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...   

Have A Little...

Faith.  A simple word with complicated meaning.  It is a seed buried deep within our spiritual cores, ready to be nourished and blossom with the sprinklings of tragedy.  It is a belief that things will work out, despite our lack of vision for fate's secretive reasons of the bumpy journey we must endure.  It is an inherent hope that has either sustained us or has failed us miserably.  Yes, to me, this is faith.

We all have known faith.  Embraced it.  Bargained with it.  Coddled it within our breaking hearts. Placed it on a pedestal of worship. I have, too.  With undertones that may be religious, spiritual, or meditative, we lean against its pillars of reassurance.  Sometimes, as they say, it is all we have to cling to during desperate times.

Working in an emergency room for 16 years, I have seen faith present its various faces many times.  It may be within the circle of a grieving family, their hands clasped in prayer.  It may be in the young mother's eyes, watchful of her sick child lying in a hospital cot.  It may be in the older gentleman's anguished cries as I share the devastating results of his wife's testing.  It may be in the silent strength of the obvious love of a dying man's partner.  It may be in the ER staff's comforting whispers.  Faith cannot be contained, especially in tragic circumstances.  I tend to think it is a part of the coping fabric that threads all of our lives.

Why do I think that?  Because, those moments of my life where I had to believe in something more, where I had to dig deep within the rubble of my soul to scrape a little bit of sanity, were during intense, personal moments.  My son's illness.  My mother's death.  My grandmother's death.  A life-threatening injury to my father.  I swear, when my mother and my son were both simultaneously enduring chemotherapy, I stared faith right in the face and bargained with it.  Threatened it, even.  "If something happens to my son," I uttered to invisible universal ears while pulling at my hair, "I will never forgive you for it." Yes, I know faith.  It has been my best friend and my worst enemy.

After my son's initial diagnosis, I stood in the hospital corridors outside of his pediatric room, disheartened and in disbelief.  Cole had just returned from the OR where a mediport had been placed in preparation for an aggressive initial round of chemotherapy.  My spiritual guidance, Father Tom, stood beside me, recognizing my slipping faith.  "Why Cole?" I asked, over and over, tearful and angry.  "Why couldn't it have been me?  What kind of world do we live in for a child to endure this?"

Father Tom, in his infinite wisdom, answered my pleas with words that I still carry to this day.  His words, to me, exemplify the true nature of faith.  "Jim," he said, his voice husky and comforting, his arm wrapped around my trembling shoulders, "I can't answer your questions.  I wish I could, but I can't."  He paused slightly, choosing his words.  "I can only pray that at some point in Cole's life, on his journey, the answers of 'Why?' will become more evident.  That the reasons will be more clear to all of us of why he was chosen to endure this illness."  In other words, in staring at a big, suffocating fog of nothingness, Father Tom was telling me that I must have faith.

How does one do that?

At my rock bottom, the openness of my mind was staggering. I listened to any words of support and encouragement, my hopes and faith hinging onto any little hint of a better tomorrow. I'd walk away from family and friends, my mind reeling and spitting out their words to suit my recovery, my belief system.  Ultimately, I learned to believe that all things in our lives happen for a reason. I had to arrive at the belief that Cole would survive and thrive, that the years we will have together would be many.  To not arrive at this point would have meant a certain death in an unattainable part of my core.  I was learning to survive by walking the path that my faith created.

Cole survived.  And as I type these words, I whisper a silent thank you to those universal ears of faith that fulfilled my every request.

Every day, though, followed by every week, every month, and every year, there is more profound sadness, more tragedy, that requires us to dig deep and rediscover our faith.  To recommit ourselves to examine our morals and ideals while we cope with a crisis.  A few years back, another setback occurred in my life, plummeting me even farther into my spiritual well.  Cole had veered from remission while my mother concurrently fought a losing battle against leukemia.  And I was back to the same dark place that I had turned my back on just a few years earlier.

Again, though, my faith sustained me.  It wasn't easy.  But now, with things going well, especially after my very own first health setback, I sit here and appreciate the moments of goodness in my life.  I have learned, from these various experiences, to give my attention to faith during the good times, too.  My faith has been tested and tried and, fortunately, has sustained me in my times of need.  It is my time to feed some nourishment back, during the good times, to those who have surrounded me with smiles and encouragement and and unwavering friendship and love. A phone call. A card. A lunch date. A smile. Some kind words.

It is a two-way street that I have learned to travel with faith.

Where does your life sit right now, on this very day?  Are things going well for you?  Are you facing crisis?  Are you recovering from or approaching a trying moment?  Are you engaged in the environment surrounding your life? How is your support system?  And, most importantly, how is your faith?  Do you think maybe that little seed patiently waiting to sprout within you, in a moment of need, might appreciate a little attention now?  If so, give it some.  Sow it.  Water it. Feed it.  Coddle it.  Embrace it. The effort taken now to examine and understand your faith will reap you rewards when you most need them.

All around me, including dear family and friends, including strangers and patients in the ER, I see daily struggles occurring.  At times, I feel helpless and out of sorts, my seat on the sidelines but a useless location to witness another's misery. But I know, from continuing to grow as a compassionate and kind person, that good times will prevail if one can just hang in there. So, please, just hang in there.

And have a little...                     

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...

Keep Your Cranky

Although the majority of my emergency department time is spent in a local 36-bed trauma center, I continue to work a few shifts each month in the small rural hospital near my childhood hometown, several hours away. It is a great change of pace, treating the local folks, while affording me a chance to spend a few evenings with my father and siblings' families.

Last week, I had to drive through white-out blizzard conditions during my most recent two-hour trip, taking approximately four hours each way because of the weather. White knuckles, breath-holding, tense and contracted muscles, stress headaches, and bouts of complaining to myself in the car--these were all part of the package deal. I imagined the cozy, 12-bed emergency department awaiting my arrival, however, and kept plugging along the icy roads, refusing to abandon my place in the thirty-car line of traffic. Going 20 mph. And braking every five seconds. Yep, good times, as any of you ever caught traveling in a snow storm are familiar with.

Arriving at the small ER, then, I was pleasantly surprised to see the festive decorations that adorned the department. Gold, shimmery garland draped the nursing station. Felt stockings and striped candy canes hung in random fashion along the glass enclosure walls. A Christmas tree was standing tall, twinkling and proud, in a nook of inactive space in the corner. It felt Norman Rockwelly and old-fashioned, and I felt welcomed. 'Tis the season.

The first of my scheduled shifts was quite hectic. From my prime seating in front of the ambulance bay doors, I was able to appreciate the outdoor weather. Blustery gusts of snow and heavy thick blankets of engorged snowflakes descended and tormented, without pause, the small town through the day. Although I felt worry and concern for anyone out in this weather, a blazing fireplace, a good book, and a glass of wine were the only things that would have added to the enjoyment and appreciation I felt for this crazy weather.

Three hours into my shift, though, I remembered what the first snowstorm of the season means to an ER staff. Multiple MVCs (multiple vehicle collisions). First-time-of-the-season shovelers developing chest pain as they try to clear their sidewalks. Frequent falls resulting in contusions and broken bones and lacerations. Cough and cold symptoms magnified tenfold with every ten degree drop. Frostbite. And on...and on...and on...

By mid morning, we were swamped. And I loved it. All twelve beds were filled and the waiting room was starting to spill over. The multiple ambulance runs to pick up and drop off ill patients created a steady, rhythmic sense of humming chaos. Despite the craziness, the staff I was working with (many of them friends from my childhood) continued to smile while pushing onward. I was proud to be part of such a team, their hardwork quite evident. We were providing excellent care in a very efficient manner, discharging and admitting and transferring patients left and right.

So, was it really a surprise to me to find that, eventually, all good things come to an end and this run of busy but gratifying work would be interrupted by something unpleasant? I guess not, although I could still hope, right?

The unpleasantness came early afternoon, in the form of a man's booming, angry voice resonating from the hallway. I had been in Room 2 at the time, examining a new patient, an elderly female with dizziness.

"If you'll excuse me, maam," I said, "I need to go see what's going on in the hallway."

I left her room and shut the sliding glass door. Several nurses were in the hallway already, standing in front of a 60ish man, his mouth moving while he leaned forward into his walker. The obvious source of the angry yelling.

"Excuse me, sir," I said, walking between the nurses and right up to him, "what seems to be the problem?"

