A Mother's Cry

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

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

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

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

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

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

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

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

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

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

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

There would be no miracle.

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

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

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

A mother's cry.

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

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

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

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

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

ER Tupperware

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

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

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

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

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

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

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

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

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

"Oh, yes dear, here it is."

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

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

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

Nooooooooooooooo! I wanted to scream. And run fast.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Be Yourself and Change The World

be the change you wish to see in the world...gandhi

I have always found music and the written word to be very influential and powerful forms of expression in my life. I simply retrace the steps of my life and a book, a quote, a song, or an artist will appear on my mind's play reel. In fact, my collection of music and books deserves some credit for defining who I am as a person.

And every year, as it comes to an end, I reexamine the year and try to determine what I did well, what I failed miserably at, and what I can do to continue improving myself and that around me on this journey we call life. I can become quite introspective, really, and can always lean to another great song or quote or book that puts my thoughts into clearer perspective.

For this year's ending and the arrival of 2010, then, I thought it would be pretty cool to pick out just one quote, just one, that would signify my hopes for myself, my family and friends, and for you for this upcoming year.

You've already read the quote at the beginning. I thumbed through so many of my favorites and kept coming back to Gandhi and his wise words. In these uncertain times, where the landscapes of politics, of medicine, of war and international relations, of our amazing country and its current conflicts, of humanity, of everything, really, seem so tempermental and fragile, I wanted to remind myself of all that I can do to make this world a better place. Cliche, I know, but still heartfelt. Simply put, I wanted a quote that would help me direct my energy towards positivity and improvement.

My second goal for this post, however, was much harder. I challenged myself to pick out one song, a favorite or otherwise, that could serve as a reminder of that which is good in this world and that which is not good but could be potentially bettered by our individual actions. For that song, click here-- http://www.youtube.com/watch?v=-Lv4yfpwTds. I challenge you not to feel something when you watch this brilliant video's stills and hear these powerful lyrics.

The common thread of both Gandhi's great words and Garth's amazing song is simply that...change. We all possess the power and energy to create a better place for ourselves, for our family, for our friends, for our children...why are we wasting time?

I hope 2010 is your year. May you all edge a little closer towards attaining your personal goals and, along the way, changing our world for the better. And if you show the world a smile along the way, all the more good.

Have a Blessed and Happy New Year!
Jim

And now, an open challenge to you. Through the comments, share with your fellow readers and I one quote or one song that has inspired you in your life. Maybe we, too, can get some inspiration from your choice for the upcoming year. As always, thanks for reading...a new medical post on Monday, January 4th, 2010!

The Family Room

It's in every emergency department.

Empty, it's just another shell of a sparsely decorated hospital room, lacking vibe and energy.

But when you fill it with nervous, hopeful family members awaiting news of their critically-ill family member, it is transformed into a room that can barely contain every possible extreme of human emotion.

It is The Family Room.

So, you ask, why is this room known as The Family Room?

This is the room where the families of the most extremely sick patients are placed while the medical team uses every available effort in their medical arsenal to save a life. It's a place for family to be alone, to comfort themselves in the face of adversity. These may be families of trauma victims, heart attack victims, stroke victims, or any other critical illness. Because the family room is usually situated on the edge of the department, it is usually quieter, more calming, and private. A far cry from the commotion that usually accompanies the room in which resuscitating a patient is happening.

Don't be fooled, though. This is no ordinary room. Physically, it may look like any other decorated hospital room, with a few extra vases and boxes of tissues thrown in, but that's where the similarities end. It is a room that demands and deserves respect. It is a room that I imagine as my friend, absorbing and buffeting and protecting all within it from the swirls of anger and the clouds of desperation. Sometimes, just sometimes, the mood is joyful. More often than not, however, this is a room where dreadful news is delivered to a family not prepared for such news.

