out the best fiber cereal for me.

Despite lots of water, prune juice, mineral oil, fiber cereal, and fiber drinks, I still had no success. I decided to be really aggressive. It was time for (drum roll, please) magnesium citrate.

For those of you not familiar with this miracle drink, it comes in a ten-ounce bottle and looks like Sprite or 7-Up. Unfortunately, it sure doesn't taste like it. Trust me, drink it fast and drink it cold. And only one bottle. After drinking it, it passes through your intestinal system, pulling water into your colon. This increases peristalsis and provides relief within one to four hours.

I called our charge nurse, Julie, in the ER and asked her to place a bottle in a brown bag for me to pick up. "And please, Julie, don't tell anybody that it's for me." Yeah, right. I should have known better.

I drove to the ER and walked in. Before locating Julie, she had found me. I heard her before I saw her.

"Dr. Jim," I heard her loud, familiar voice yell, "here I am." I turned to find Julie wearing a big grin, standing in the middle of the crowded nurses' station. Don't do it, Julie, please.

She continued. "Here's the bottle of "mag citrate" you called in for yourself. I sure hope it works for you." Ugh. She gently held my brown bag above her shoulders and did a slow 360', showcasing the temporary trophy that was in her possession. Bad girl, Julie, bad girl.

I had forgotten that magnesium citrate can be purchased over-the-counter for a dollar. A stinking lousy dollar--the cost of saving me my dignity. But at that moment, I had no pride.

Well, I am happy to report that I am a magnesium citrate success story. I am a survivor of acute constipation. Starting next month, I will be the new spokesman for magnesium citrate (I said no to the prune juice company), so look for my commercial on a Japanese television station near you. Soon, I hope to have brown wrist bands finished to bond all of us who have braved similar success stories. I hope others will step forward to share their courageous stories and inspire you as I know I have.

Okay, enough. Thanks for bearing through my obscene level of silliness. I am proud to say, however, that I have not had one piece, nada one, of Laffy Taffy since that 7 a.m. shift. Whenever I get the urge, I just slap on another Chex patch and I'm fine.

As always, thanks for reading. The next post will be Friday, January 1. Please take this fluffy post as intended...I hope you smiled. Feel free to comment if you are a banana taffy fan! LOL

Why Medicine?

One of the more frequently asked questions I face is "Why did you become a doctor?"

Trust me, that's a question I have asked myself on more than one occasion. In fact, I think the last time I asked myself that question, it was 4 a.m. and the obnoxious, drunk guy had just finished puking on my new running shoes. Why exactly did I become a doctor? It certainly wasn't so the kind people at Dick's Sporting Goods would know me on a first name basis.

I come from a large family, both immediate and extended. I am the fifth of seven kids, three of us boys. On my father's side, every male is or was involved in the forestry industry. This includes my father, three paternal uncles, my two brothers, and multiple cousins. Since I was a young boy, around age five, I have strong memories of waking up before the morning darkness dissipated, jumping with my father and brothers into one of the company work trucks, and heading out into the pristine Pennsylvania woods. It was expected that I, like my brothers and cousins, would someday pursue a college education in forestry and then continue in our family's international business.

I always knew, though, that I was made from a different cloth. My paternal grandmother, our family matriarch, encouraged me to pursue my dreams, even if those dreams did not include the forestry business. She knew I had a different calling and I loved her for her easy acceptance of this. As much as I enjoyed the beautiful woods, the fresh air, and hard work that came with my family's business, I needed something different.

So, until then, during summer vacations and on Saturdays during the school year, I could be found in the woods carrying a Stihl chainsaw or steering a John Deere skidder loaded with freshly cut logs down a narrow path to an accessible landing where logging trucks would pick them up. Smiling. And ducking behind the occasional tree, convinced that I had seen Bigfoot yet again.

When, then, did I discover my illuminated path toward medicine?

I'd like to say I had one defining moment where it just popped with me, that I would be a doctor, but that wasn't the case. During my tenth grade year in high school, however, multiple happenings occurred in my life that exposed me to medicine and reinforced my belief that I would be a doctor someday. That year, I lost both of my grandfathers to medical illnesses, and I was a firsthand witness to their struggles. I also witnessed my father's leg, crushed in a freak logging accident, be saved by incredible surgeons who refused to look at amputation as an option.

Personally, before these deaths and my father's injury, I also sustained an injury that reinforced my pursuit of medicine.

Chainsaw lacerations were very common in the forestry business, at least before protective chaps gained widespread use. This injury did not spare me and, as a result, I had my first and only ER experience as a patient when I needed a laceration repair.

Right after lunch on that death-defying summer day, I was trimming some obstructing tree branches to reach a felled log. Suddenly, my saw kicked back and cut into my thigh just above my left knee. At first, I thought the pain was just another tree limb poking at my leg. When I looked down and saw my cut denim pant leg outlined with a circle of red blood, though, I knew that I had just been initiated into the Lacerations Are Us Forestry Club.

Trying not to panic and fighting off the dizzying angst of near-death that accompanies a two-inch superficial laceration, I quickly ran out of the woods and jumped onto the skidder, driving it without abandon (yes, 10 mph on a rocky trail) to find Louie, one of the crew guys. Louie, not known for his strong work ethic, was only too happy to drive me to the local hospital's ER. I still don't know to this day how he could eat his bologna sandwich (with ketchup) and listen to Paul Harvey while I sat beside him in the pickup truck, hemorrhaging. And now, page two. The kid sitting beside you in the truck is bleeding to death, Louie. Put the bologna sandwich down and drive faster.

By the time we arrived at the ER, the bleeding had slowed considerably and thoughts of my family catering to my every whim after such a tragic accident waned. As Louie called my Dad from the waiting room, I was placed in an ER room, given a gown to change into, and waited for my Dad's arrival. When he arrived, he was, of course, sympathetic. His face was a hard read, though, bordering between pride for my initiation and disappointment that it wasn't worse.

What happened next for me was nothing short of a miracle. Within minutes of Dad's arrival, the doctor walked in and repaired my laceration. He was kind. He was normal. He was compassionate. And he was thoughtful enough to ask me if I wanted to watch him repair my cut. Absolutely, I said. He propped a pillow behind my back and lifted my cot upright to 90 degrees.

With precision, the doctor explained every step of my laceration repair, from numbing the wound edges with lidocaine to how he would close the laceration in two layers--the buried, dissolvable stitches that would hold my muscle together followed by the external sutures that would closely approximate my skin. Fifteen stitches later, he was done. The nurse, lacking any dramatic flare, applied a big, bulky dressing and antibiotic ointment and I was discharged to home.

Needless to say, I had seen the light. I had experienced medicine. I had been snatched from the jaws of death by the brilliance of medicine (and fifteen measly stitches). From this experience to how the rest of that year played out, I had no doubts about what I wanted to do with the rest of my life.

Is that enough to explain why I went into medicine? I hope so, although at 4 a.m. with that fresh puke all over me, I sometimes wish my personal revelations to pursue a career in medicine held more flare.

So, if you are in my ER in the middle of the night and I smell like bile, please do me a big favor and ignore the stink. And if you see me rubbing my scar above my left knee, don't pay me any attention. I'm just remembering why I went into medicine. Again.

As always, thanks for reading. I hope everyone is having a great holidays. Thanks for all the kind holiday wishes. Next post will be Wednesday, December 30. Until then...

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.