If any of you have seen the movies Grumpy Old Men and Grumpier Old Men, picture a shorter version of Walter Matthau with slightly more gray hair peeking out from his baseball cap. A pinched-up face. Angry, flaring eyes and a reddened, ruddy complexion. His flannel shirt was untucked from his blue denim pants. And his hands were balled into fists while maintaining his grip on his walker.

Those angry, flaring eyes didn't take long to focus on me. "Who the hell are you?" he asked, practically spitting on me with his disgust.

"I'm Dr. Jim, the emergency room doctor on shift for the day," I said, keeping my cool. "And you are...?" I deliberately left the question open.

"I'm the God-damned boyfriend of Room 6, if any of you lazy sons-of-bitches care," he screamed out, "and I need somebody from this God-damned first-aid station to tell me what the hell is going on with her."

I was surprised at this man's behavior, wondering to myself if he had tipped a few back during lunch. The level of rudeness and obnoxious behavior I encounter through my shifts continues to amaze me. Trying to placate this man would turn out to be an obvious failure.

Room 6, this patient's girlfriend, contained a woman in her 60s who had lingering burping and belching for six months. Today, this day of stormy weather, was the day she decided to pursue her symptoms, for no other reason than just "because I figured it was time to get checked out." She was right to come in, since her EKG revealed signs of heart ischemia that were confirmed by her elevated cardiac enzymes via blood work. I had seen and treated her immediately upon her arrival to our ER, as well as checked-in with her multiple times, making sure her symptoms had resolved and explaining the results of her tests. Currently, the cardiologist was on his way to the ER to make further recommendations.

At no time during this woman's hour stay did a boyfriend present himself. She had been in the room alone.

"Sir, keep your voice down," I told him, "we have a lot of sick patients in this ER today. And when did you get here," I continued, "since I've been in your girlfriend's room multiple times in the past hour."

"Me, too," piped in Marsha, the patient's nurse.

"I just got here," he said, shaking his head in disgust, "and nobody made it a point to explain things to me." He continued to rant and rave, insulting anyone associated with the small rural hospital.

"That's not true," Marsha disputed, "I explained everything I knew to you, just a few minutes ago, after you walked into your girlfriend's room. I even offered you a chair, coffee, a blanket."

"Regardless, sir," I said, proud of Marsha, "you could have asked in a much better way than walking into the hallway and screaming like this for everyone to hear." He eyed me up, surprised at my confronting him on his behavior. "Now," I said, "these are your two choices. Either leave the department and wait in the waiting room, or go back into your girlfriend's room and act like a gentleman. After she answers your questions, I'll be in to answer anything further. With her permission, of course."

There was a standoff. He eyed me. I eyed him. The nurses all held their breath. Finally, he spoke. Or yelled. "Screw you. I'm going to go, God-damn it, and feed her God-damn mutt of a dog. But I'll be back," he said.

Before leaving, he tried one last parting shot. "I envy your God-damn generation," he muttered, "none of you know what hard work is. Not a single one."

Well, I thought back to my 14 hour days working with my father's crews in the woods when I was a teenager. I thought about waking up in my childhood on Saturdays and Sundays to cut and stack firewood and cut grass. I thought about the numerous chores our parents expected of us. I thought about the endless sleepless nights I spent, first studying through college, then medical school, and finally through residency, before some semblance of normalcy finally arrived to my life.

"Sir, you don't know me or any of the nurses, do you?" I asked, sweeping my hand towards them. He nodded "no." "Then how," I continued, "can you say such a rude thing? I would never consider insulting you the way you've insulted our staff. It's not necessary and your bad attitude isn't helping anyone. It's time for you to go."

"Well," he stammered, "even if you aren't lazy, most of your God-damn generation is."

And with that, he continued on his way out of our "first-aid station," decorated to celebrate the joy of the wondrous holiday, shaking his head in disgust until he walked through the waiting room doors.

After he left, our staff regrouped in the nursing station. Amazingly, not one person was affected negatively by this gentleman. Everyone had the good sense to dispel his insults and demeaning behavior without a second thought. "I can only hope," I warned them all, "that I'm not that grouchy when I get older."

I visited Room 6, the girlfriend. She was still clear of all her symptoms, but looked teary-eyed. "I'm so sorry for his behavior," she said, obviously hearing the conversation that had just occurred in the hallway, "he's like that all the time. But Doctor, just so you know, your staff treated me wonderfully today." She assured me, upon my questioning, that she was safe and not being abused physically. She declined any counseling offers. "He's a dog with a big bark and no bite," was how she put it. I wanted to ask her "Why?" Why in the world would she stay with a man so unpleasant, so abrupt and obnoxious? But I didn't. We all have our reasons for living our lives the way we do, and she was no exception. Besides, the world was continuing to revolve and I was needed in several other rooms.

An hour later, Mr. Crank was back. Before even entering his girlfriend's room, he walked himself right through the nursing station, stopping on its edge. "Now what the hell is going on?" he yelled, lifting his walker from the floor before banging it back down, startling me from the chart I was working on.

And the conversation continued as before--him insulting our staff and hospital with vulgar language, me giving him the option of either going to his girlfriend's room or the waiting room. In my book, this was his last chance, and I conveyed it respectfully to him.

He walked to his girlfriend's room, entered it, and shut the glass door behind him. Surprisingly, he was only in there for a minute or two before opening the door, walking into the hallway and out the ER while muttering to himself. Whereas before he had conveyed, with his body language, some misplaced pride, this time while walking past our nursing station he looked like a man who had just been brow-beatened. No doubt, the girlfriend had the last say in this matter.

Throughout this holiday season, we will have many opportunities to spread good cheer and love. Compassion and kindness. And endless smiles. Or, we will have opportunities to spread poison and malignant anger. Hurtful words and deliberate insults. And pinched-up frowns.

The choice is yours. The choice is mine. Just remember to pause and look at the infinite garland, the Christmas trees, the stockings, and the candy canes--all of the beauty of the season that surrounds us. Notice and acknowledge the smiles on the faces you pass. Remember your inner child's spirit and reflect on the deeper meaning of this holiday.

I can only hope your choice fills your heart with warmth.

And I wish for nothing less for Mr. Crank.

As always, big thanks for reading. Despite our respectful attempts to break through Mr. Crank's grumpy exterior, we were unsuccessful. Darn it! I hope this finds you well and ready for the holiday season and all it brings your way...see you early next week.

I Got Me Some Flu

I am one of those people who has avoided the flu shot, at least for the past six years. Outside of diligently receiving it during the few years that my son, Cole, and my mother were on chemotherapy, I find that the constant bombardment of exposures to various infections during a typical shift in my emergency department has given me the small doses of immunity needed to remain healthy and infection-free.

Although I'm not one to ascribe to the notion that the flu vaccination is the cause of a multiple sequalae of ailments after receiving it, several years ago I myself had developed an odd peripheral neuropathy after my third yearly shot. After multiple MRIs and blood work, including a spinal tap, failed to reveal the reason, I have since avoided the flu shot on this basis. And my peripheral neuropathy, thankfully, is a thing of the past.

Do I think the peripheral neuropathy was due to the flu shot? It depends on the day you ask me. After witnessing the flu shot being blamed for everything from causing heart attacks to promoting cancer, though, I was hesitant to put the blame on it for my own symptoms. I was young (in my thirties), healthy, and in great physical shape. I was admittedly stressed out, however, between Cole's relapse from remission and my mother's battle with leukemia, all the while desperately struggling to show the world nothing but a smile on my face. We all know how important a healthy mental state translates into physical well-being (known as "psychosomatic" in the medical community), so I had obvious other reasons, besides receiving a recent flu shot, to suspect my body's failings.

That said, I think the flu shot is a wonderful option for people who pursue it after an informed decision, and I have no doubt that it is responsible for saving a significant number of lives, especially those from the populations of being elderly, young, or immunocompromised.

It's just not for me.

Recently, after having several days off during this past Thanksgiving holiday, I returned to work, on Sunday, only to learn that the nasty GI bug had exploded in our community. Diffuse abdominal cramping, nausea with uncontrolled vomiting, diarrhea, fevers, aching muscles, headache--it seems this little bug was responsible for a multitude of holiday gifts to a multitude of people from every background. Gifts, unfortunately, that kept on giving. According to one of our senior resident physicians, during his prior day's shift, he treated twenty patients, seventeen of which had this flu syndrome. And, it seemed, the virus was working its way through our staff.