Our own family room is just as I described above. It sits in the corner of our department, nestled between our waiting room on one side and the entrance hallway to our department on the other. It's painted beige and coral with a flowery border at the top--comfort colors, I guess. Short shag navy rug. Two of the corners hold lamps, usually lit for better ambiance. The furniture consists of two love seats and two wing-backed chairs, a couple in dark blue floral patterns, the other in pink and coral. Slightly better quality fabric and stuffing than the standard hospital furniture, but not by much.

How do I know these details? It's amazing the small things that I notice when I'm trying to blink back my own tears in sharing a family's misery. Sometimes I'm transported back to tenth grade when I counted Christmas tree ornaments on our church tree during my grandfather's funeral, all in the hopes of distracting my impending tears. 157 ornaments on the tree closest to the Virgin Mary.

I rarely deliver news alone to a family waiting. Either the ER social worker or the supervising nurse accompany me, sometimes both. I wear my long, official white coat to respect the gravity of the situation.

Imagine that moment right before walking into the family room with bad news. I hesitate at the door, take a deep breath, and remember that my words and support will be paramount to the family. I open the door, usually to be greeted by several anxious family members either pacing or sitting well beyond the edge of their chairs. After introductions of myself and my team, I ask them how they are each related to the patient.

Then, the hard part follows. I sit close to the spouse or family. Sometimes, I am offered a hand to hold and I eagerly take it. If the patient has already died, I make it a point to not linger and share the news almost immediately. It is important to be blunt but heartfelt, using the words "dead," "expired," and "we did everything we could." It has been shown that a family needs to hear several variations of the word "dead" so that the news sinks through their despair. Reassurances are given that everything possible was done.

If the patient is still alive, I review with the family everything being done to save their loved one. I explain any prehospital treatment, what we are currently doing for the patient in the ER, and give the family a brief opportunity to ask questions. We sometimes need to review the patient's living will or DNR status and to what level efforts should be pursued. Family members may even be invited to witness the resuscitation.

Through all of this, I don't lose eye contact. I focus on each person in the room, letting my eyes say something different from my words. "I'm so sorry" is the most simple and heartfelt offering.

As an ER doctor, I have a protective shell around me that I can usually maintain. But in the family room, I am different. It is not rare for me to leave with tears in my eyes, and that does not shame me. It is my privilege and blessing, really, to accompany a family through some of their darkest moments. I appreciate their acceptance of my presence during their misery. Who am I to bear witness to their profound loss?

I have been told by several staff members that my greatest gift is how I interact in that family room. But, for whatever I bring to that room, it is but a feather compared to the weight I carry away from it each and every time I meet another family.

I am humbled by this part of my job. And respectful of the family room's role in our ER.


Thank you, as always, for reading. I am grateful...may your week go well. Next post will be Wednesday, December 23.

Meeting Candy

It was early morning, 4 a.m., the first time I met Candy. I had been on the job for about a year. Not having any idea what I was walking into, I slid Candy's curtain to the side to enter her treatment room. What I walked into was better than a shot of espresso.

Candy was running her fingers through her nurse's long blond hair.

"Honey, what I could do with your hair if you let me," she was saying to Mo, who was being an awfully good sport about it. I'm not sure I could let some stranger caress my scalp and hair in this manner.

"Yeah, yeah. Thanks, Candy," Mo answered, "that's what you told me last time, too."

So, Mo already knew Candy. I later learned that everyone who works in our ER knew Candy.

Candy, as it turns out, is a transgender male-to-female. These terms can be confusing, but transgender simply means that a person is living cross-gendered without sexual reassignment surgery.

Candy was known for handing out brutally honest fashion advice to our staff during her treatment time. I was only too happy to watch her interaction with Mo play out.

"Yes, honey," Candy continued as she held tight to Mo's hair, "you need to cut it a little shorter, get some highlights, and have it frame your face better."

"Um, okay, thanks Candy. I'll get right on that," Mo answered, still the good sport. "You do remember, though, that it's four in the morning, right? I'm sure not getting gussied up for an overnight shift."

