I Feel Things...

I'm  back! Thanks to the many people in my life for their support and encouragement upon my returning--you know who you are! Please feel free to repost, share my return, and visit my archive!

Well, well, well...hello my long, lost friends. I missed you!

It seems like a long, long time since I have written a post for my blog, StorytellERdoc, and I am excited, nervous and humbled to be reentering your lives while returning to my baby.

What started as a small adventure and challenge from my writing group, with my first posting on November 19, 2009, turned into quite an amazing ride throughout the literary and social media world. The number of friends I met was staggering. I received recognition and awards. I won prizes. I was interviewed and contacted for my opinions. I got over a million hits. All of these things, though, were secondary to my intent. I simply wanted to pull you into my world, through my words, to focus on obscure life and ER moments that possessed a level of rawness and realness that connected you and I as fellow human beings. I wanted my words to be a reminder that choosing empathy and compassion over cynicism and sarcasm was possible.

On this journey, I posted 150 essays about life, patient encounters, and magnificent small moments--writings that to this day I can still read and feel the array of emotions I poured into my words. These writings made my heart swell, my eyes tear, and my smile broaden. They still do. My last post, on March 16, 2015, was not a planned exit from writing for my blog but, unfortunately, life happens and I needed to take some time to gather the bits of myself that became brittle and crumbled over the years. I had life lessons I needed to absorb. I had experiences I needed to process. I had to refocus my energy and passions and love onto the things and people that deserved my attention.

I am human and I have flaws. My life isn't perfect. Not even close. Now, though, it's in a much better place, thanks to a lot of internal work and introspection. I have more clarity.

I am back and stronger than ever. Personally, I look forward to sharing with you my journey. I hope to entwine my life experiences into my writings. Professionally, I still smile when I go to work, which is all I really need to say about that, right? The emergency department where I have worked for 22 years as an ER physician is busier than it's ever been. We are treating everything from devastating traumas to irritating hang nails. Among the 90,000 patients that we treat yearly, you can imagine the numerous interactions and situations that exist, simply waiting to be witnessed and observed.

I hope to be that witness, that observer. I hope to bring to you, through my storytelling, a perspective that is unique and intriguing in the way it unfolds the the human spirit with the laughter, the tears, the triumphs, and the pain of an encounter. Some stories will be personal, some will be professional, but all of them will be heartfelt.

In many ways, I am still the same person you got to know through my essays over the past few years. If you revisit these essays (visit the archive or try Gigi or The Witness), you will still capture my essence. As before, I still love my three amazing kids and my big forestry family. I still miss hearing my mother's voice. I still wear my heart on my sleeve. I still love my diverse friends and music and books and the gym and laughing and a good meal and sleeping in. I still love the privileges of my job--I continue to meet, accompany and treat some pretty amazing and memorable patients and their families during their stressful ER journeys.

In other ways, though, I have changed immensely. These changes will be revealed slowly, with time.

At this very moment, as I sit here in front of my computer screen, I am very nervous but grateful for the chance to enter your life with my stories. I offer my warmest thanks for your patience and time as I begin to expose my layers to you, once again.

While recently deciding to pursue this journey again, I signed into my ignored email account and was surprised to find many unopened emails from the past few years. They were wonderful, supportive, and encouraging. Some correspondences took the time to share their personal experiences and connections to my essays, and these emails made my decision to return even easier.

Let me share..."I don't remember what prompted it, but I ended up over at your blog the other day. What I thought would be a quick trip is turning into a multi-day journey back through all of the posts I read years ago. Once again, I was amazed at your gifted storytelling, your attention to detail and the way they're all seamlessly woven throughout, and the gentle, inspirational way you share with us readers perspectives we will otherwise never be able to see. Katie"

Again..."Thanks for the beautiful stories and insight from the physician's perspective. Please keep the stories coming. I look forward to each and every one. Thanks for sharing your experiences with us. They touch our hearts and many times make us smile and feel uplifted if only for but a while. Shirley"

And again..."Yours is not the first ER blog that I've read but there is an obvious difference. You don't seem to have the customary judgmental bitterness. I've been thinking about it and what makes you different from another doctor. I think part of it is that you are not afraid to feel things. Most of us spend our whole lives trying to get away from the bad/uncomfortable feelings. After a break up you stay busy and party with friends to avoid those feelings of sadness, etc. I think many ER doctors have shut themselves off from the feelings of their patients. Their goal is to become immune to the suffering by reason of self-preservation. You, on the other hand, seem to see that it's ok to be sad about something sad. You are not afraid to experience your feelings but you also don't live in them, either. I think this is why you've kept your humanity. Anyways, thank you very much for your writing. Jennifer"

So all my mumblings above come down to this...

I feel things...

I hope I can make you feel things, too...

Until next time...

As always, big thanks for reading. To all my faithful readers--hello, friends! Thank you for returning. To my new friends, thank you for giving me a chance. I look forward to sharing this incredible new journey with all of you!

Jim

The Other Side

the years teach much which the days never knew

Ralph Waldo Emerson

As I sit at our dining room table to write my first words in five months, I am realizing just how much I've missed writing about both my personal and professional life experiences. Though my family and close friends may know my reasons for this unplanned break, you, my friends and readers from StorytellERdoc, do not. So instead of diving head-first into writing a funny, planned posting, I thought I might simply change course to write and say "hello" and "how the hell are you" to each of you.

Let me briefly explain my absence. Simply, I began to have some vision problems last November, ultimately resulting in urgent surgery. Always the doctor and never the patient, this was my first real health scare. Following successful eye surgery, I was forced to take a few months time to recover. This break included absolutely no gym time and, most odd for me, no work time. Looking back on my career, I had never had so much as a week or two break from working in the ER. This inactivity, at first painfully frustrating, ultimately proved to be one of the greatest learning experiences thus far in my life.

For the first few weeks following surgery, I had to wear an eye patch, a blue, oval-shaped piece of perforated aluminum paper-taped to my face. With this new accessory, I spent much time in front of the mirror, looking to find that invincible, healthy fellow I once was. I couldn't find him. Friends tried to make me feel better, telling me I looked "sexier" with an eye-patch, but I saw through their flimsy compliment--the only way to look sexier, I reasoned while laughing with them, was to have sexy to begin with. My kids, hesitant at first, realized that patch or no patch, I was still the same Dad that I had always been. In fact, soon after surgery, Cole had a basketball game that I wanted to attend. "Cole," I asked, "is it okay if I come to your game with my patch or would you rather I stay home?" Without even a hint of pause, his resounding reply inspired me. "Of course you are coming, Dad, why wouldn't you?"

After several weeks, I was able to lose the eye patch. More importantly, with healing and some serious introspection and reflection, I was able to regain my perspective of what is most important in this journey of life. Family. Friends. Humor. Love. Compassion and kindness. Living a purposeful life.

Part of this time away included reevaluating my job differently. Although I still considered kindness and compassion at the forefront of my ER interactions with patients and their families, even I was not immune to a growing cynicism that occasionally seems to be pervading our medical field. Maybe this had even leaked itself into some previous writings. Luckily, though, I feel more privileged than I ever have, since residency even, in walking the halls of our emergency department and providing care to such a diverse and unique collection of patients. Of course, there will always be patients that are obnoxiously difficult, but my reserve to find something good in each and every patient has definitely been refueled. I've been honestly warned, however, by several of my hard-working partners. "Just give it a few months, Jim," they said, "and then see if you feel the same way about things." I can only hope that I have some great staying-power. I feel I do.

