To Feed Or Not To Feed

I walked into Room 22 to find a very interesting patient who presented to our ER with complaints of abdominal pain and associated nausea and vomiting.

The patient sat on her cot with her pant legs rolled up above her knees, refusing, according to her nurse, Gwen, to put on a treatment gown. Her left leg hung in the air, her ankle crossed over the knee of her right leg. Her feet were bare and dirty. Nestled in the crook of her left hip, resting on the cot, was a worn bible, opened to the first page of The Book of Genesis. As Gwen was trying to obtain a better history, the patient was obviously ignoring her, giving all of her attention to the her bible.

Or so I thought. I walked into the room and introduced myself to this patient. She briefly flit her eyes up at me several times. Finally, after gaining her approval, she steadied her gaze on me and extended her hand. We shook. Gwen, meanwhile, seemed to have gotten an even colder-shoulder than before, as the patient turned her back on her to give me her undivided attention.

With her gaze on me, I absorbed this patient's features. She had dirty-blond hair pulled away from her face. Long, thready, frazzled dreadlocks started at the crown of her head and were gathered behind in a bulky ponytail. Her eyes were piercing blue and, quite honestly, unsettling. High cheekbones, clear skin smudged with some dirt, and thin narrow lips accented her prominent nose. Her hemp clothes were worn and faded, tattered almost, and, like her skin and bare feet, smudged with dirt.

She was in her early twenties.

"Hello, Rose," I said with a warm smile, "what brought you to our ER today?"

Her voice was husky yet quiet. "I ate some fish yesterday and I think it was rotten." She went on to explain that she, at the time, wondered if the fish was "not good" because it had "a funny, pink color to it, like salmon. And" she confidently added, "I know my fish--it wasn't salmon."

"Where did you eat this fish?" I asked her. She blatantly ignored my question, which made me wonder if it was from a clean site or a garbage can.

She continued, however, to explain that since eating the fish, she had vomited three times later that evening and once this morning, prior to coming to our ER. "I feel better now, though," she said. She hesitated before continuing. "I'm feeling well enough for a cup of coffee and a sandwich, even."

And there we go--the main reason why Rose was in our ER. She was hungry.

It turned out that she had already asked Gwen for some food and coffee and Gwen had put her on hold. "Rose," Gwen had explained, "we need the doctor to see you and get some of your blood results back before we can give you anything to eat." That explained the snubbing of Gwen. I had to smile, since Gwen was an extremely compassionate, cognizant nurse.

"Rose," I said, looking her in the eyes, "is this the real reason you came to our ER? Are you hungry?"

Rose stared at me as I visualized the cog wheels in her brain churning. Finally, she spoke. "Um," she started, "I came here because I ate some bad fish. But now I feel better. So yeah, I guess so. I was hoping, I guess, that you guys would be able to give me something to eat." As she spoke, she held my gaze. I appreciated her efforts at honesty.

Gwen looked at me with her knowing smile. I looked back to Rose. "Rose," I said, "I need to perform an exam and, since the triage nurse ordered some blood work, I need to review your results and make sure they are all good before we can let you eat. You understand this, right?"

Rose nodded her approval. With Gwen at bedside, I performed a thorough exam of Rose. Everything checked out well. Specifically, she had no abdominal pain on exam. I walked out of Rose's room and reviewed her stable vital signs and her stable blood work on my computer station.

As far as I was concerned, we could now feed Rose.

Which presents the dilemma we sometimes face in the ER. Frequently, we get unfortunate patients that present for reasons other than emergent medical care. It might be a drunk, homeless person, refused for the night by the homeless shelter for his alcohol abuse, who is looking for a place to sleep. It could be a patient who is looking for free prescription vouchers to get his medications renewed. And, in Rose's case, it could be a person simply looking for a meal, a cup of coffee, a warm blanket, or some companionship.

As far as I am concerned, we should extend ourselves, as long as it doesn't take away from providing emergency care to those in dire need. And, as long as our efforts are appreciated. Is a bed free? Go ahead and lie down for a short while. You're hungry? Let's see if we have any pudding or turkey sandwiches for you. Your cold? Here is an extra blanket for you from our trauma blanket warmer. Free vouchers? Well, I see those cigarettes and iPhone poking from your pocket, so we're not going to be able to help you with that tonight. Sorry, but I can only go so far.

With these acts of kindnesses, though, I understand the flip of this coin. You set yourself, your ER, and your staff up for repeat visits by these patients who come to expect these kindnesses every time. And, as a result, they keep coming back and coming back and coming back. Sometimes clogging the system. Eventually, these kind acts are no longer appreciated but, rather, demanded. We've all seen this happen. And it's at this moment when our thought process changes.

With Rose, she had only been to our ER once before so, after Gwen and I agreed, she received a full meal, some warm coffee, some foot slip-ons, and a social service consult prior to being discharged. She was gracious for everything, which helps the cause. And it was our pleasure, really.

However, there are repeat offenders whose visits to our ER number in the fifties and hundreds. Seriously. And, unfortunately, these handfuls of patients are the ones who can ruin it for the others.

The ER presents many moments of internal struggle where, as an individual working there, you have to review and examine your moral fiber and essence. This is one of those struggles for me. I wish we could accommodate every single person's needs, but that is unrealistic. So, I'll just continue to provide on an individual basis. And, hopefully, these kind acts will be appreciated and not abused and demanded.

To feed or not to feed...that is the question.