"Ugghhh," Candy continued, ignoring Mo's defense, "and your split ends! Girlfriend, how could you? Go get me some scissors and I'll take care of this mess right now."

Mo extracted herself and her hair from Candy's grip. And then noticed me standing by the entrance.

"Oh, Candy, look who we have here! One of our doctors is waiting to see you." I do believe that Mo had just thrown me under the bus!

I stepped forward with my hand extended and introduced myself to Candy, feeling her eyes bore into my every fiber.

"Well, well, well," she said thoughtfully, "what do we have here?"

Nope. I'm first. Let me describe Candy to you. First, her outfit. She was in a white with black polka-dot mini-skirt with white tights, humongous red heels capping the ends of her lower extremities. Her shirt was sheer, white and black zebra-striped, hanging loosely over her skirt. She had a five o'clock shadow, a prominent Adam's apple, and thin scraggly hair that hung limply to her shoulders. Her makeup was very loud, despite the facial contusions and abrasions from the assault that brought her to us this night. She was sitting upright comfortably in her cot, one leg bent under her thin frame.

Okay, now your turn, Candy.

"Hair, good. Body, good. Nice eyes. Nice lips. Wow, look at those cheekbones!" Yes, I was really liking this Candy character, but made a mental note to myself that I should probably check her vision on this visit. Mo, who I thought was leaving the room, decided to hover to see what advice I would be receiving. She was leaning against the wall, arms crossed, smirking at me, thoroughly enjoying me being in the hot seat. She must have known it was going to get ugly soon.

"Wait. Oh yes," Candy exclaimed, pointing at my mouth, "look at that tooth!"

Shoot. I can't believe she narrowed in on my tooth. I think I have pretty nice teeth, barring one slightly off-colored one on my right upper front. And even this tooth isn't so bad. I had gotten knocked in the mouth playing basketball a few years ago, resulting in this tooth turning slightly off-white. My dentist had thought it would die and I would ultimately need to get it pulled, posted, and replaced. However, the darn thing didn't die off completely, and now I was stuck with a half-living tooth. Kind of like tooth purgatory.

Eventually, I knew I would have to get the tooth addressed, but it didn't bother me, and you had to look really hard to see it. At least I thought so. Thanks, Candy, for looking hard.

"Yeah, sugar," Candy continued, Mo now in a full-bloom smile, "get that thing taken care of, would you? Jesus H. Christ! Why would you walk around looking like that?"

How can you not smile? I started laughing, but Candy was just getting warmed up.

"Honey, can you spell manicure? Because you need one bad. Look at those bitten-up nails!"

I looked down at my hands, appreciating my nails, actually thinking that they looked pretty good to me. Now, though, I was feeling the need to apologize. "I'm sorry, Candy, I can't help it."

"Well, help it. You're a doctor, right? There's no reason you shouldn't be getting yourself some manicures (she said it like "man-neeeee-cures") and pedicures." She shuddered and continued. "I can only imagine what your feet look like!"

"Do you want to see them, Candy?" I asked, now enjoying this immensely. I had on hospital clogs, it would be easy to accommodate her.

"Ugghhh," she said, "find somebody else with a foot fetish. That ain't me, honey."

Ouch! She was tough. Clinton and Stacey from "What Not To Wear" held nothing on Candy.

Well, I'm happy to say that Candy turned out alright that night. Just some bumps and bruises. Interestingly, she had been working a corner in one of our less-desirable neighborhoods and had been picked up by four college boys for her services (this was her version). Less than a mile later, when they found out her true gender, they assaulted her and threw her out of their barely stopped car.

I'd like to think it wasn't her gender that bothered them as much as her fashion critiques. Can you even imagine? "Honey," she'd start out as she bent to get into the car, "what's up with all those pimples on your face? And you," she'd continue, looking at another one, "what's up with that greasy haircut you're sporting?" Yep, out the door she went.