Being a patient, I have also learned and witnessed first-hand just how important a role a doctor can play in one's recovery. Luckily, I am surrounded by four absolutely incredible individuals who have prioritized being a compassionate person first and playing a doctor second, proving that one doesn't need to place himself on a pedestal to be amazing at what he can do. This all-star team of providers, however, did not come without some rearranging on my part. I removed from my team, so to speak, one nationally-recognized specialist who was less than stellar in both his personality and in his style of delivering unwanted news. Although this specialist may have been quite good at what he does, I was less than impressed with his all-around abilities to communicate. To heal well and remain positive throughout my ordeal, I insisted on only being surrounded by similar individuals.

Overall, I have much to be thankful for. An almost complete recovery. A supportive family. Supportive friends. And supportive co-workers. What could have been a terrible outcome was not. For this reason, I will always be humble and grateful. Returning to work, I was greeted with many kindnesses and friendly, encouraging words. Hugs included. I also returned to some sadness as well. One of my favorite nurses, Sue, tragically lost her son during my absence. My ordeal embarrassingly pales in comparison to this tragic event of her life. To hug her and share tears with her as she attempted to give me a warm welcome-back smile speaks volumes of her strength and character.    

So there you have it. Officially, I have now returned to my life as I know it. Playing doctor full-time. Playing Dad full-time. Attempting to be a writer again. And, most importantly, continuing to look at my wife with complete wonderment, appreciating more than ever her infinite strength, support and love. Except for the glasses outwardly, my most significant changes from my ordeal have come from within. For this, I am most appreciative. I am stronger than ever, actually. As Ralph wisely stated above, the small day-to-day battles were worth the positive hindsight of it all.

It feels so very good to be back...

As always, I thank you much for reading, my friend. More importantly, I thank you for your patience and returning to read my words.

To Like Or Dislike

I was shocked by her appearance. Although she was in her early 50s, she looked closer to 80.  Matted peroxide hair.  Dull, lifeless eyes.  Sagging skin and deep wrinkles.  Protruding cheek bones.  Cracked, dry lips with a hint of yesterday's lipstick caked in their corners.  Gray and yellow-stained teeth, some chipped. In her prime and before alcohol and cigarettes became her every thought, I could imagine an attractive, lovely woman.  Now, sadly, what sat in front of me on the hospital cot in Room 12 was nothing short of a shell of a human being.  This was a woman who lived a hard life.

She had presented to our ER in respiratory distress.  Although she already had an established diagnosis of emphysema, she continued to smoke two packs of cigarettes a day.  On top of this, she had just finished a ten-day drinking binge, the last five of which she spent either passed out or drinking.  She claimed to have not eaten in that time.  I was called to her room because she was in such dire respiratory distress.

"Maam," I said after introducing myself, "how long have you been having trouble breathing?"  She was gasping for air, her nasal folds flaring with each struggle to breath deeply in.  Through her thin hospital gown, I could see her ribcage and diaphragm heaving, compensating for her non-compliant lungs, trying to pull that extra oomph of air into her body.

"I...don't...know," she managed to answer, each word a struggle for her.  Her hands, I noticed, were pale, their spidery veins popping through her thin transparent skin.  They gripped the top rail of the cot for dear life.

Immediately, I ordered breathing treatments.  Steroids.  BiPAP (a machine with an attached mask that would force supplemented oxygenated air into the patient's lungs every time she initiated a breath).  Blood work.  A stat chest x-ray.  The rapid intubation kit and ventilator for stand-by.  I asked more questions, questions she could answer simply by nodding her head.  "If you get worse, maam," I spoke, asking the most important question of all, "we may need to insert a breathing tube into your lungs, hook you up to a ventilator, and do your breathing for you.  Do you want that if it comes to that?"

A "yes" nod.  She tried to speak.  "I've...had...that...before," she gasped.  "You've been intubated before, maam?" I repeated.  She held up two fingers of her left hand in a peace-sign.  "Twice," she said.

Within the half-hour, surprisingly, she began to turn around for us.  I spent considerable time in her room during this period, making sure she would not decompensate before our eyes.  With the additional attention of two stellar nurses and a respiratory therapist at bedside, she thrived and slowly improved.  Finally, as her lungs began to fill with more air, her nasal flaring and ribcage retractions subsided.

After stabilizing her breathing, we began to treat her other problems.  For malnutrition and dehydration, we gave her several liters of normal saline and a "banana bag," a liter of fluid supplemented with thiamine, folic acid, and multi-vitamins, giving it a yellowish-color.  For her withdrawal tremors, we gave her Ativan, a longer acting valium-derivative.  We fed her ice-chips.  We gave her anti-nausea medicine and several low doses of pain medication for her evolving alcohol-induced pancreatitis.  Her chest x-ray revealed pneumonia in both lungs, and we began antibiotics to cover her for the common community-acquired organisms as well as for aspiration organisms (only God knew if she swallowed some puke into her lungs).

Finally, after a lot of attention and energy given to her, she was at the point where I could sit down a few extra minutes with her, making sure I understood all of her history and didn't miss anything.

"Maam," I started, "have you ever tried to quit smoking?"  "Yeah," she said, her voice now a little stronger, more gruff, "but I don't really want to.  I like it."  She looked at me with challenging eyes as she said it.

"And maam," I continued, "do you consider yourself to be an alcoholic?  Have you ever had treatment for it before?"  She answered immediately.  "No, I'm not an alcoholic.  I like my booze, but I don't drink nearly as much as my husband.  Now he's an alcoholic.  But I'm not."  She enunciated "he," spitting out the word like it was poison.  Her denial was remarkable.  And expected.  "Do you want help while your hospitalized for your drinking, then?"  "Why," she asked me, "if I don't have a problem?"

I asked her about abuse.  She denied physical abuse but claimed "that he yells at me a lot."  Again, she refused to accept any counseling.

Finally, as I was finishing, she said "Can I ask you a question, Doctor?"

"Of course you can, maam," I said.  "What can I do for you?"

"Well," she said, "I don't understand why doctors can't take care of my problems.  I don't like coming here all the time for belly pain and breathing problems.  Why can't they just get it right the first time I come in?"

I was shocked.  Completely and utterly thrown off my game.  Hackles up.  The nurse, standing at the room counter with her back to us, writing on her chart, turned her head around to face the patient, her mouth gaping and shoulders tightening.  I'm sure mine were, too.  Although we don't expect appreciation, we certainly don't expect to be blamed for a patient's medical problems, either.

"Maam," I said in my calmest , most respectful voice, "you have emphysema and, yet, continue to smoke two packs a day.  You have pancreatitis and, yet, continue to drink.  You completely ignore your body's needs, not drinking water or eating food for five days.  You are hacking up phlegm and don't use your inhaler or pursue treatment of these symptoms, resulting in pneumonia.  You've been intubated twice and have come to the ER multiple times.  And you can't understand why your doctors 'can't take care of your problems'?  Have you considered that your problems might be from your own poor decisions?"