Uggggggghhhh. Welcome back to me.

I took every precaution I typically take before starting my shift. I got the industrial, kill-everything wipes (in the container warning to wear gloves before touching them) and wiped down my phone, my computer and its keyboard, my workspace counter, my pen, my stethoscope, my chair handles, etc. If there was a chance I was going to touch it during my shift, it got wiped. I may have even gone overboard, obtaining a clean bed sheet, folding it several times, and putting it on the cloth chair I was using. In my mind, I ridiculously believed I had effectively halted any bug from climbing from the navy blue seat, through my khakis, through my underwear, to my skin, where it would multiply and overtake me, unselfishly sharing all of its pleasant symptoms with me. I'm surprised at myself, on hindsight, that I didn't soak the bed sheet in ammonia first.

I'd be damned if I was going to get that nasty flu.

As usual, I made sure to put on latex gloves, from the hallway station, before entering any patient's room. Every time. Without exception. I wasn't going to be shaking any hands or touching any bed railings if I could help it. When necessary, I also donned a mask and disposable body gown, rendering me as a wrapped mummy. You can only imagine the screams from the pediatric patient who, on a normal basis, suffers from white-coat syndrome now being approached by a tall blob of a person bulkily wrapped in pastel-yellow paper, purple latex gloves, and a light-blue mask, two eyes peeking out of its top border. I think I would probably scare myself, even.

For added precaution, to make sure I didn't pass anything on to my family, I stripped myself immediately after walking into our mudroom from a shift, depositing my clothes in the washer and running quite briskly through the house to our bedroom shower, where I proceeded to scrub myself down. I'm hopeful I won't hear from any of our neighbors claiming to see, through our house windows, a naked man running around. Make that a sexy naked man, thank you very much.

So, after all of my precautions and not getting the flu for the past six years, I was pretty confident that I wouldn't be one of the unfortunate many getting ill during this recent outbreak. Nope, not me. Get out of here, you nasty bug, and find someone else to populate a new colony in.

Fast forward to my third and final shift. Tuesday evening. Eight hours into my ten-hour shift. Me, sitting at my computer in my tan cords and long-sleeved rugby shirt, happily typing in orders on yet another patient, thinking about having off the next four days.

And suddenly, just like that, I heard it. And then felt it. A loud gurgle, followed by a wave of cramping. "On no," I thought to myself, "it must be the fish sandwich and steak fries I ate for dinner." How easy our minds can hide the truth from us, sometimes. Despite my denial, the gurgling continued and the cramping waxed and waned. Finally, the shift over, I drove home, mumbling useless prayers, barely making it into my house before visiting the bathroom.

What a great way to spend a few days off! After missing basketball practices with my son and youngest daughter, skipping family meals, taking numerous small sips of water with repeated doses of ibuprofen, and imbibing in several warm baths followed by extended naps (yesterday from 1 p.m. to 5 p.m.), I am actually able to stand up from bed this morning without getting dizzy. I am hopeful that the cause of these past two days of misery is now on its way out.

I even missed writing group last night, which speaks volumes of just how miserable I was.

Are there any benefits to having the flu? Heck yeah. Like I just mentioned, the warm baths and extended naps. Trust me, those two things alone almost made being sick worth it. And being pampered by the family; for example, having a cup of tea made lovingly (after threatening to lick her face) by my youngest, Grace. However, if I am being honest, I don't think I was pampered nearly enough by my kids or wife. Whether it was simply avoiding me to prevent getting the flu themselves, or possibly avoiding my incessant manly whining, I'm really not sure. A moan from me, though, was more often met with laughter rather than concern. Maybe I was imagining it, in my febrile delirium, but I don't think so.

When I'm done finishing this post, I may go lick the clean rim of my wife's coffee mug before replacing it back on the shelf. That would teach her to give me more lovin' when I'm near-death.

Not really, of course. After all, at some point during my recovery, she and the kids carried up all of the numerous boxes of Christmas decorations from the basement and began to transform our house into a welcoming winter wonderland. What an appreciated, beautiful sight for me to behold after being bed-ridden for a few days.

If anything, though, now I may just have to reconsider the flu shot.

Oops, I have to run--the bathroom is calling for me. I hope this finds you all flu-free and healthy during this post-Thanksgiving season.

Flu shot or no flu shot? That is the question...

I'm back. As always, big thanks for reading. I hope you all had full bellies during this past Thanksgiving holiday. See you soon.

The Willing Caregiver

I imagine the world as a vast, boundless frontier weathered by our swirling human emotions and complicated energies--hurricanes of intense heartbreak and tornadoes of joyous, unbridled celebrations, with every weather pattern in between. Sunshine and rain included.

If I could gather this world, foolishly believing that I could sweep my arms and hands through the unsuspecting air to collect a smaller, more-contained version of reality, I know with absolute sureness that what I would be left with is a typical day's worth of experiences in the emergency department. It is a microcosm of something similar to big life.

So many patients, so many illnesses, so many human interactions. So many words of comfort. So many experiences bombarding us daily. And try as we might to protect ourselves, building brick-by-brick our fortress of emotional barriers, ultimately, we cannot help but let some of our patients weave their very own threads into our personal life blankets.

I walked into Room 20 to treat my next patient, a woman in her mid-seventies. Because of a life-long battle with diabetes and its resulting circulatory problems, she was now permanently wheelchair-bound. She sat upright in her cot, in a hospital gown, without any blankets covering her. At the base of her right thigh, poking out from her gown, was a puckered-up cork of skin, where her leg had healed from an above-knee amputation. On her left-side, her leg extended just slightly lower, below knee-level, where, again, the rest of her leg had been amputated secondary to gangrene several years prior.

She was petite and frail. Despite a high fever and feeling ill, she sported a recently washed-and-set hairdo. She also wore some light makeup and dark lipstick, appearing well-cared for. The smell of her room, however, suggested otherwise--it permeated with the familiar stench of a Depend diaper that was overdue to be changed, most likely saturated with stale urine.

In her room's corner, sitting quietly and patiently, was her only child. A son, probably in his late-forties to early-fifties. He appeared fidgety at times, but was very attentive to both myself and his mother. He was, as it turned out, his mother's only living relative.

And her primary caregiver.

"Hello," I said to both of them, extending my hand to shake first the patient's and then her son's. "I understand you're here because you don't feel well, Mrs. Smith. Is that right?"

"Yes," she answered, slightly nodding her head as she spoke in a high-pitched, whispery voice, "I think I probably have a urine infection." She was probably spot-on, since that can be one of the most common causes of illness and fever in an elderly woman. She went on to explain the burning she experienced with recent urinations and her need for wearing Depend diapers because of the resulting incontinence.

"Have you had a urine infection before?" I asked her.

"A few months ago, yes, but otherwise I've been lucky, knock on wood," she answered, lightly knocking her closed fist against her imagined wooden temple. She then went on to explain to me that her right stump had healed beautifully from her recent surgery and had little reason to suspect that this might be the problem.

After reviewing the rest of her history and performing a stable physical exam, I ordered the patient's tests. And sure enough, she had a UTI, just like she suspected. With the help of some Tylenol, we were able to break her fever and by the time her blood results returned stable, she had been cleaned up and was feeling much better, with an IV dose of antibiotic finishing its run into her left arm's receptive vein.

I explained the results to her and her son, who, despite his mother's good response, had remained quietly sitting in the corner. He was edged forward on his seat, however, as if eager to say something.

"Sir," I said, "you look like you have something to say."

"Well," he said, glancing between his mother and myself, "do you think it's my fault that Mom got the urinary infection? I'm still learning how to help care for her."

"Michael," the patient answered quickly, "of course not. These things happen."

I liked her answer, but his question opened a floodgate of mine. "Why would you ask that, Michael?" I asked him, intrigued.

As it turns out, Michael, this patient's successful, independent son, had sold his out-of-town condo, sacrificed a current relationship, and moved back to our region and into his mother's home, all to take care of his mother after her second amputation.

"Do you have a medical background, Michael?" I asked him, amazed at his devotion. He nodded "no" to my question. "Have you ever been a caregiver before?" I continued, fully understanding just how much weight now sat on his shoulders.