I've seen Candy in the ER a few more times since then and always enjoy her wisdom and our conversations. Most recently, I was out to a dinner party at a local restaurant that was having a simultaneous gathering of transgender/transsexual localites. As my party followed the waitress to our table, we passed the gathering and there was Candy, sitting at a table with three other members, laughing and smiling and being quite animated.

Her hair is still scraggly. My tooth still isn't fixed.

You go, Candy!

Thanks for reading, as always, and have a great weekend. Next post will be Monday, December 21.

Please Make Her Comfortable

During a recent shift, I was witness to a family's struggle and courage in facing their mother's illness.

Their mother, age 96, had broken her hip a week prior. Because of significant health and social issues, the family and patient concurred with the orthopedic team that it wouldn't be wise to operate.

The patient was sent to a local rehabilitation facility. Prior to the transfer, the patient and her family had discussed at length a living will and to what degree heroics were to be performed in the event of a medical emergency. They opted for no intervention whatsoever--no CPR, no medical testing, no antibiotics, no intubation, no resuscitation efforts. Basically, they wanted only comfort measures for pain and anxiety relief.

A very difficult decision, of course.

Within a week of being transferred to the rehabilitation facility, unfortunately, the patient started to have a cough. Soon after, she began to have a harder time breathing.

The facility, despite their best efforts, eventually sent the patient to our ER when it was discovered that she had very low oxygenation levels. They were not equipped for this.

I walked into this patient's room and after introducing myself to her and meeting her family, consisting of two sons, a daughter, and a daughter-in-law, I began to sort out what I could do to help this patient and her family.

On exam, this patient was obviously struggling and appeared to have pneumonia. She had a fever and very low oxygen levels. When I listened to her lungs with my stethoscope, she had classic findings for infection. She was starting to get very fatigued and was not as mentally alert as her family knew her to be.

Normally, with a patient in this situation, we are very aggressive. She would have been intubated and received three, sometimes four, antibiotics intravenously. She would have gotten a very thorough workup that would have included x-rays, blood work, and possibly a CT scan of her chest to make sure she didn't have a blood clot in her lungs, a possible consequence of her hip fracture.

However, upon review of the patient's paperwork sent from the rehab facility and the family's personal request at her bedside, we did none of this. We respected their wishes and this patient's living will.

I did order this patient some low doses of morphine and valium which made her more comfortable. The family was quite appreciative. Although the patient was critically ill, she was not yet near her end. After another discussion with the family, we came to a mutual decision to admit their mother to the hospital and continue her comfort care. The family was uncomfortable taking the patient home with her hip fracture. I called their family doctor and he graciously came in and handled the admission.

During the admission, I was stopped by the daughter in the hallway. She was very tearful, as any of us would be, and second-guessing their family decision of no heroics.

"Mom lead an amazing life. I know it's time...but this is so hard to watch. I feel like we should be doing something more."

I put my arm around her. "God Bless your family," I said.

"Well," she sighed, "this is how Mom wanted it, so I guess we have to respect her decision."

I nodded at her words. I have several times witnessed these decisions reversed, but it seemed that this family was not going to follow that route.

The daughter, though, still needed to reconcile the decision with her anguish.

"What would you do?" she asked me suddenly.

Her question caught me off-guard. It was a question that I couldn't possibly answer for her. Her family's decision was made after weighing many specific circumstances, circumstances that I knew nothing about. So no, I couldn't give her a direct answer.

I explained this to her. "But," I continued, "does the rest of your family still support this decision?"

"Yes," she said, "and I think I do, too."

I decided to open up to her. I shared with her how several years ago, my beautiful mother, after courageously fighting and beating back leukemia for several years, decided that it was time to stop. It had been an extremely difficult decision, fully supported by my father, my six siblings, and myself. Because Mom knew. And despite all the setbacks, her faith had never wavered and her spirit had remained unconquerable. She had fought the fight and had benefited from that fight. But, unfortunately, her disease had come back with a vengeance. After several failed attempts to reenter remission, she chose to stop all further treatments and go home to spend her remaining days enveloped in our love.