I stopped and stared at her.  She stared back.  I waited for her to speak.  I was going to stand there all day if I had to.  Finally, with the nurse now standing along her other side, the patient spoke.  "I guess you are right.  Some of these problems are my own fault."

"Not some of them, maam," I said, "all of them.  By accepting personal responsibility for them, though, maybe you can move on and start treating yourself and your body a little better."  Although I'm sure my words fell on deaf ears, I still needed to have my say.  Especially when we all worked so hard to turn this unappreciative patient around from her multiple medical problems, some life-threatening.

I grabbed the patient's hand.  "Listen, maam," I said, "I wish you well.  I want nothing but the best for you.  But if you don't change your habits, I am sure I will see you in our ER again.  And again.  And, one of these times, I fear, we won't be able to undo your problems."

I let go of her hand and turned to walk out the door.  She was admitted to the ICU and was going to be transported up shortly.  Before leaving, though, she called out.  "Doctor!"  I paused and turned around.  "Yes, maam?"  She hesitated before speaking.  "Thank you for your help today.  I'll think about the counseling, okay?"

I nodded to her.  "Good luck," I said before continuing out the door.

One of the most frustrating parts of my jobs is dealing with patients' frustrations of their medical problems, simply because of their lack of personal responsibility.  It's rampant, too.  I cannot cure patient's who do not put their own effort into their health.  None of us in the medical field can.  We are here to help you along your journey, to walk sided-by-side with you in your, hopefully, healthy path.  Of course, some people do everything right, by the book, and still have medical issues.  That's different. But if you want to eat profuse and bad meals, please don't expect us to cure it with a simple "sugar" pill. If you want to eat fatty and greasy foods, please don't get pissed at us when your cholesterol pill isn't helping.

I love my ER patients.  Seriously.  I have met some very cool people over the years, from both different and similar walks of life, simply from what I chose to do for a living.  I appreciate and enjoy learning the diverse stories that rest behind their faces.  Sometimes, though, I get frustrated.  We all do in the medical field.  At the end of the day, we are all human, whether we perch ourselves on a pedestal or not.  And, regardless, we want the best for you, the patient.

To my patients that have made my job rewarding, a simple thank you...it has been my pleasure learning about you and helping you on your healthy path.

As always, big thanks for reading...I hope this finds you all well.  Enjoy the weekend...

Scratching Below

He was a good-looking guy, my next patient.  Even before walking into his treatment room to introduce myself, I had overheard the nurses talking about him in their nursing station.  "Did you see those brown eyes of his?" his primary nurse said.  "And that hair," added a tech, "so wavy and thick."  "I like his smile," added a second nurse, one who had helped settle this patient after he arrived by ambulance.  I could only have imagined the argument between the nurses as to who would get to be this patient's primary nurse.  I had no doubt that lots of pillow fluffing, extra blankets, repeated exams and vitals, and a turkey sandwich were all in his future.

The aggressive, single, newly-graduated nurse won out.  Secretly, I had my money on her.

I walked into the room to find a gentleman in his mid-twenties, sitting upright in his cot, in a properly worn hospital gown (I had no doubt the nurse helped him put it on correctly).  He seemed tall, six-foot maybe, and weighed around a buck eighty.  He was thick-shouldered and clean-cut, in good shape, his brown hair appearing recently-cut.  He was modern and hip--tattoos poking out from the sleeves of his gown.   

The nurses were right, of course, he was a good-looking guy.  In fact, I would have even agreed with their assessment that this patient could have modeled at one point.  More for Land's End or Eddie Bauer, though.  He would have had to imbibe in plain chicken breasts and no carbs for months to make it into a Hollister or American Eagle ad.

Good-looking or not, this patient was in our ER to be treated.  And doing a quick, cursory once-over, I could tell that all was not right.  This patient's brown eyes were dilated, tracking my every move, his deer-in-the-headlights glances matching his nervousness.  He was breathing rapidly as well, fidgeting with the pulse-ox monitor clipped to his finger.  Before I could approach him and introduce myself, his anxiety was revealed in his rapid-fire speaking.  "Are you the doctor," he blurted out.  "Yes, sir," I answered, "I am your doctor today.  I'm Dr. Jim."

He paused to take me in, looking me up-and-down.  I remained quiet during his assessment of me.  Finally he spoke.  "Do you work out?"  Of all the questions and comments I was prepared for, this one surprised me.  "Yes, sir, I work out.  You, too, I take it?"  He nodded his head yes.  Obviously, physical appearances meant something to this patient.

I decided to gain control of this interview.  "Mr. Nalstead," I asked, "what brought you to our ER today.  What can we do to help you?"

"I think I'm having a heart attack, Doc."

"Why do you think that?" I asked him.  "Are you having chest pain?"  He certainly didn't come across as a patient at risk of having a heart attack.

"No," he answered, "but I'm having a hard time breathing.  And sometimes I get palpitations, like my heart is going to pound out of my chest."

I reviewed his cardiac risk factors with him.  The patient admitted to smoking and his father was being treated for hypertension but never had a heart attack, himself.  "What are you doing when you develop this 'hard time breathing?'" I asked him.

"Usually I'm just sitting, Doc, and thinking."  "About?" I asked.  He continued.  "About my kids."  "How many do you have?" I asked, guessing, from his age, one or two.  "Three," he answered.  I wasn't too far off.

"How old are they?" I continued, interested now in his social history.  And although it is hard, after working in the ER for so many years, to catch me off-guard, this patient's answer did.

"They are 22 months, 19 months, and 16 months."  He paused, staring at me, waiting to see what my reaction would be.  I wore my poker face, though.  I'm sure he was anticipating what my next question would be.  I was no Ob/Gyn, but even I could figure out that this scenario was not possible with just one mother, one woman.

After asking him, he admitted to me that "I had gone through a pretty rough period, yeah."  He had three children to three women.  In a remarkably short period of time.  Currently, none of the three mothers of his children would let him see his kids.  Whenever he thought about his kids and his lack of involvement in their lives, he started the rapid breathing, the nervous tremor, and the heart palpitations.  Raising my suspicions for an anxiety disorder.

I dug deeper.  As it turns out, this patient had had a pretty miserable childhood.  A piss-poor father-figure.  A mother who cut him down repeatedly.  Alcohol and drugs since his early teens.  Prison time.  Although he denied any recent alcohol or drug abuse to me, I suspected he was teetering on using again.  It was a vicious cycle that needed to be broken.  And he knew it.

After doing some baseline tests to make sure he was clinically sound, I sat back down with him. His testing results, I assured him, were excellent.  "So you don't think I'm having a heart attack, Doc?" he asked me.  "I'm sure," I reassured him.  We talked a little further about how he had to break his cycle of behavior, though.  "You have to," I repeated, sternly, "if not for you, then, for those three little kids out there in our community who don't know their father's love."  My words must have gotten to him--I saw the glistening brown eyes well-up before tears spilled onto his cheeks.