The patient chimed in. "I told him to stay put, but he wouldn't hear of it. I feel bad he's halted his life to help me with mine."

"Mom, I wouldn't have it any other way. You talked me out of returning after your first surgery," he spoke shyly, pausing to nod at her left leg, "but there was no way I was going to stay away after this recent amputation. Unfortunately, I think your urine infection is from me not cleaning you well enough."

Now, imagine being a grown child, with no previous caregiver experience or medical background, halting the life that you've created only to move in with your sick parent. Your parent of the opposite sex, no less. Assuming care that included bathing responsibilities, bathroom runs, feedings, cleanings, appointment dates, and on and on and on.

And on. This was role reversal at its most intimate level.

Michael became an official caregiver. A frightening word for some, a privileged word for others. Regardless, it is a word that many people rightfully now use to describe themselves. Whether it be a sick child, a parent, a spouse, a partner, a grandparent, a relative, a neighbor, or a friend, there are currently 49 million people in our country who provide care in either a professional or personal sense.

Suddenly, I looked at this son in a new light. With no obvious agenda, he was doing what he felt was the right thing for his needing parent. And with his new responsibilities, he was going to be facing a whole new world of emotional weather.

Without any warning, my memories transported me back to when my father, my six siblings, and myself committed ourselves to providing 100% of Mom's home care during her last few months of battling leukemia. Although filled with much learning and many surprises, I think I can say that we all became extremely appreciative of the effort involved in taking total and complete care of a loved one. We were grateful for the experience, though none moreso than Mom, whose beauty and bravery during her last few days only magnified under our personal and steady care.

The patient spoke again, bringing me back to the present. "Michael," she said half-heartedly, "I wish you would have just agreed to put me in a nursing home like I wanted you to do."

"Mom," he responded emphatically, "I won't hear of it. At least not now. If things get too complicated, then we'll talk about it again. But wouldn't you rather be home, still? Seriously?" The patient took her time answering. "Yes," she finally admitted, "yes, I would rather remain home. But not if it means you are going to stop living your own life."

"I'm fine with it, Mom. I would never have moved back if I wasn't. And quite honestly, there is no where I would rather be right now than here, helping you the best I can."

Their smiles reflected off one another while another brick crumbled and fell from my fortified emotional barrier.

I finished the patient's treatment with a case management consult to ensure that Michael and his mother would benefit from several available resources, including home nursing visits. Walking out the door, I wished them both luck. But before leaving, I had to ask. "Michael, did you help your mother with her makeup, hair and clothes today?"

They both laughed. "Yes, he did," the patient answered. "How do you think he did?" Now it was my turn to laugh with the patient and good son. "I think he did a darn good job," I answered, "you look very nice, maam." I turned to Michael. "Well done, buddy." And I'm sure he knew I wasn't talking about how his mother looked that day.

Now, if only he would learn how to change a Depend diaper...

As always, big thanks for reading. And especially for bearing with me through a few weeks of barren writing. Much happening, but all good. I dedicate this post to all of you who have intimate knowledge of the sacrifices and hardwork necessary to be a great caregiver. See you back in a few days...

No Baby Yet

Despite the weighted concern and anticipation that enveloped Room 21, I was greeted with two genuine, hopeful smiles. Innocent smiles, actually. Smiles that unassumingly revealed a faith and confidence that life would be fair and good to them.

From the moment of our introductions, I liked this youthful couple, both just entering their twenties. She was the patient, sitting upright in her treatment cot, her legs fully-extended in front of her and nervously crossed at the ankles. She was thin but strongly built, her athleticism exposed by her muscular tone. Her angular jaw and full cheekbones were framed by the pixie-cut of her light brown hair. Her blue eyes sparkled.

He stood beside her, to the right of her cot, holding the hand she offered him. He was tall and pudgy, several times nervously swiping at the sheen of worry revealed by his forehead. His blondish hair was haphazard and messy. His face was average, muted, nothing quite as striking as his girlfriend's, and yet his brown eyes burned with a fierce intensity.

They had presented to our ER with a a significant concern. The patient was pregnant, barely nine weeks, and had started having abdominal cramping and vaginal spotting approximately thirty hours before they arrived. "Now I am bleeding so much, it almost seems like a period," she shared, looking from me to her boyfriend before looking back to me again. Her face was expectant, almost willing me to tell her that everything would be fine. That this bleeding and cramping was not out of the ordinary.

Unfortunately, I couldn't speak those words.

"How far along are you?" I asked them. "Nine weeks and two days," the boyfriend answered. Such exactness already answered my next question. "Is this your first pregnancy?" They both nodded yes. The excitement and magic that accompanies a first pregnancy is unbridled and elicits many memorable moments--including ticking off each day of the forty weeks. I could picture this couple's calendar hanging on the wall in a small, canary-yellow kitchen with old white appliances, an "x" drawn through each passed day.

"You really want this baby, don't you?" I asked, trying to learn about this couple, after I had finished with my pertinent medical questions.

The patient answered. "We do. We've faced a lot of opposition from our families and friends. And this pregnancy certainly wasn't planned." She paused here, looking up at her boyfriend, before continuing. "But, we are both certain we want this."

"And," the boyfriend added, "we just got engaged last week. We might just be throwing ourselves a wedding in the next few months, too." Without letting go of his fiance's hand, he continued to explain that they had dated since their sophomore year in high school. They were certain they had both found their soul mates.

I congratulated both of them on their happiness. Through work, I have seen every imaginable angle that accompanies an unplanned pregnancy and, although their story wasn't new to me, their can-do spirit and enthusiasm for one another and their situation made me think, just maybe, that, with or without this pregnancy, this was a couple that could endure and thrive on their life journey together.

Trust me, though, when I say that I don't get this warm and fuzzy feeling with every unplanned pregnancy. Their commitment was refreshing, plain and simple.

I called in their nurse, Carla, and we performed a pelvic exam. Unfortunately, the patient appeared to have some active bleeding that resembled a typical period. On her bi-manual exam, the opening to her cervix (the lower part of the uterus), which is usually tightly closed during this stage of pregnancy, was loosely open. Things did not look good.

"What do you think, doctor?" the boyfriend asked, unsure where to direct his nervous energy.

I needed to ask one more question before explaining the exam at length. I looked to the patient. "Have you passed any small clots or anything unusual with this bleeding?"

She hesitated somewhat before answering me. "Yes, this morning. That's not good, is it?"

Quite honestly, no--it wasn't good. Not only had her exam concerned me, but her quantitative hCG hormone level, through blood work, had come back barely traceable. Again, at this stage, the level should have returned significantly higher. Every indication was that this patient was not going to have a healthy, full-term pregnancy and was, in fact, actively miscarrying.

"No," I said softly, answering the patient's question, "it doesn't look good. I'm sorry."

It was important for this couple to start connecting the dots on their own terms. Inherently, I had to believe that they knew she was having a miscarriage, and just needed a little guidance and coaxing from my part to start accepting this reality. So I sat there on my stool a minute, silent, absorbing their response.

They both grew glassy-eyed right there in front of me. Remarkably, though, in that split moment where life can make you angry, or defeat you, or make you question everything about yourself after you've received unfair, upsetting news, this couple did an amazing thing.

They didn't get angry. Instead, they wiped one another's tears with caring thumbs. Tenderly. Sweetly. With a maturity and naturalness that belied their years. And, when they were done, they feebly smiled at one another before the boyfriend bent down to envelope his fiance' in a genuine, heartfelt embrace. He whispered in her ear and she nodded at his words.

I looked to Carla, who was watching the couple with the same wistfulness that I felt. One simply could not help but cheer for this young love. Nor could one be in that room and escape the emotional intensity of their love. Despite their youth, they were demonstrating the stuff of which people spend years trying to instill in their own relationships.

When they had collected themselves, I explained everything at length. The patient would need to get repeat blood work in two days. If the hormone level hadn't doubled in that time, or had stayed the same or even dropped, it would be confirmation of our suspicions. Suspicions that were extremely solid, already.

Sitting at my computer station after treating them, out of sight, I heard their familiar voices speak to our secretary on their way out of our department. "Please tell Dr. Jim and Nurse Carla that we appreciate all they did for us today." I rolled my chair through the doorway into their view. "Thank you," I said. "I hope you both have a fantastic future together. You deserve it."

And I meant it. They did deserve a bright future.