"So, yes," I said, "it was very hard to watch. But it was the right thing for Mom and our family."

Now, the daughter nodded at my words. After a moment or two, she spoke. "Mom did have an amazing life, but yes, it is time."

I squeezed her hand in support and she leaned in and gave me a hug.

"Thank you," she said as we parted.

No, I thought to myself as I walked away remembering my mother's beautiful spirit, thank you.

Grim Google

I walked into one of our big trauma rooms to see a medical patient who had been placed there because of overflow.

After introducing myself to the patient and his very pregnant companion, I asked him what brought him to our ER.

His chief complaint was as big as the room.

"Doctor, I'm dying of colon cancer."

His exact words. And as he spoke, his words were accompanied by his companion's eye-rolling.

I think now is a good time to describe the patient. He was 25. Yes, 25. He looked very nervous but otherwise normal appearing, short brown hair, 6'0", 220 lbs. Pure muscle. I think he ate a side of beef for lunch every day.

"Why do you think that?" I asked, suspicious I might already know. "Do you have a family history of colon cancer?"

"Well, no. I don't think anyone in my family ever had it--until now. But," he hesitated, choking back his emotions, "every time I go to the bathroom, you know, from behind, I see blood in the toilet and on the tissue."

"Bright red?" I asked. "Yeah," he replied.

What twisted human nature compels each of us to look in the toilet when we are done using it? I am reminded, though, of reading that if you put just one ml of blood in a toilet bowl, most people would overestimate how much blood they were actually seeing. I doubt this patient was an exception.

His concern for his health was very real. And although he was not your average demographics for a colon cancer patient, he still warranted a thorough physical exam and blood work.

"So, every time you have a bowel movement, you see blood?"

"Yes, sir, for the last two days."

"Any pain?" I asked.

"Not, really," he replied, "just a little itching and discomfort."

"Have you ever been constipated?"

"Well, yeah, I have," he answered.

"And obviously, you work out a lot. Do you do a lot of sit-ups? Crunches? Core workout?"

"Yeah, how did you know?" Don't give me too much credit--like I said, the patient was pure muscle. A four-pack wasn't a far stretch of the imagination. However, the abdominal strain and pressure from those exercises could be a contributing factor to his problem.

My next question surprised him. "Do you have internet access?"

"What?" he asked, glancing at his companion.

"Well, did you 'Google' your symptoms?" I asked with sincerity.

His female companion jumped in and answered for him. "Yeah, he did. Yesterday. And since then that's all I've heard about--'I'm dying,' 'I'm not gonna see my kid be born,' 'Why me?'."

On a roll, she took a deep breath and continued. "I have to be honest. I'm 37 weeks pregnant and I have to listen to him whine? I don't think so--it should be the other way around, right? Just tell him he's okay, Doctor, and we'll get out of here."

She finished speaking, looked at the patient, and gave him another dismissive eye-roll.

I loved it. I was going to ask her to give me an eye-rolling lesson when we were done. Twenty times a day, easy, I could be using that talent. And who knows, maybe for extra credit, she could teach me to bob my head, hold up my defiant index finger, and drawl out, all with a little attitude, "Mmmm hmmmm". High-pitched, of course.

After finishing the patient's history, we moved on to his exam. I reviewed the patient's vital signs with him--all good. I performed a very thorough physical exam--all good. This included a pain-free abdominal exam. I reviewed the patient's blood work results as ordered from triage--all good. Again, this included a normal CBC (no signs of anemia). I saved the best for last.

"I'm going to need to do a rectal exam to see exactly what's going on."