We offered him counseling.  He took it.  We offered him a follow-up appointment with a family doctor who was accepting patients.  He took it.  I offered him a short-term prescription for a few anxiolytics.  Six pills.  He took it.  He asked me about my social life--and I shared with him that I was married with three kids.  "Are they fun?" he asked.  I simply nodded my head "yes."  In my mind, though, I imagined my life without my kids, a thought that made me shudder. 

The patient stared me in the eyes.  "I want to do this, Doc.  I want to be a good father to my kids."  By all appearances, he appeared sincere in wanting to break the cycle he was caught up in.  I could only hope.

I left his room, after my last recheck, thinking about all of this patient's problems, problems that were buried deep below a good-looking exterior.  On the inside.  Hidden from anyone who didn't take the time to uncover the true essence of his person.  An exterior that didn't match our society's standards of what we suppose a good-looking person has within them. After all, if a woman is beautiful or a man is good-looking, why would they have any internal turmoil?  Why would we think anything but their outer beauty would be matched by their inner beauty?  What do they have to be upset about?  How could they have any problems?

It goes back to the common thought--physical beauty is temporary, spiritual beauty remains forever.  We are all guilty of judging a book by its cover, aren't we?  I know I am, despite my awareness of trying not to.  However, I have learned, with time, that I find much more pleasure from a book by opening it.  Pretty, pretty cover, maybe.  But what are the words saying inside?

Thankfully, this patient reminded me that, yeah, I am in my mid-forties, and my body and looks might be fading a bit (some characters in my life would probably argue more than "a bit"), but I have inner peace.  I am loved.  I give love.  If you make me look like an ogre, but guarantee me my love and inner peace, I will take that deal and run with it.

I walked back to my desk.  His primary nurse approached me.  "Hey," she said, "is it okay if I discharge Mr. Nalstead?"  I nodded my head "yes" to her, adding "He is a pretty nice guy, isn't he?  I hope he can turn his life around."

She looked at me like I was crazy.  "Are you kidding," she said, "he has been in jail and has three kids to three different women!  I'm not up for instant motherhood!"  She chuckled at her words. I was surprised, this response coming from her, when just a few hours prior she had been thinking this guy was the most glorious specimen to come from the human race.

Scratch below the surface...

As always, big thanks for reading.  And a big thank you for your patience with my frequency of posting... 

The Barn Door Is Open

One of the things that continually amazes me, intrigues me even, about medicine is the scale of personalities that exist within our community.  From the obnoxious "know-it-all" to the warm-hearted "everybody's friend" types, you can find just about any recipe for a personality among us.  Take a dash of kindness, a pinch of self-doubt, a teaspoon of over-eagerness, and a dollop of sharp wit, and viola, you may have this nurse during your next visit to the ER.

Me?  I'd like to think that I am a straight-shooter, the furthest orbit away from the central pedestal that so many doctors feel they deserve to be perched on.  Their livelihood depends on this precarious position.  Mine doesn't.  I ask my team to call me Jim.  I don't wear a white coat during a shift (except in the family room, where I insist on a higher level of decorum to be followed). I welcome anyone to question why I am doing something in a certain way.  I am kind and compassionate.  I love to laugh and smile among the infectious camaraderie of a good team during a rough shift   

However, I am human, too, which means I sometimes need to really fight myself during a crazy shift or odd patient-encounter to avoid cynicism, sarcasm, anger, or disappointment.  Although rare, I have had some breaking moments.  For example, to have a patient with a top-of-the-line cell phone, decked out in a designer outfit and $300 dollar running shoes, with a pack of cigarettes hanging from their pocket demand (in an irate, demanding manner) a free ride home and free prescription fills is still something I struggle with, although my answer remains the same.  "No."  And patients who have attained their medical degree via a ten minute Google search prior to their ER visit, trying to dictate the course of their treatment, can test my limits in a weaker moment.

My idols, those inspiring physicians I've encountered through my career, seem to be the "regular Joe" doctors who have a quiet confidence and a humble self-assuredness combined with a normalcy of expected kindness and respect.  They don't want their coffee brought to them, they don't want everybody to bow at their feet, and they don't feel the need to brag and show-off their endless knowledge base (a pet peeve of mine--I'd rather one show me how good they are, through their actions, rather that waste their words by telling me).  They just want to be a friend, a mentor, a good person defined by their entire world, not just their world of medicine.  Their greatness as a physician is simply an extension of their excellence as a human being.

It is a fact I stress with our residents.  "Don't emulate just one of us," I say, "but rather, skim from each of us the characteristics you want to carry with you throughout your life, your career."  I reiterate that none of us, their mentor physicians, are perfect.  We are all human.  I can only hope that they choose to combine hard-work, compassion, and humility among their other qualities.

If I ever decide to pursue a big head and an uppity view, though, about my professional accomplishments, I think I will fail miserably.  Too many times through the day I am humbled by reminders that I am nothing special.

Case in point?  Just last week, during another busy shift, I was standing in front of the counter of Room 22.  In the treatment cot lie Mr. Smith, his mental status dwindling and his extremity weaknesses gaining.  His wife, expectedly concerned and apprehensive, sat in a corner chair just a few feet to my left, watchful of her husband and our treatment team.  Her worried look, her disheveled gray hair, her furrowed brows, her dilated pupils, the way she edged her body forward on her seat, utilizing but a few inches of its support, all spoke of her love of her husband.  Of her inherent sense that something was terribly wrong.

And she was absolutely right in her suspicions.  Mr. Smith's CT scan had confirmed a significant intracranial bleed, a stroke of devastating proportions.  A stroke that limited us, between his previous strokes and extensive medical history, in our aggressiveness.  Together, the ER nurse and I had walked into the room to share their grim news with them while we contacted the neurology and neurosurgical teams.

"Mr. and Mrs. Smith," I spoke, quietly and gently, yet urgently, "I have some disheartening news.  It appears that Mr. Smith has had another stroke, this one quite involved within the entire brain."  We talked at length about the findings, our plan of action, of how aggressive they wanted our team to be, despite our hands being tied from this CVA's severity.

Mrs. Smith took the news much better than I expected, her acceptance belying her body's expressions. While her husband floated in and out of awakeness, she explained their position.  "We were told last time that the next stroke could be the final one.  It appears we have arrived at this final one, yes?"

I couldn't help but like Mrs. Smith.  Her inner strength was simply astounding.  I nodded "yes" to her, but added "Let's at least have the specialists see your husband and make their recommendations to you."

Now she nodded "yes."  "But," she added, "neither of us want heroic measures."

I understood.  "I'm just going to remain here with you a few minutes," I said, "if that's alright, while we wait for the specialists to arrive."  Although the ER was busy, I wouldn't let that fact prevent the nurse and I from providing a few minutes of necessary companionship.

And then, it happened.  Another realization of my humanness.  After removing my supportive arm from around Mrs. Smith's shoulders, I stepped back to the front of the counter, bowed my head, and cupped my hands in front of me.  I looked to the floor, to my brown Clark clogs, as I started to say a silent prayer for this family.

Instead of finishing my prayer, though, I became distracted.  Thoroughly and completely.  Because there, in this extreme moment of crisis, in the middle of my wishful thoughts for this family, I noticed my zipper.