As always, big thanks for reading. I hope this finds you all enjoying the last days of summer...

It's Not Working

She was the wife of the patient in Room 24, a gentleman in his early sixties seeking treatment for his abdominal pain. She was of slight stature, barely over five feet tall. Her hair, straight and gray and hanging to her shoulders, was tucked behind her ears. The lenses of her glasses were thick, the type that disproportionately magnify the eyes and give them a non-human appearance. Her thin, gold-wired frames seemed to sag from their weight. Between the constant retucking of her hair behind her ears and the adjusting of her glasses, with her right index finger, on her nasal bridge, this woman came across as quite fidgety.

Although I wasn't treating her husband, I was sitting in my hallway seat just between Room 24 and the nurses' station and had heard the nurse mention the "nervous Nellie" wife of the patient in Room 24.

That was the understatement of the year.

I had first noticed her as she walked out of her husband's treatment room and approached the station. "Excuse me," she said to the unit secretary in a soft, feebly voice, "but can someone help me?" "Sure, maam," the secretary answered, "what can we do for you?"

As she spoke, the wife picked some lint off her craft-store sweater, doctored up with sewn-on pom-poms. "Well," she said, "the monitor keeps beeping in my husband's room."

"Okay, maam," the secretary said, "I'll send someone right in." As the woman turned and walked back into the room, the secretary paged Liz, the nurse for Room 24, who, after examining the monitor, found it to be working just fine.

A few minutes later, as I was hunched over a chart while writing on it, I heard someone clear their throat. I looked up to find the patient's wife, moving in to take ownership of my personal space. "Can I help you, maam?" I asked, amused. "Well, yes," she said, again with a crackling, muted voice, "my husband's phone in his room isn't working."

"Oh," I explained, "you just need to dial "9" first and that will give you an outside line." She nodded as I continued. "Do you need to make a call, maam?" "Well, actually, no," she said, hesitantly, "I just want to make sure it's working in case there is an emergency with my husband. You can never be too prepared."

She didn't strike me as the boy scout type.

I gave her a smile before standing to go meet my next patient. She turned and walked away from me, heading back into Room 24. After finishing with the new patient several minutes later, I returned to sit at my computer, only to find Liz shaking her head in frustration. "What's the matter, Liz?" I asked, quite sure that I would know the answer. "Are you having one of those days?"

"That wife is going to be the death of me," she chuckled, good-naturedly. "She just came out and said our counter drawers are broken because when she opened them to see what was inside, they wouldn't 'close right'." It turns out that a safety-latch had caught that prevented the drawers from closing. "What's she doing going through our drawers, anyway?" Liz added.

Well, unfortunate for us, this woman was just getting warmed up. Soon, and in no particular order, she came out to request an extra pillow for her husband (an impossible task in our ER). "Oh," she added a minute later when she came back out, "and another warm blanket, too." She requested coffee for herself. "And a more comfortable chair if you have one." A few minutes later and she was back. "Do you know that the waste basket is almost full and will probably need emptied? Oh, and that red container on the wall looks like it's filled with needles."

Seriously, she had an endless list of issues that soon became quite comical to us, the staff.

"Shouldn't my husband's IV be dripping faster?"
"Do you have an extra pair of those slippers that I can take home?"
"When's the last time someone washed the room's curtain?"
"Can someone look at the mole on my husband's back as long as he's here?"
"Was that a helicopter I heard outside?"
"Do you think we'll be home before Jeopardy starts at 7:30?"
"Are you sure you set the wheel-brakes on the cot (they were)?"
"I think one of the fluorescent bulbs is burned out in the ceiling (it wasn't)."
"The blood pressure cuff is broken, I can't get it to inflate on my arm."
"Your ER still validates parking vouchers, right?"

I found her initiative and gumption to be refreshing. And funny. It was easy for me to be amused by the ongoing antics since I wasn't the one in this woman's line of fire. That would be Liz, who appeared less and less amused with each new request or complaint.

Although this woman consumed much of our energy, we recognized that she was harmless. At one point, the staff pulled the curtains shut and slid the glass doors to the room closed, trying in vain to contain this woman and her nervousness. But slowly, as we all watched closely, she eased the curtain open about two feet, with the utmost caution and silence, before she slid the glass doors open enough for her to poke her head out, looking up the hallway and looking down the hallway, making sure she wasn't missing anything.

Finally, with about twenty minutes left to my shift, this woman approached the nurses' station yet again. "She's coming, she's coming," I heard the secretary hiss to everyone. Suddenly, everyone gave the appearance they were deeply immersed in charting about the many patients they had single-handedly saved that day in the ER. All but me, that is. I wasn't lucky to be holding a chart at the time.

The woman cleared her throat. "Hmmm, hmmm." "Yes, maam," I asked, "may I help you?"

"Yes, you can. I just used that bathroom right there (she pointed to one of our public restrooms just three doors down from her husband's room) and I don't think the motion-control sensor on the paper towel dispenser is working--it only gave me one piece of paper to dry off with."

"Well," I said, the others glancing at us from their eyes' corners to see if I would address this woman's issues or turf them, "how about we go take a look." She couldn't hurt me now that I only had 15 or so minutes left to my shift.

"And you are sure it didn't work?" I asked her as we walked the short distance to the bathroom. "Nope, I'm sure." "And you just used the bathroom right now? Or earlier today?" I asked her, trying to keep her talking and not complaining. "Oh," she answered, "just right now. I came straight to the station to tell you all about it."

We came to the bathroom door, which was loosely shut. We knocked to make sure it was empty. It was. I went in first, opening the door while I flicked on the lights. I took two steps into the bathroom before it hit me.

The smell, that is. It smacked me right in the face. The bathroom utterly stunk in the most primitive, disgusting, and vile way possible. And trust me, those of us who work in the ER are intimately familiar with stink. It has to be something impressive to rile us up.

While I was trying not to vomit in my mouth, the woman spoke. "See, right there," she said, pointing to the motion-controlled paper-towel dispenser, "I couldn't get more than one piece out of that thing." How, I had wondered to myself, was she even able to take a breath in while this fog of stink gripped my neck, suffocating me?

I moved quickly now, my life goal dramatically reduced to making sure the motion-sensor worked before I dropped to the floor and seized, my body's attempt at violently shaking any trace of this stench from my being. At the paper-towel dispenser, I waved my hand three different times in front of the sensor and, each time, a healthy piece of paper towel came out. "Well," said the woman, "I'll be. It does work!" Like a fireman leading a victim from a burning building, I grabbed this woman's hand and pulled her from the bathroom into the hallway, pulling the door closed behind us.

"Are you okay, sir?" she asked me as I bent over to take a deep breath. "I will be," I said dramatically, which was lost on her. I continued. "You said you just used that room, as in just right now." She nodded yes. Why on earth couldn't she have waited ten minutes before coming to us with this complaint?

"Okay, maam," I said, escorting her back to Room 24, "I know you have come out to the nurses' station several times for help, but go ahead and relax in the room a bit with your husband. I'm sure he will be going home shortly."

This was the last I saw of that woman before I left my ER shift (running out the door), eager to get home to change my clothes. I had told Liz exactly what had gone on in that bathroom. "I swear, that woman must have dropped a deuce to shame all deuces," I said. "That little, frail woman?" Liz asked in disbelief. "And she didn't smell it?" "Not once," I said, incredulous, "did she act like she smelled it or was embarrassed by the stench." "Amazing," Liz muttered, stifling her laughter, "she complained this entire visit and then led you to a bathroom she was responsible for smelling up. She had to have known..."

I drove home in my car thinking about this wife. I had, at one point wanted to meet the husband, to see what kind of guy this woman was married to. But, in my haste to leave the ER, I had abandoned that venture.

Since this wife had been very critical of our ER, though, I think it's only fair that I give a little critique of my own.

1. This wife's olfactory senses, well, they ain't workin'.
2. This wife's bowels, well, they are working just fine. Trust me.
3. And finally, if you ever need a bathroom's motion-sensor checked, do not, and I repeat, do not come looking for me. I'm retired.

As always, big thanks for reading. I hope everyone had a great weekend. To the commenters on Bald Is Beautiful, thank you for sharing your stories. I'll see you Wednesday, July 28th. Emma update--she is home and safe and slept 16 straight hours, a house record! Our circle is complete again. Thank you all for your prayers and well-wishes!