This was the moment when I knew this patient seriously did think he was dying. He had no objections to a rectal exam. There are very few reasons that a 25 y.o. male wouldn't object to a medical rectal exam. Very few. So his willingness for this exam spoke volumes of how ill he thought he was.

I performed the exam. And, I'm happy to report, it was in his favor--no blood, no pain (a touch of discomfort, at most), and no unusual findings.

Well, except for one. He had two small, inflamed hemorrhoids that were the most likely source of his bleeding.

Ugh! More near-death hemorrhoids! God's joke on the human race, they are.

I explained in detail to this patient what hemorrhoids are. I explained that we treat them with sitz baths, suppositories ("you mean I gotta put one up my ass?"), creams, and stool softeners. If his symptoms continued, I explained, his family doctor may change treatment, order a colonoscopy or CT scan, or have him see a colo-rectal specialist.

"An ass doctor?" he asked. "They really exist?" Oh yes, Virginia, there is a Santa Clause. And to you, buddy, yes--ass doctors do exist. They're the ones wearing heavy cologne along with plastic face shields and cover-up procedure gowns.

During this conversation, out of the corner of my eye, I saw this patient's girlfriend trying to hold back her smile and failing miserably. And yes, she was rolling her eyes at him. Again.

I liked her. And I liked this patient. In all seriousness, his worries could have been any of ours.

Finally, after my best reassurances that he was not dying of colon cancer, the patient finally relaxed and joked a little about "his new little buddies down there." I actually think he was going to name them.

I pulled out a blank sheet of paper and wrote on it. H.E.M.O.R.R.H.O.I.D.S.

I handed it to him.

"What's this?" he asked, taking the note and reading it aloud.

"Your next Google search," I answered, smiling.

His companion laughed out loud and rolled her eyes. Again. Only this time, they were directed at me.


After the recent news report of how people are bypassing their doctors and relying on search engines to make self-diagnoses of their symptoms, I decided to flip that coin. Thanks for reading, as always. Next post will be Wednesday, December 9.

Big Stuff, Big Words

I have become quite good at reading people within the first few minutes of meeting them. It comes with the job, actually. Thirty patients (and their families) a shift and rest assured, after 16 years in the ER, I have been exposed to many different personalities. I am a poker player of sorts, keeping my personal feelings hidden behind my smile while I measure up the alpha male, the needy daughter, and the nosy neighbor, all begging for more attention than the actual patient.

With all the family dynamics swirling around a patient's room, it is important for me to swiftly figure out the who, what, when, where and how so that I can attend to the patient's illness. You would be amazed how just one person can affect the entire ER experience, either positively or negatively.

And in Room 12, that one person happened to be a father of two boy, ages 10 and 12.

I walked into the room to find the ten year-old boy lying on the treatment cot, his forearm bent in the shape of an "L", obviously broken. The nurse was starting an IV to give him some morphine. Sitting in the corner of the room was this patient's twelve year-old brother, his face tear-stained and agonized, looking as hurt if not more than his younger brother. Pacing nervously alongside the patient's cot was their father.

Nothing really too much out of the ordinary.

Except the tension in the room was explosive. Something wasn't adding up.

And then Dad opened his mouth to speak to the son in the corner and it all made sense.

"I hope you're happy, damn it. Just look at your brother's arm. What the hell is wrong with you?"

Whoa, back up here. As the nurse was starting the IV, she looked up in the middle of Dad's rant to give me "the look," a warning that all was not good in this room. I interrupted Dad to introduce myself.

Dad bit his tongue during the introduction, but as soon as I asked what happened, Dad jumped right back in where he left off.

"He's always causing problems...pain in my ass...doesn't care about anyone but himself..."

His rant against his older son continued and the more he spoke, the more his son's shoulders shook from silent sobbing. The younger son with the broken arm sat silent, his pained expression speaking volumes.

The story played out that the two brothers were in the front yard playing soccer. Soon after, bored from kicking the ball, they started tackling one another. It was then that the older brother tackled his younger brother and, in the midst of the tackle, broke his younger brother's arm.