My wide-open unzipped zipper.  How long had it been down?  I shuddered at the thought that my zipper may have been this way for several hours and through several other patient encounters.

Not only was my zipper open and lingering at its lowest possible point, but its edges were widely gaping, exposing my hunter green, 3% spandex and 97% cotton, boxer briefs.  My hip-huggers were there for the world to take in at possibly one of the most inopportune moments.  "Hello," they screamed, "look at me.  Look here!"  Ugh!  For some unexplained reason, I remember thinking the situation would have been better had I chosen to wear my tighty-whities that day.

Slowly, I tried to cover this embarrassment with my cupped hands, but to no avail.  I shifted my legs back and forth, trying to see if the sway of my motion might magically reacquaint my zipper edges.  No go.  I looked up at the nurse, who was oblivious to my predicament, and Mrs. Smith, who was not.  She was focused on my every move. It didn't help, either, that she was sitting in her chair, eye-level of my indiscretion.  Secretly, I think she was quite entertained by my distraction.  Heck, I'd go so far to say that she enjoyed watching me squirm of embarrassment.

Suddenly, though, she looked me in the eyes, her eyes sparkling with amusement and yet glistening with sadness.  I returned her gaze.  We both remained quiet. All was okay.  I abandoned any sense of correcting the situation and remained leaning against the counter.  Graciously, she turned her head from me and refocused on her husband.  As did I.  As was the nurse this entire time.

By the grace of God, I got paged overhead for a phone call.  Probably the neurologist, I thought.  I excused myself from the room and rushed to my physician station, where I yanked up my zipper before attending to any other tasks.  Later on, as we do in our twisted ER ways, the team would have a hearty laugh at my expense.

Yep, I'm human.  I put my underwear on just like the next person.  As do every one of my fellow physicians. Oh, and my zipper will occasionally fail me and that's okay.  How can one possibly get an exaggerated ego with that in mind?

I will remember Mrs. Smith and her quiet resolve, her inner strength, in the face of such a crisis.  And I'm sure she will remember me, too, but, unfortunately, not for the same reasons. 

I hope my residents take my words to heart and emulate the best I have to offer.  Which, during that shift, was this advice--never, ever go into a patient's room without checking your zipper first!

Otherwise, I'll just keep preaching kindness and compassion.  And, oh yeah, humility...

As always, big thanks for reading.  I hope this finds you all well.  On HHI for the week and having a grand ol' time.  Any embarrassing medical stories you'd like to share?  Please do... 

Future Hopes

Vote for StorytellERdoc for Best Literary Blog at the Medgadget Medical Blog Awards! Thanks for your support...

After another recent shift with a predominance of patients suffering from lingering flu symptoms, I decided to swing by our local Walmart to stock up on our home supply of pediatric medications, just in case. Some acetaminophen, ibuprofen, decongestant, and cough suppressant would hopefully get us through the rest of this winter season. And, of course, what a great variety of favorite flavors--orange, bubble gum, berry, and grape. Heck, some of them taste so good that faking the flu for the little cups of "candy" might be to my kids' benefit.

Unfortunately, on the way to the pharmacy area, one of the first aisles I always encounter is the candy and gum aisle. Not a good thing for me, since I have quite a recent fascination and taste for Gobstoppers, a Wonka jawbreaker product (don't tell my dentist). The yellow psychodelic boxes scream at me from their shelf, "Jim, come and put a couple of us in your cart," and regardless how much I fight it, the pull is too strong.

Needless to say, my kids love going to Walmart with me.

On this particular day, then, I walked to the mid-aisle to grab a few boxes of the candy. I wasn't alone in the aisle, though. To the right of the Gobstoppers, two parents stood looking at the shelf of big Hershey chocolate bars, immersed in a conversation (yes, I listened) of milk chocolate versus dark chocolate. To my left, a grocery cart with a makeshift, rigged-up kiddy car, driver seats and steering wheels included, on its handle-end. Two kids sat in those seats--an approximate four-year old girl and a three-year old boy. The Gobstoppers sat waiting for me between the parents and kids.

As I approached the family, I was caught off-guard with the screaming and fighting going on with the young kids. In fact, at one point, as I was kneeling down to grab the boxes of candy, I was appalled to find the little boy trying to punch his sister in the face, her hands rapidly moving to block each of his thrown punches, protecting herself. Still on my knees, I looked toward the parents, who must have completely tuned-out their kids. I was just about to say something when the little boy stopped, but not before his sister screamed out, "Get the hell off me, God damn it!" Still no reaction from the parents.

After this, I stayed kneeling, observing these peculiar parenting skills (or lack of) while looking at a box of Junior mints. While I was debating getting the mints, the little girl and boy started to talk to one another. About me! I actually wrote the conversation down in the pharmacy because it had shocked me much. It went like this.

Little girl: "Who the hell is that guy?" I looked at them looking at me.

Little boy: "I don't know, but if he gets close enough, I'm going to kick the shit out of him."

Little girl: "That will be fun. Try to knock him out." For good measure, she added, "God damn it." Again.

I was disheartened. I was shocked. I was annoyed with the parents for not addressing such obnoxiousness from their young kids. I looked from the kids to the parents, who had quickly glanced our way before figuring their conversation about chocolate was more important. I looked back to the kids again, before standing up and walking away with my Gobstoppers. I was upset and figured this was the best option for me, at that time. I knew it wasn't the kids' faults, but rather their parents. Their role models. But I wondered to myself, "What kind of adults are these kids going to become?"

This happening got me to thinking about our society. For the most part, we all know great kids in our lives, from our own to our friends' and families'. To raise respectful, kind, compassionate and loving kids and guide them appropriately into adulthood, when we choose this road of parenthood, should be the primary goal in each of our lives. We may not always succeed, darn it, but we have to try our best and throw our energy into the effort. Because that effort translates into the brilliance of the future generation coming up to govern our world.

These parents demonstrated no effort. And, unfortunately, they are not alone.

How many of us see the changing pattern with our society's kids. Talking back to well-meaning adults. Not respecting our elders (at least hold the door open for them and smile!). Tolerating vulgar language and meaningless violence via computer games and TV. Not respecting one another's uniqueness. Forgetting manners. Immersing oneself into texting instead of holding actual conversation. Avoiding volunteerism and chores. Placing more importance on material possessions rather than relationships.

Although I see both ends of the spectrum every day in the ER, I can only imagine the stories a teacher can tell.

I carried this Walmart story with me for a few weeks, bummed at the behavior of those children, constantly on vigil to find a hopeful story to balance out this disappointment. And then, the other day during an ER shift, I found it.

I walked into Room 17 to see my next patient, a nine-year old girl who had sustained minor anterior chest burns after bumping into her mother, who had been holding a pot of boiled water. Because the room was quiet and calm, I was quite surprised to find five people in total in the room, four kids and their mother. The mother was standing to the patient's right, beside the cot, while the oldest and youngest children, girls, shared a corner seat and their brother sat to their left on a stool.

Despite a TV in the room, it was not on, and the children all sat with an opened book before them, reading. Mom was whispering to her daughter with the burns, consoling her with her words and touch, gently stroking the back of her hand and her ribboned braids.