Bald Is Beautiful

She was sitting up and resting comfortably in her hospital cot, her home-made mauve and black afghan tucked comfortably under her arms. A pale yellow handkerchief was lumped on the bedside table beside the phone. She looked up at me as I walked into the room, greeting me with her big smile and sparkling hazel eyes. Except for a few patches of sparse, fuzzy auburn hair, she was bald.

"Hi, Mom," I said, walking up to her and pulling my mask down to gently kiss her cheek, "how are you today?" Despite the heart-breaking circumstances which lead to her being a patient lying in a hospital bed, I had never seen Mom look so beautifully breath-taking. And under normal, healthy circumstances, she was already quite a beautiful person, inside and out.

Mom ran her hands over her scalp, weakly smiling. "Well, honey," she said, "I guess we can cancel the rest of my hair-dressing appointments for the year." Over the past few days, the ravaging effects of Mom's chemotherapy regiment had taken ahold, which included her hair falling out in clumps.

"Mom," I said, reassuringly, "I don't think I have ever seen you look more beautiful." I walked over to the yellow handkerchief and picked it up, examining it. Strands of her thick, wavy hair clung to it. "What do you say we just throw this out?"

"Oh, Jimmy," she said, exhaling a deep breath, "I just don't think I am ready for that yet."

I understood completely. Mom had been raised in an era where curlers and perms and colorings played an important part of a woman's presentation. And although Mom was far from vain (how could she be when she was busy raising seven kids), she thoroughly enjoyed indulging in her hair. Hair that was now gone.

Despite a custom-made wig and multiple handkerchiefs, I don't think Mom's beauty was ever more evident than when she went bald during her chemotherapy days. Her baldness only seemed to enhance her indomitable spirit. Her eyes danced more openly. Her raw facial expressions confirmed her appreciation of life. Her prominent cheekbones exuded her infinite strength And the curve of her smiling lips were only that much more welcoming, appropriately framing the beauty of her words.

Accompanying her baldness, the truth of Mom's bravery in fighting her illness could not have been any more evident.

As I go along in my typical days of being an ER physician and the father of a child who has survived his own life-threatening illness, I can only tell you, without hesitation, that this baldness that accompanies one's fight for their life is as pure and as defining of one's character as any physical attribute can be. Without any words spoken, a patient's baldness from chemotherapy reveals a fighting spirit and a commitment to continue living. It reveals a strength drawn from reservoirs most people don't recognize they have until faced with crisis.

It commands my respect. And I rightfully give it.

Recently, at my gym, I couldn't help but notice one of the trainers, Barb, working-out with a woman who wore a handkerchief over her scalp. It was obvious that this client was intimately familiar with chemotherapy. It was very inspiring, to say the least, to watch this woman physically push herself through a workout despite her recent setback.

A few weeks later, surprisingly, I saw this same woman working-out without her handkerchief. Evidently, she chose not to cover up her baldness. And she looked stunning. As Barb and she worked out beside me in the cable room, I decided I had to speak up.

"Excuse me," I said to the woman. keeping it simple, as Barb looked on, "but I just have to tell you how stunning you look. I have no idea what you are going through, but I've seen you working out and pushing yourself these past few weeks and am thoroughly impressed. I wish you the best."

Well, Barb's client blushed a little as she thanked me. And later on, Barb came up to me and said that my words were exactly what her client had needed to hear since she was having a bad day. I hadn't been sure I should have said something, but Barb reassured me that my words were quite welcomed by this brave woman.

Especially in our ER, because of our regional cancer institute, we are privileged to treat many people who are wearing their baldness proudly as they undergo chemotherapy treatments. Both male and female. From the very young to the very old. And every time I have a patient who is bald for this reason, I make sure they know that they have my utmost respect. And if it is a child, that respect is also accompanied by a pile of stickers, a coloring book, and a Popsicle, if allowed.

A few weeks back, a brave little seven year-old girl greeted me as I walked into her ER room. She had been battling acute lymphocytic leukemia and, despite some mouth sores, still managed to greet me with her fading smile. On her head, nothing but baldness. At most, just a few patches of fine blond hair clinging desperately to their homeland. I smiled back at her as I approached, hoping my eyes conveyed my happiness to meet her. I must have looked like a big giant Smurf--I had donned a blue paper gown, a blue mask, blue foot covers, and cream-colored gloves. Until we figured out her immune status, we had to protect her from us.

"Hello, May," I said, extending my hand. "It sure is nice to meet you." We talked a few minutes about school, her best friend, and who her favorite doctors at the regional Children's Hospital were. Her mother sat at May's bedside, contributing to May's memories. "May," I continued, when there was a pause in conversation, "when did you lose your hair?"

She got quiet, hesitant almost. Her mom spoke up. "About three weeks ago, doctor." "Well, May" I said, my eyes hopefully conveying my sincerity, "I've seen many patients who have lost their hair because of their medicines, but I must say that you are by far the most beautiful." May looked up at me, serious now, and locked her eyes onto mine. I didn't flinch nor did I look away.

"Seriously?" she asked. "Seriously," I replied. In her child's voice, she softly said "But I don't like it. Everybody stares at me."

"You know why, May?" I asked, grabbing her hand with my gloved one. "They aren't staring because you lost your hair. They are staring because they are amazed to see such a brave and courageous seven year-old. And that's you. Showing all these people that you can be beautiful and brave no matter what medicines you are on or no matter what disease you are fighting." She nodded at my words. "The next time someone stares at you, May, just give them your biggest smile ever!"

"Like this?" she asked before donning one of the most perfect smiles I have ever seen.

"Just like that." I told her, admiring her gaps from losing her baby teeth.

I'm not saying that if you are undergoing chemotherapy and have lost your hair, that you need to express your baldness. Hardly. Wear a wig or a bandana if you feel more comfortable. During your fight, you do what you need to do and don't worry about what the rest of us think. But if you are in my ER or if you pass a middle-aged guy who happens to take a second glance at you, don't be alarmed.

It's just me, sending you good energy and well-wishes. And recognizing your courage.

Yes, indeed. Bald is beautiful.

As always, big thanks for reading. I appreciate your time. Emma update--day 15 of 17. Swimming at the Great Barrier Reef today before beginning the long trip home tomorrow. If she comes home, that is! Australia, you have a new, wildly-excited admirer in my daughter. Thank you. See you in a few days...

"The Patient Is Deaf"

At my ER computer station, I signed on to treat my next patient, a 42 y.o. woman who had presented with abdominal pain and, just prior to arrival, had noticed some blood in her stools. Despite her complaints, her vital signs were stable.

I went to pick up the clipboard for Room 31, her room, when I noticed a bundle of 8 1/2" by 11" white copier paper trapped under its metal clip, the top page of the pile covered with a lot of rushed handwriting. Stuck to this top page was a pink Post-it.

I grabbed the clipboard, with all of these extra papers and pink Post-it, and walked to the station counter, setting the clipboard down on some open space. I grabbed the Post-it and read. "The patient is deaf." This explained all of the writing on the top page. Between our triage nurse and this patient's room nurse, a conversation must have occurred where the patient wrote all of her answers to the various questions asked on the paper.

I smiled to myself about how great our nurses are. Not only did they save me time by saving the written responses of the patient, but they also gave me a "heads-up" Post-it. In the event the nurse and I hadn't yet had a chance to talk about a patient, I welcome when they let me know about a patient's special needs or circumstances this way.

Reviewing the top page, I appreciated just how in-depth the nurses asked their questions. There was not much more I would need to review with this patient.

I walked into Room 31 to find a middle-aged woman lying on her left side, eyes closed, with her hospital gown loosely-tied at her back's nape. A scratchy, white hospital blanket covered her up to her elbows. Her hair was flat and matted, as if she had spent the last few days in bed with her pillow. An empty chair had been pulled up beside her cot on the side she was facing. The room was dimly-lit and, since the TV was off, a calming quiet pervaded the space.

Since I wasn't sure if she was napping, I gently nudged her toe until she opened her eyes and looked at me. I could see her initial fog of "Where am I?" lift before me.

"Hello, maam," I said, paying special attention to enunciating my words, "do you read lips?" She nodded her head "yes." I smiled at her and continued. "It's nice to meet you. My name is Dr. Jim," I said, pausing to spell out J...I...M in sign language for her, "and I will be your doctor today."