An accident, pure and simple. I could see it, the nurse could see it, and I know as you read this you see it.

Dad didn't see it. And I was finding it difficult to give him some benefit of doubt during his family's stressful crisis.

After several more hurtful insults, I had had enough.

"Come outside into the hallway with me, Dad. We need to talk."

In the hallway, Dad tried to start all over again with how his older son was a "problem child" and always created conflict in their family, but I halted him. Rarely have I met a "problem child" that didn't have a "problem adult" in his life.

I took a deep breath, not wanting to be anything but professional during this conversation. Deep down, though, my insides were screaming. I wanted to grab this guy and shake him, make him take an outside look at what he was doing to his older son.

"Listen, sir, I understand you're upset. But you have the power to make this a better experience for both of your sons right now. As things stand, your words are only making the situation worse."

"But damn it, he's got..."

I stopped him. "I've heard you already. And so has the nurse. And so have both of your sons. What I am asking of you is to go back in the room, find something nice to say to your older son, and then sit on the cot with your younger son and help him get through this visit. I don't want any more negative talk from you while we help your family, okay?"

I stared at him and he was silent. "Okay?" I asked again, more loudly.

He shook his head yes.

We walked back into the room. I looked at Dad. He was ready to talk to the son in the corner.

"See," the father said, "now you got me in trouble. I hope you're happy with yourself."

I was shocked. And angry. And frustrated with this man who, I felt, was clearly not appreciating the blessings of having children.

He looked at my face and, for once, I failed to hide my emotions. He did not say another word while we fixed his son's fracture.

After successfully reducing the broken arm, we sent the younger son to X-Ray for post-reduction films. We had Dad accompany him. I hung back with the older son.

Over popsicles, we got better acquainted. He shared that his dad said "a lot of mean things" to him. Words "that hurt sometimes." He assured me, though, that this was the extent of his father's unkindness. "He treats me okay most of the time," he added.

"You know this isn't your fault, right?"

He thought I meant his brother's broken arm. "But it is. I shouldn't have tackled him so hard."

"No, but that's not your fault, either. Things like this happen between brothers. I'm talking about the angry words you hear from your dad. Some parents love their kids very much but just don't know how to pick the right words to tell them."

He nodded while he looked down at his sneakers. I continued. "I have no doubt that you are a good son and brother." We talked a few more minutes that culminated with a smile from him.

Dad had calmed down before his son was discharged. Prior to leaving, I had an instinct that he wanted to say something to me--something apologetic, by his expression. But he didn't. A part of me, though, could only hope that he had looked in the mirror and didn't like what he had seen.

The nurse planned to arrange follow-up with this family.

Sometimes, despite our best efforts and resources in the ER, life and fate will continue to play out the way they were destined to.

Darn it all.


Next post will be Friday, December 4. See you then...and hats off to the caring nurse who provided more than just good medical care for this family.

The Saddest Night

Recently, my thirteen year-old daughter did a school report on my job, focusing on the emergency room setting and what my role within all the chaos was. While we were in the emergency room touring and taking anonymous pictures for her power-point presentation, she found a new appreciation for what I did when a young knifing victim was brought in by ambulance.

Because my only purpose that day was to help her collect information and take pictures, I didn't go into the patient's room and obviously shielded her from any gore. She was mesmerized by all the commotion. We waited around until we received word that the eighteen year-old would be okay. I could see her exhale at the news and, in a moment of tenderness, look at me with saddened eyes. I could not have given her a clearer perspective of what I am sometimes called to treat.

During the drive home, she was quiet and affected. Slowly, though, I was able to pull her from her private thoughts and talk aloud about what she had seen.

"Dad," she asked thoughtfully, "what was the saddest patient you ever took care of?"

"Oh, honey," I said, "you don't really want to know that, do you?"