I walked up to Mom and the patient and introduced myself. "Hello, Doctor," the patient said, bravely trying to smile over her discomfort. She melted my heart, trying to be respectful while a three inch patch of skin lay peeled from her body between her clavicles. The mother turned to the other children. "Say 'hello' to Sissy's doctor," she said, and I was greeted with three more genuine smiles and greetings. They spoke with a bashful confidence that I fully appreciated.

We talked, the mother and patient and I, for quite a bit about what happened that brought them to our ER. After a stable exam, the nurse came in to clean the burn and show Mom how to care for it the next few days at home.

While finishing with this patient, I felt compelled to share with Mom how impressed I was by her kids. Not once did they talk without calling me 'sir' or the nurse 'maam'." They took turns, one at a time, to step up to their sister's cot to be supportive of her. No arguing or fighting, only kind words were uttered. No scowls, only warm smiles were worn. They were unabashed with their hugs and physical contact, sharing their seats and coats with one another. The mood and energy of the room was lighthearted and fantastic.

"Your kids," I shared with Mom before discharge, "are absolutely wonderful. It has been such a pleasure to see how well-behaved and loving they are with one another and with you. Even most of our staff has commented on their excellent behavior. Well done, Mom."

Mom was somewhat embarrassed by my compliment. "Trust me," I assured her, "I mean my words. What a wonderful job you are doing raising such fine young kids." As I spoke, the kids all grinned, bumping into one another with their elbows and bodies. I looked at all of them and smiled.

Mom thanked me, shyly, before explaining that she was a single parent. "Although I get tired by the end of the day, things seem to be going quite well with the kids." How could they not? This was an amazing woman, a role model for all, well aware of the importance of raising good children. And she was accomplishing, on her own, what two parents with less children weren't.

A hero.

After complimenting the children on their behavior and their impeccable church clothing, I ran to the freezer and grabbed four Italian ices. Grape. And lots of stickers from the nursing station. Just some small gestures to acknowledge their good behavior.

My hopes for our future have been restored. It took a few weeks, but I'm back to focusing on the good of our children. Thanks to the brilliant unselfishness of a great mother...

As always, big thanks for reading. Well done job to the mother of these four children! Also, thanks for your support in the recent Medgadget Medical Blog Awards voting. It continues until Sunday at midnight. If you enjoy my blog and posts, I would greatly appreciate your support and vote.

Take A Picture

Like anyone else who works in the ER, I wish I could take pictures and videotape some of our more absurd, inebriated patients. Of course, though, I can't--patient confidentiality and all that blah-blah stuff. But how great would it be to sit a patient down, after they sobered up, and show them how ridiculous their behavior was while in our care? Maybe, even, send a copy to their proud parents or spouse.

Personally, if I ever had twelve beers and ten shots of tequila before proceeding to crap and vomit all over myself, I would like a picture or two to convince me it really happened.

It was 2 am and I was standing at the counter of our nursing station nearest the ambulance bay doors, finishing a chart while dreaming about going home within the next hour, when the doors suddenly swung open and a prehospital team proceeded to wheel a disheveled patient into our ER hallway. Usually, the team contacts us by radio to alert us of their pending arrival with a patient, so their unannounced visit was a surprise to all of us.

The chief paramedic shrugged. "Sorry," he said, "but we picked her up at a bar just a few blocks away and didn't have time to call."

On their cot, obviously intoxicated, sat a peroxide-blond female, in her mid-twenties, with her head slumped to her right side and her breasts barely contained by her skimpy halter. Her hair was messed, the hairspray she spritzed earlier in the evening unintentionally spiking clumps in all directions. Her face was streaked with tears, darkened trails of waterproof-less mascara collecting at her chin. Drool gathered at her mouth's angles.

So, so pretty.

Of course, I was intrigued. "She was at the bar," the paramedic continued, "drinking for the past three hours, when her friends got concerned because she wasn't 'acting right.' Remembering she had diabetes, they called us to come 'check her out.' When we got there, she was passed out on a bench in front of the tavern, a puddle of vomit at her feet. Her finger stick was 87, so we decided to bring her in. She doesn't have any signs of trauma, doc."

Well, thank you fellas.

As the paramedic was speaking, as if on cue, the patient cocked her one eye open and, realizing she had an audience, started wailing and shrieking, her cry alternating between forced hiccups and gasping sobs. The hallway filled with various heads poking out of the treatment rooms, wondering how a hyena ended up in our ER.

"Room 23," the charge nurse said. The paramedics hurried off with their patient.

A few minutes later, walking back to my computer station, I passed Room 23, slowing down to check-out what was going on with our new patient (yes, I was nibshitting). I'm glad I did, though, if for no other reason than to find the paramedic holding this patient in both arms, a hero carrying his damsel-in-distress, while transferring her dead-weight from his cot to ours. I stopped and waved to him, laughing, and he shook his head in disgust. "Sometimes I hate my job," he muttered with a smile.

I stopped in and did a brief primary exam, listening to the patient's heart and lungs, confirming her stable vitals, and making sure she had no evidence of trauma. She didn't. All the while, she kept asking for the bouncer from the bar. Over and over and over. "Maam," I finally said, "nobody came with you. I'm sure the bouncer had to stay to finish out his shift."

"Ahh," she slurred, "screw him. He has a small penis, anyway." As she spoke, she pinched her thumb and index finger an inch apart from one another, giggling to herself while amusing us. "How do you know that?" her nurse, Barb, asked. "Well, duh," the patient replied, "I can hardly feel him when we have sex." I almost threw up in my mouth from her sharing so much (or so little) information.

So, so classy.

As the nurse removed this patient's clothing to put her in a gown, we discovered that the patient had on three layers of compression garments around her middle--a spanx, a girdle, followed by another spanx. For those of you not familiar with spanx (and I wasn't, so the nursing staff kindly informed me), it is a stretchy, spandex-type piece that, after you hold your breath and squeeze yourself into it, acts like a casing to your sausage body. Miraculously, you look thinner and more fit. Without going to the gym or watching your diet. Your difficulty breathing, profuse sweating, and pinched-up, cyanotic face, though, might just be dead-giveaways that you are wearing one.

"Why in God's name," Barb continued, not learning her lesson about asking questions from before, "are you wearing three of these? I've never seen anything like this."

"Well, duh," the patient answered again, "maybe so I can get laid by a guy who likes skinny girls." I get it--three layers tripled her chances.

I'm assuming that she was assuming that she looked more attractive all squished into her itty-bitty jeans and shirt with the help of her garments, but really? Did she think this situation through? What guy, one who was probably out drinking at the same bar as her, would be able to remove three of these things? Would the effort be worth it? Would his spanx-removal talent have a big payoff? Sober, I doubt any guy would be able to succeed in getting this patient out of her spanx, but throw some drinks into the equation and what do you have? Besides the fumbling, frustrated fingers of her date? Failure, through and through.

All the while, the patient continued talking in a slurring half-whisper, occasionally bursting out in giggles from her self-amusement. Several times, she belched so obnoxiously that it would have made any beer-guzzling, football-watching male proud. And one time, she dug her finger so high up her nose for a booger that I think her elbow was resting on her chin. Needless to say, I was fascinated by her influenced behavior and lack of awareness.