She smiled at me and asked for the clipboard. She wrote out "Do you sign?"

I nodded "no." "I can spell my name," I spoke, giving her my undivided attention, "and I can sign all the words to 'You Are My Sunshine'." I did a little of the first verse for her, which revealed her hearty, guttural, infectious laugh, the first verbalization I had heard from her.

I thought back to my kids' preschool teacher, a wonderful woman who had the foresight to recognize sign language as a fantastic learning tool at their age. Because Ms. Denise's own son was deaf, she had made learning sign language one of her top teaching priorities, a priority she has carried with her to her new elementary job. My kids are a part of a group of lucky kids who have benefited from her forward thinking.

After a few minutes of general conversation, with me speaking and her writing, I began asking her a few more detailed medical questions. She grabbed the clipboard and flipped over the first page, now writing on the second, clean page. "Can you wait until my husband comes out of the bathroom? He can speak." She continued writing. "He just got here."

I nodded my head "yes" while I spoke. "Absolutely." As if on cue, the curtain pulled back to the room and a middle-aged, medium-height man in jean shorts and a t-shirt with wispy thinning hair walked in. He gave his wife a genuine smile before turning his attention to me. "Hello, sir," I said, approaching him with my hand extended, "I'm Dr. Jim and I will be your wife's doctor today. Nice to meet you."

He too had watched my face intently as I spoke, but it wasn't until he answered me that I connected the dots. Slowly, with thickened syllables and deliberate slowness, he answered me back. "Nice to meet you." The patient's husband was deaf, too. Like his wife, he could read lips and sign. But when he answered, unlike his wife, he verbalized his words alongside his signing. Very impressively and adequately, I might add. After just a few words, I was able to adapt to his speaking skills.

Between the small-talk, the rest of my history-taking, and the physical exam, I was able to witness the magic of their relationship unfold. It was extraordinarily ordinary, watching this couple interact. I don't know what exactly I had expected, since this was the first time I had interacted in the ER setting with a deaf couple, but they were a typical married couple who, through their various forms of conversation, skillfully interrupted and joked with one another.

Standing on the patient's right side of her cot, with her husband on the left, I was pleasantly reminded, yet again, that we fellow humans, despite our individual differences, are more similar than what we sometimes recognize. That, in the end, we all want nothing more or less than our neighbor.

It was during the explanation of the rectal exam, between the husband and wife, that I saw just how typical and ordinary this couple was. With the nurse now in the room, I explained to both the patient and her husband the necessary reasons for the exam. I explained how the exam would be done and what we would be looking for. When I was done speaking, as the nurse and I began preparing for the exam, the husband began gently teasing the patient about the exam, making a ring with his left thumb and index finger and sliding his right index finger through, mimicking the exam. Laughing the whole time he was doing it.

Well, the patient (probably nervous about the exam) did not seem to appreciate her husband's attempts at humor and, before we knew it, there was a flurry of hand movements between these two that could only be interpreted as a full-fledged argument. It was fascinating to watch. Despite our presence, they argued for about twenty to thirty seconds before their hands calmed down. The husband, after giving his wife the last signed-word, spoke clearly to her. "I'm sorry." He wouldn't be teasing her about this exam again. Ever.

Tenderly, they entwined their hands. The same hands that had just finished an argument.

I walked up to both of them, smiling, my gloved-hands ready for action. Before initiating the exam, though, I held up my right index finger to them, asking them to wait. When, at last, the room's calm returned, I did what I knew would make us all smile again.

I signed "You Are My Sunshine." Laughter filled this deaf couple's room.

This patient ended up having a lower GI bleed. As a result of this, we admitted her and she had a colonoscopy that revealed a bleeding polyp that responded nicely to the GI team's interventions.

Sometimes, I can only shake my head at how lucky I am to be doing this ER physician thing. I signed up for this job, yeah, but I had not expected my personal interactions with patients and their families to be as fulfilling as it has been in my career. Maybe even more fulfilling than providing good emergency care. Sure, like any other job, there are times through a shift when the hassles can outweigh the good. But, after the privilege of meeting this amazing couple as well as similar patients, you tell me how the rest of that shift could be a bad one?

It couldn't.

As always, big thanks for reading. I hope you all have a great weekend. Emma update--today is day 11 of 17. Yesterday was Kakadu National Park and today she continues the visiting and learning of the Aboriginal people and their customs. How lucky is she! See you early next week...

Traveling Pain

Because of our jobs in the emergency room, we tend to see the extremes of human behavior. We may be cursed at, spit at, or physically assaulted just five minutes before being incessantly hugged and complimented by the same patient, an elderly woman with dementia. We may be talked down to or screamed at by the frequent narcotic abuser. We may be treated with the kindness, respect, and compassion, the way our parents taught us to treat others, by yet other patients, despite their not feeling well. The combinations of personalities and behaviors are endless. And interesting.

As a result, most of us have learned to be on-guard with our observations and our emotions. Because of so many interactions with patients and their families and friends, we have become experts, to use the term loosely, in quickly recognizing the differing personalities that may dominate a treatment room during a visit. Demanding? Check. Abusive? Check. Genuine kindness? Check. Attention-seeking? Check. Fun-loving? Check. Shy? Check.

Once we recognize a patient's personality, we can tweak our approach, our interview, our exam, and our treatment to fit that individual patient. It becomes easier to climb over the hill and treat the medical emergency that brought the patient to us.

Walking into Room 22, I was surprised to find a woman in her mid-thirties lying on her treatment cot, appearing quite comfortable as she watched TV. However, as her eyes darted in my direction while I walked through the door, she immediately began rocking and writhing in her bed, loudly moaning her misery.

I stood and watched her for a few seconds. Her behavior was interesting. It appeared that this patient was trying to tightly blink her eyes, to produce some tears, while she kept glancing out of their corners to gauge my reaction. I continued to stand quietly by the foot of her bed.

Finally, she calmed down enough for me to introduce myself. "Maam," I said, acknowledging her pain, "I'm sorry you're in pain. As soon as we talk and I do an exam, I'll be able to share with you what I think and what work-up and treatment you may need."

It turns out that this woman, diagnosed with irritable bowel syndrome, chronic abdominal pain of unknown etiology, and fibromyalgia, drove two hours with her boyfriend and two children to spend a long vacation weekend in our town. Within an hour of arriving, she developed her abdominal pain and decided to seek out an emergency room for treatment. "Honey," she had said, repeating the story for me, "you take the girls and have fun while I go get something for this pain." The ambulance picked her up at her hotel and brought her in while the family went to the beach.

Out-of-town visitors presenting to our ER with chronic pain issues always make me a bit more cautious of suspecting narcotic abuse, and this woman certainly seemed to fit the part. Sure, etiologies do exist for abdominal pain that can come on suddenly and wax-and-wane, but this woman, with a little distraction of conversation, seemed to be able to turn her pain outbursts "on" and "off" with the flick of a switch. As I palpated her abdomen, she would scream out even before I touched her. And during one scream, when I asked the patient her daughters' ages, she stopped the screaming immediately and answered my question as if we were at a restaurant having a dinner conversation. Hhhmmm.

"Maam," I said, after finishing her physical exam, "your findings are very atypical. You have good vital signs, no fever, and your abdominal exam, outside of your bursts of pain, is not revealing anything specifically wrong." As if on cue, she began to moan and rock within her cot again. It was over in just a few seconds. I continued. "We'll get some blood and urine samples to test, perform a pelvic exam, and give you something to make you more comfortable."

She nodded before asking the question I presumed would come. "Umm, doctor," she asked, "what are you going to give me for pain?"

"Toradol," I answered, watching her face closely for a response. Yep, there it was--her grimace. Toradol, as many patients know, is a non-narcotic IV and oral pain relief medication. It works great for several emergency illnesses, including kidney stones and migraines, and is a good alternative medication to offer someone in pain that might be suspected of having narcotic abuse issues. Of course, half the patients will say it doesn't work or they are allergic to it.

"But it doesn't work for me," the patient said, again on cue.

"I'm sorry, maam," I said, "but that is what I can offer you as we do your work-up. She decided to refuse the toradol dose.