After a little more convincing, she had me scanning my brain for my most haunting "sad" cases, which I could count on way too many hands. In an odd way, I think as an ER doc you build a protective wall and tuck your memorable cases neatly behind it, adding it to the "sad" list, the "happy" list, the "traumatic" list, the "old-people" list, the "funny" list, the "you're never going to believe it" list--endless lists of cases that touch your essence.

Look at me, even now, protecting myself by calling these encounters "cases" and not "patients." Shame on me. But trust me, it's a big, big wall.

Anyway, her sweet voice brought me back to reality. "Please, Dad. Just tell me."

I decided to face down her request. She was thirteen and she was persistent. So I broke and shared with her one of my most heart-wrenching moments.

It had been one of those long, endless overnight shifts early in my career. There had been no time to breathe as one critical patient after another continued to present to the ER, even up until 6 a.m. We had just received word that an elderly gentleman who had presented to our ER with low blood pressure and severe abdominal pain (a quickly made diagnosis of a ruptured abdominal aortic aneurysm) had died "on the table" during surgery, this after transfusing him with six units of blood while waiting for the cardiovascular team to arrive.

My nursing staff and I were beaten up, unable to shake this moment of our failed heroics.

"Well, this night sure can't get any worse," Lisa, one of our best nurses, said. She should have known better. She had barely finished speaking before the prehospital radio sounded off.

An ambulance was bringing us a SIDS (sudden infant death syndrome) baby just discovered by her parents.

Our team was sullen and quiet as we waited in one of our resuscitation rooms for the ambulance's arrival. Within minutes, the paramedics rushed through the door carrying a lifeless little body, about eight months or so. Following them were two young, frantic parents carrying another living child of the same age. The SIDS baby was a twin. As our social worker took the living baby from dad's arms, my medical team and myself urgently examined the tiny patient lying on the cot, allowing the parents to stay in the room with us.

Sadly, it was too late. Death had visited this child hours before and we had no arsenal to reverse this devastating event. We later had learned through the paramedics that this family of four shared one mattress, tucked in the corner of a rundown studio apartment. When mom had rolled over during the night, she had discovered that her baby "felt cold."

When you "pronounce" a patient (declare their death and exact time of death) in the emergency room, at least two phone calls must be made--to the coroner, in case an investigation or autopsy is necessary, and to the family doctor. These are "must-dos" for me professionally, but are hardly the things I feel are necessary to begin a family's healing.

We sat the parents in rocking chairs and gave mom her little baby. We had the social worker bring in the other child and handed her to dad. I stood in the corner of the resuscitation room, lights dimmed, absorbing two parents with two children, one living and one dead, rocking slowly back and forth, enveloped in their grief. I had held their hands, shared their misery (as a parent, I was witnessing one of the most earth-shattering nightmares any parent could have), and had chosen my useless, sympathetic words carefully. There was but one thing left to do.

I went and found Lisa and asked her if we could please clip a few strands of the deceased infant's hair to give to the family. This was something I had learned from our pediatric trauma center during residency. It can be a vital part of a family's healing process. The hair was tangible, something to hold when a memory isn't sufficient, something to smell, something to touch with trembling fingers, something to press against a broken heart. If not now, a day would come when the family would be thankful to have this possession.

As Lisa and I quietly reentered the room, I will never, ever forget the scene that awaited us.

Mom was still holding the deceased twin while the living twin sat in dad's lap, her grasp within reach of her twin sister. Her hand was on her deceased sister's head, gently patting it, quietly twisting the dark strands around her fingers, almost as if urging her sister to wake up and play. The potency of this action--the playful innocence of her little hand wrapped in her dead sibling's hair--was a moment of both stunning serenity and infinite devastation that I will carry with me always.

I finished the story and looked over at my daughter, her big brown eyes fixed on my face.

"Dad," she asked quietly, "did you cry?"

"Honey," I said to her, choking up, "I still do."




My next post will be Wednesday, November 25. I promise it will light-hearted...