Finally, though, my biggest shock of the evening came from what the nurse shared with me. It seems that as the tech and nurse finished undressing the patient for observation, they were unpleasantly surprised to find this patient and all her southern female parts barely covered by her thong underwear.

Her American flag thong underwear!!! Three square inches of red, white, and blue fabric.

I was never less proud to be an American.

For various reasons, I found this news appalling. And so did the nurse and tech. Never before, in my vast experiences, did I see some skimpy underwear fashioned in this manner. When did a manufacturer start finding it appropriate to place the American flag, our sacred national symbol, on a little triangular patch that covers a woman's privates. Or worse (I'm shuddering here), a man's? I mean, let's reason this out. If our flag touches the ground, out of respect, isn't the protocol to attempt to lift it up from the ground (if possible) and, if not, burn it. Yet, it's perfectly okay for someone to wear our prideful flag pressed against their privates? Something about this thought just didn't sit right with me.

Let's be proactive. I say we gather all the existing American flag thongs out there and have ourselves a big--no, make that huge-- bonfire. Quite honestly, though, that's one bonfire I would probably dread attending.

I did get to eventually leave at my scheduled time, 3 am, after signing out my active patients to the overnight doctor. The patient, who had no sober friends or family available to come take her home, did fine throughout the night's observations, barring the occasional outbursts of swearing, drunk mumbling, and promiscuous suggestions. When she sobered up, however, according to the morning team, she turned out to be a very nice, pleasant young woman who just happened to "have a rough night."

"She could have been your sister or mine," the nurse added.

"Umm, no," I thought to myself, "I don't think so." I wasn't about to picture any of my sisters in an American flag thong, let alone being ridiculously drunk while holding their thumb and index finger an inch apart.

My final thought...maybe I don't need to take a picture or videotape this stuff, after all. Really, the mental image is reminder enough for me. Who needs a timeless picture to document such dread? Or the nightmares that would follow? If anything, I guess you can just take a picture of me, the treating physician. I'll give you permission. Just excuse my gaping mouth, my surprising eyes, and my befuddled expression when you get it printed...

As always, big thanks for reading. If you own a pair of American flag thong underwear, do me a big favor and throw them out. STAT! See you soon...

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...

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 Pit Stop

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Was this the reason?

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

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

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

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

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

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

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...

Kung Fu Fighting

I love a distraction. Especially in the ER. Sometimes the distraction can be subtle and minor, one that I have to search out to find. Other times, though, a distraction can be glaringly obvious, practically smacking me in the face. Whatever the diversion, these moments can make a hectic, chaotic day in the ER much more tolerable. Not to mention fun.

Although it's usually the patients who provide the main attraction, occasionally it can be the waiting family or friends of the patient. For example, Aunt Alice's nose mole and smeared lipstick might make me do a double-take, detracting from the attention I would otherwise have given her nephew, the patient. Grandpa Ben isn't fooling anyone about his gas problem either, sitting over in the room's corner wearing a smug smile, shifting around on his chair before releasing another foul air biscuit.

The possibilities of distractions are endless and, quite frankly, most welcomed by my receptive self.

A few weeks back, I had a two-for-one zinger--both an intriguing patient and her entertaining boyfriend. The patient herself had a significant history of anxiety, bipolar depression, and schizophrenia and, while at an appointment at her mental health clinic, she had become extremely anxious and began to hyperventilate, ultimately passing out. This lead to her trip to our ER via the ambulance service. Her boyfriend, I was told, met her after she arrived.

Walking into Room 22, I found an anxious-appearing, thirty-ish, blond woman with extremely poor dentition. In fact, one of her front teeth was angled outward, barely hinged to her gums, and her tongue seemed to constantly caress this wayward tooth. Her blue eyes seemed out of focus, glazed-over even, probably a result of the valium given to her by the prehospital team. She fidgeted with her hands while her right foot rhythmically rubbed up and down her left shin. Her room smelled quite strongly of stale cigarette smoke.

Standing in the obscure corner of the treatment room was this patient's boyfriend. He was a small man, maybe 5'5", balding with a gathered ponytail. As I took his appearance in, he looked shyly down at his feet while pressing his hands together in front of him, prayer-like. Interestingly, he had no shirt on, just sandals and some worn jeans. His chest was sunken-in and fuzzy. His abandoned white t-shirt rested on the room's only counter top.

Between the two of them, I would have been quite content to spend the rest of my shift hanging out in their room, people-watching. I had a feeling that this interaction would be a memorable one.

The patient eyed me suspiciously as I approached her with my hand extended, ready to introduce myself. While in the middle of saying my name and explaining that I would be her doctor during this ER visit, I heard a loud exhalation followed by a hum originate from behind me, from the corner where the boyfriend stood. Quite frankly, it startled me.

I turned my head to look at the boyfriend, only to find him performing exaggerated motions of what I assumed to be some form of martial arts. After several moments of unorganized, flailing movements, he quit humming and folded his hands back together, bowing his head to me. Although I'm sure he didn't mean it to be, his actions and behavior were quite comical, and I fought myself from laughing out loud.

"Eddie," the patient shrieked, bringing my attention back to her, "cut that shit out. I ain't gonna watch your bogus karate while I'm lying here sick."

At this, Eddie began to hum loudly (again), keeping his head bowed, his hands folded, and his eyes closed. Suddenly, though, as if an "on" button had been pushed, he launched into another routine of air karate, randomly slicing and jabbing his hands while awkwardly kicking his feet outward. For his grand finale, he did a spin kick, almost tripping and falling to the ground on his landing. After collecting himself, he again folded his hands, bowed his head, and nodded to me before closing his eyes.

Funny, but I didn't feel threatened or in danger. I was, however, completely and totally mesmerized.

"Eddie," screamed the patient again, "if you do that one more time, I'm going to climb out of my bed and come over there to kick your ass. Got it?" Eddie apparently didn't, or else simply chose to ignore the patient's threats, remaining in his deep meditative state.

I tried to diffuse the situation. "Eddie," I said, smiling, "that's some really good stuff. Are you a professional?"

I had barely finished my question when the patient chimed in, laughing hysterically at my question. "Professional? You've got to be kidding!" she exclaimed, now choking on her words. "Hell, he's just making all of this shit up as he goes along."

"Well," I said, "his routine sure impressed the heck out of me." I was telling the truth, too. His routine was unlike any I had ever seen before.

With this, Eddie bowed forward again, I assume in thanks of my words.

"Bullshit," the patient said, emphatically, "he doesn't know shit about karate or anything else. Tell him, Eddie." I looked from the patient to Eddie and, after he remained silent in his own world, back to the patient again. "Oh, that's right, I forgot," she added, now sarcasm dripping from her words, "you don't talk during your karate sessions. How could I have forgotten?" She rolled her glazed eyes as she spoke.

Ouch. For her sake, I could only hope that Eddie would never try out his routine on her.

They became the couple of the moment in our ER. When they were alone in their room, there seemed to be a quietness, a calm, to the area. But the moment someone, anyone, walked into the room, the show began. A loud exhalation by Eddie. Humming. Eddie's routine of his remarkable abilities, capped off by his spin kick and landing. The bowing of his head and folding of his hands in conclusion. The girlfriend's free earful of screaming at Eddie for his ridiculousness. The exit of the person who entered.