As we waited for her results to come back, I had asked the nurse to leave this patient's curtain open a little bit and observe her. Sure enough, when this patient didn't think she was being observed, she calmly watched TV and even, at one point, climbed out of the bed and used the telephone while opening a top cabinet drawer. She was probably disappointed to find the q-tips, the strep-collecting tubes, and the tongue blades that greeted her. The other drawers, of course, were locked.

And every time the nurse or I entered the treatment room, the patient would begin rocking and moaning almost immediately. And stopped again as we walked out. Walk-in--scream and moan. Walk-out--TV-watching time.

Coincidence? Or not?

Her test results, as we suspected, returned negative. Every single one. Surprisingly, this patient gave me information to call her family doctor, which I did, and found out that she had significant pain control issues despite having a thorough, negative work-up and multiple visits to varying emergency rooms. "Please, do not give her any narcotics," her doctor had explicitly asked, although I had already arrived at this decision on my own. "I suspect," he continued, "that she may be abusing pain medication."

I went back into the room and explained everything to the patient, including my conversation with her family doctor. "I can give you something for the pain, maam," I said, "but it will be a non-narcotic, similar to toradol."

"Forget it," she said, easily jumping out of her cot to begin changing from her gown. "I think the pain has passed." I wished her the best before stepping out of her room. Before leaving, I was told, the patient got upset that we would not call an ambulance to transport her back to her hotel. "How about the beach, then?" she asked.

At the end of the day, most of us in medicine want to be wrong when our hackles go up and we suspect someone of narcotic abuse. Unfortunately, though, this sub population of patients does exist. And in certain geographical regions, it can be quite large. Unless I am extremely suspicious, as I was in this case, I will typically treat pain complaints and then try to figure out if the source of pain is real or made-up for abuse reasons.

Would it be wrong of me to say that we are happy when the pain turns out to be real?

I finally figured out who this patient was on the phone with, though, when she was in her treatment room. It was Sandra Bullock. Calling this patient to tell her that she wanted her Best-Actress Oscar back.

As always, big thanks for reading. I would sincerely like to thank all of you for your awesome comments in wishing my daughter the best and safest of trips. To the commenting Australians, thank you for your reassuring words...she arrived yesterday and has already fallen in love with Sydney! Well done. Have a great weekend and see you next week...Jim.

The Damaged Eyes of Alcoholism

I walked into the dimly lit treatment room, Room 31, to find my next patient quietly and calmly lying in her cot. She had curly graying hair which, when added with the deeply creased wrinkles of her face, made her look much older than her stated age. Despite her attempts to welcome me with a warm smile, her greeting seemed forced. Her smile was but a thready, thin blanket failing to cover the the cold of her pain.

The pain of an alcoholic.

Standing in the corner, huddled together as a unified front, stood two teenagers. A boy and girl. Unlike their mother, they made no attempt to cover their worry. Their appearances were youthful--Converse Chuck Taylor sneakers, straight-legged jeans, graphic t-shirts, and hip stylish haircuts. But their eyes, those pained and aching eyes, bore an unfortunate truth to the years of sadness they had endured. Of their lost innocence.

I introduced myself to the patient before focusing my attention a little more closely on her children. Despite their worry, they were gracious in returning my hellos, introducing themselves.
I turned back to the patient. "Ms. Smith," I asked, "what happened that brought you to our ER this evening?"

Ms. Smith looked at me blankly, a confused haze slowly overtaking her face. I spoke again. "Do you know why you are here this evening?" She continued to stare at me, worrying me with her silence, before eventually nodding her head "no." She spoke. "I have no idea what happened."

I turned to her children. "Can either of you tell me what happened with your mother?"

The son stared down at his feet in response to my question. The daughter, however, connected with my eye contact and spoke up as she nervously tucked her wispy, blondish curls behind her ears. "I think she had a seizure." She got quiet then, her eyes getting more glassy as we continued to hold one another's gaze.

"Please, go on," I encouraged her and she bravely continued her story. She and her brother had been out and, upon returning home, had found their mother lying on the kitchen floor, unresponsive. An abrasion on their mother's forehead and a bleeding tongue greeted them upon closer inspection. After finding a pulse but failing to arouse their mother with yelling and shaking her flaccid body, they called 911. They all rode in the ambulance to the ER. They later put together, with the help of the paramedics, that their mother had probably had an alcohol withdrawal seizure. "She tried to quit cold turkey a few days ago," the daughter continued, shaking her head, "and I told her she needed to go somewhere to get some help."

The mother, intently witnessing her children struggling, started crying as she spoke. "I haven't had a drink for two weeks, honey."

With her words, the son looked up from his feet. "No, Mom, that's not true. You were drunk just over the weekend." The mother offered no excuses to his words.

Just then, the room's curtain pulled open and in walked a middle-aged man, his face strongly resembling the children's faces in both looks and worry.

"Daddy," the girl exclaimed, jumping away from her brother and into her father's arms. "Hi Dad," the son added shyly, giving his father a brief smile before turning his eyes downward again. His pain was palpable.

"Hello, sir," I said, introducing myself, "you must be Mr. Smith."

"I am," he replied, thanking me for taking care of his ex-wife. He turned from me back to his children. "Are you both okay?" he asked, pulling them into his chest for a hug. I caught my breath at his genuine display of love and concern for his kids. It was just what they needed at just the right time.

The kids smiled and looked up into their father's eyes, nodding their heads "yes." Their worried eyes relaxed and I was able to see some small sparkles mirror off their reflection as they continued gazing at their father.

Before turning to a physical exam, I asked a few more questions. It turns out that this patient had an extensive alcohol abuse history. Eight years prior, she had successfully completed an alcohol rehabilitation program and had remained sober for six years, before succumbing to alcohol's temptations again just two years earlier. According to her children and ex-husband, the past few years had been "hell" and had affected all of their lives in a very gloomy, detrimental way. They were just nearing the point of giving up on her, I'm afraid, when two weeks back, the patient announced to her family that she was done with alcohol "for good."

"That didn't last long, though," the son added, "because she got drunk that very night and passed out."

On exam, this woman appeared very fatigued, both mentally and physically. She did have the forehead abrasion that the kids had noticed on their kitchen floor, her eyes nervously flittered horizontally (known medically as nystagmus) within their reddened borders, and her tongue, on the left side, was bitten. Her vital signs were stable and the rest of her exam was unremarkable. It was evident that she had had some type of seizure, most likely an alcohol withdrawal seizure.

We did a full work-up. Her head CT was negative, her labs reflected dangerously low levels of both magnesium and potassium (which we began immediately replacing via her IV), and her alcohol level was zero. Besides addressing her electrolyte imbalances, we also gave her IV multivitamins, hydration, and thiamine to protect her damaged body.

We admitted this patient, much to her family's appreciation. She needed specific medical attention for her alcohol abuse and withdrawal seizure. After arranging all of this, I went back into her room to find this patient and her family much as I had left them, with much love being shared between the children and their father and their mother quietly sitting in the cot observing her children. There was much sadness, for me, from the many facets of this scenario.

"Maam," I said, after reviewing her work-up and disposition, "do you want to stop drinking? Will you accept some help for your problem with alcohol?"

Her answer was music to my ears, and it came without hesitation. "I have to stop drinking," she said. "If not for me, I need to do this for my kids." She paused and looked at her kids, who were now watching her intently. "I love you both too much to continue on this path anymore." With those words, both kids gingerly walked over and wrapped their arms around their mother, the daughter now openly weeping.

How do I know this patient was sincere about wanting help? As I spoke to them about their options for several available in-patient rehabilitation programs, she seemed to be intimately familiar with most of the options. This mother had done her research and had begun taking her own steps toward sobering up and becoming the mother she could be to her children again. She appeared very sincere in wanting nothing more.

I looked at both children hunched over the railings on either side of the treatment cot as they hugged their mother. Despite the daughter's weeping and the son's hesitancy, I could see that their eyes, despite their sparkling and youthfulness just minutes earlier as their father had hugged them, had become edgy, wistful, and nervous again. Old and young and, unfortunately, back to old again, reflecting their aged, hurt souls.

I am not naive. I know it is going to take a lot regained trust and renewed love to keep these children's eyes permanently young. To erase the damage caused by their mother's alcoholism.

Then again, maybe I am naive, because a large part of me thinks that this mother can succeed. For her children's sakes, I can hope for nothing more.

As always, big thanks for reading. I hope your holiday weekend is a good one. Next posting will be Monday, July 5. See you then...