The nurse walked out of Room 22, shaking her head and laughing after witnessing this same show that I did. So did the x-ray tech. And EKG tech. "Is this for real?" I heard several of our staff ask, after checking out the scene on their own.

"It is," I assured them.

After clearing the patient with a good physical exam and several tests, we quickly discharged her, if only to get Eddie out before he hurt someone or himself.

You can't buy a ticket for this stuff. And you surely can't make it up. The only thing you can do, really, is appreciate these distractions that come with a job in the ER. Well, that and closely inspect the room's corners to make sure there isn't a hidden camera trying to record your response for some reality TV show. That you've been set-up, somehow.

I look forward to the next distraction to arrive. Somehow, as sure as time keeps ticking, I know I won't be disappointed.

Hiiiiii-yaaaah!

As always, big thanks for reading. I hope you have a great, distracting weekend...

The Emaciated Shoulder

She paced protectively beside the hospital bed and its current patient, her grown son, the mother lioness protecting her vulnerable cub. In her hand, she gripped a small notepad, a pen snugly tucked into the coiled-wire binding. Her worried eyes peered through her small rectangular frames, suspiciously watching my arrival. Without blinking, she tucked her short gray bob behind her ears, readying their acuity to my words.

She was the mother of a son infected with HIV.

I focused on the patient. He was my age, in his early forties, with mussed up reddish-blond hair. His face wore the fatigue and ravages of his illness. His temples were sunken-in, his bluish eyes dull, his teeth fragile. Although he gave an effort to smile, his sagging skin weighed down the corners of his mouth. His body was tucked and bundled to his chin with several hospital blankets. To say that he was tired-appearing would have been an understatement.

While introducing myself, I approached him with my outstretched hand. After we shook, I turned to his mother and repeated myself. She took my hand warmly. After introductions, she opened up her notepad and asked me to spell my name, writing it on a fresh clean sheet near the pad's end. I could see most of the previous pages, worn and tattered, were filled with her busywork.

"Well, John," I said, leaning back into the room's counter, "what brought you here today that I can help you with?"

Without hesitating, John's mother began to talk. "Mother," John interrupted her, "I can tell the doctor my problems on my own." I hoped that she wouldn't take his abruptness personally, instead recognizing his attempts to cling to his independence. She quickly silenced herself, slightly embarrassed, as John began to share his story with me.

In the mid-90s, John discovered he was infected with HIV. Through his diligent compliance of lifestyle and medication, he maintained an almost non-existent viral load. He worked-out, he ate well, he enjoyed life to the fullest. Unfortunately, in the past few years, his body and illness became resistant to his previous successful approach and, suddenly, he was dealing with the ravages of advancing HIV. Weight-loss, skin issues, opportunistic infections--each and every new problem was another lost battle in his war. After his most recent diagnosis of HIV-associated lymphoma, he moved back in with his mother and began chemotherapy. He was struggling immensely from both the effects of chemotherapy and his disease.

"Look, Doc," he said, unwrapping his blankets and lifting up his gown to reveal a swollen abdomen and legs, multiple tiny, kinked, bluish-veins spotting his transparent skin, "I have so much edema now that I rely on pain medication to help with the discomfort." His predicament looked painful. In fact, this uncontrolled and worsening swelling had been the purpose of his ER visit.

We talked a little longer about his life, his illness, and his recent setbacks. And through this conversation, I noticed John's mother slowly sadden and withdraw to the chair in the corner of the room. My heart went out to her--I couldn't imagine her pain, having to watch one of her children slowly dwindle from this sometimes devastating and unforgiving illness. Her anguished face, just moments before alert, now wore a look of tattered defeat.

"John," I assured him, "let me finish my physical exam and then I will order up some medications to make you comfortable." His mother wrote in her notebook as I talked.

I continued with my examination, after closely inspecting his protuding abdomen and edematous legs. His exam was difficult. He seemed to have significant findings with every system of his body, despite his vital signs begin stable.

Finally, I asked John to sit up so that I could auscultate his lungs from a posterior approach. "Can you help me, doc?" he asked, holding out his right arm to me. "Sure, John," I answered, grabbing his hand with my right hand and placing my left on his shoulder.

And that's when it hit me. Hard. Just how terrible John's predicament was. Don't get me wrong, I fully understood just how much suffering he had been dealing with recently as his body seemed to succumb to his setbacks, but touching his right shoulder had made me catch my breath.

Under the grip of my left hand, while coaxing John's worn body to sit up, the bareness and emaciation of his right shoulder astounded me. He had absolutely no bulk to it--no muscle, no fat, no cushiony subcutaneous tissue that one typically has to their shoulder contour. Nothing. All I could feel was bone. His clavicle, his humeral head, and his shoulder blade all right there. It was remarkably sad. I shifted my fingers in a futile attempt to palpate any "meat" on his bones. There was none.

After successfully sitting John up, with his mother's help on his other side, I shifted his gown off his shoulder while listening to his lungs. My eyes fixated on his shoulder's thin, transparent skin barely accomodating the stretching from his protruding bones. I simply couldn't quit looking at the fragile shoulder, a dichotomy to John's enlarged, padded ascitic legs and abdomen. What a damn, awful disease.

I left John's room and ordered his work-up and medications. Soon after, he was much more comfortable.

A few minutes later, the secretary called me. "Dr. Jim," she said, "the mother of Room 28 is waiting at the nurses' station to talk to you." I finished with a chart and walked the hallway, finding the mother leaning into the station counter, flipping through her notepad. "Hello, maam," I said, approaching her, "I understand you wanted to talk to me?"

She looked up from her notepad, closing it, while her eyes settled on mine. "Yes, doctor, I do." She paused before continuing. "I just want to thank you for your kindness to John. I know you are just doing your job, per se, but there was something more from you, something I can't put a finger on, that made us both feel very good." She choked up as she spoke.

I grabbed her hands, one of which still held her precious notepad, and thanked her for her kind words. "My heart goes out to both of you," I continued, watching her tears progress to sobs, "what an awful disease for anybody to endure." She took her eyes from mine and looked at her feet. I thought of what to say next, the words coming quite easy. "John is so lucky and blessed to have a mother like you. You opened your home, you take notes, you accompany him to all of his appointments. We should all be so lucky." I paused before finishing. "And loved."

She looked at me again, her act of the protective mother lioness long-abandoned. "Thank you," she repeated before turning and walking back towards John's room.

We admitted John for further care.

Although I pride myself on my composure through all of the emergency department's chaos, I am only human and sometimes cannot shake a patient's affect on me. John was one such patient. It must have visibly shown, too, since several of my coworkers asked me if I was okay. "No," I answered honestly, "but I will be."

At the end of the day, we are all human. We are all in this world together. We are all united by the common threads of emotions. We are all prone to the extremes of happiness and sadness and everything between. We are all in need of compassion and kindness and love.

Especially, though, those who are suffering. And John was suffering. My greatest hope for John is that he may find much love, compassion, and kindness on his continued life journey.

There is no human being who deserves anything less.

As always, big thanks for reading.