Happy Monday. I'm eager to hear your thoughts on this post... As always, big thanks for reading. Next post will be Wednesday, May 26th. See you then...

The Golden Smile

A few years back, I met a very endearing patient. Sweet and likable. Polite and respectful. The interaction was thoroughly enjoyable, fun even, and by the time I had finished treating her in our ER, Miss Claire had wormed her way onto my favorite patient list. Maybe even into my heart.

I had walked into her treatment room not quite knowing what to expect. By the triage report, Miss Claire seemed a little off-center. She had complaints of some shortness of breath for the past two weeks. And she smoked. However, she didn't have any complaints of a recent cough or cold and denied any chest pain or recent trauma. She believed, according to her nurse's charting, that "my next-door neighbors are spraying fumes through the wall that are making me sick." Interestingly, she did have a psychiatric history, although the nurse didn't specify.

Armed with this knowledge, I slid the glass door to her treatment room open, pushing the privacy curtain aside as I stepped in. And as I did, I was greeted by one of the biggest, most genuine smiles I think I have ever seen.

Miss Claire was sitting upright in her cot, alone, just waiting for someone, anyone, to walk into her room. She didn't have a book or magazine. Her TV wasn't turned on. She was just patiently and good-naturedly waiting. And that anyone who walked in? Well, lucky me.

I held out my hand as I approached this smiling patient, feeling a very nice vibe to the room.

"Hello, Miss Claire. My name is Doctor Jim and I'll be taking care of you today."

"Hello, Dr. Jim. I'm sure glad to meet you, sir," she replied, taking my extended hand into the both of hers, warm and soft, and squeezing it gently. Still smiling.

I had a chance to take in her unique appearance as we made small talk. For being on the young side of fifty, Miss Claire certainly didn't look her age. She had smooth, unwrinkled skin, barring the furrowed creases at her lips' edges. Her laugh lines. She had dreadlocks, thickly-braided and black, pulled back from her face and tied in a loose bundle at her neck's nape. She had high cheekbones that danced and small ears that wiggled with each facial expression.

It was hard to pinpoint the exact charm of her warm smile. Her eyes, richly-browned chestnuts, were alive and sincere to the moment. Her smile itself, well, it encompassed the bulk of her face's frame. Full lips outlined her white, rectangled teeth. And the topper? She had a gold-plated incisor that sparkled, with just the slightest head movement, from the overhead lights.

Her golden smile.

I sat on the available bedside stool and got down to business. "Miss Claire," I said, "I read the nurse's notes about what brought you here today. Do you mind if I ask you a few more questions?"

"I would be glad to answer any of your questions, Dr. Jim."

I reviewed her complaints, listening to her patiently explain, again, that she was having shortness of breath, for over two weeks, that she felt was most likely due to her neighbors infiltrating her walls with fumes. "What kind of fumes, maam?" I asked. "Oh, I don't know," she said, not losing her smile, "I guess 'carvon mitoxide' or something like that. And sometimes the fumes smell like frying bacon."

On review, she didn't have a fever. Or a cold. Or chest pain. Or any calf trauma (a cause of lower extremity blood clots that can occasionally travel to the lungs). Nothing suspicious, really, that would raise my hackles to think she might have a serious illness.

"And maam," I continued, "may I ask you about your mental history?"

"Of course you can, Dr. Jim." She had a history of bipolar depression. And sometimes, she admitted, she heard voices. "But I'm on medicine for all of that," she assured me. She was not having any suicidal or homicidal ideations. She had never tried to harm herself or anyone else. She did have a counselor and did meet with him on a regular basis. With all of my questions, she proudly faced them head-on. And with a beguiling pleasantness.

She had even gone so far as to have her apartment supervisor come to her residence and "check things out." Everything had checked out fine, including a normal "carvon mitoxide" reading.

I really liked this woman. And to her credit, she was easy to like.

I proceeded with my exam. Great vital signs. Good pulse-ox. A completely normal exam, including regular heart sounds and clear aerations of her lungs on auscultation. Given Miss Claire's age and waiting time, her nurse had ordered an EKG, a CXR, a d-dimer (a nonspecific blood test that, if positive, increases suspicion for a blood clot), and a carbon monoxide level. Ultimately, the results all returned favorably.

At one point, after I had reviewed Miss Claire's EKG and CXR, I stopped in her room to explain those results and let her know that her blood tests should be returning shortly.

She was still smiling.

I decided to slow down for a few minutes and, after walking to her bedside, sat down on the vacant stool. "You know, Miss Claire," I said, relaxing, "you have one of the most welcoming and kind smiles I think I have ever seen. What a great way for you to greet the world."

"Thank you, Dr. Jim. There ain't no sense in showing the world anything else, now, is there?" I nodded my agreement at this wise woman. "And," she continued, "you seem to be smiling as much as me, sir." I thanked her back, flattered by her genuine compliment, before we continued on and had ourselves a fine ten-minute conversation.

After her normal blood work returned, I had two conversations on Miss Claire's behalf. One, to her counselor, who, upon learning I was calling on behalf of Miss Claire, said "Isn't she the sweetest lady?" Her counselor was going to follow up with her the next morning. The second call was to Miss Claire's family doctor. Although I think Miss Claire's complaints were based on a mild paranoia, I wanted her family doctor to follow her closely in the event she needed any further, non-emergent work-up, including allergy testing. The office nurse gave me a follow-up appointment, ending our conversation with "Isn't she a pleasure?" She certainly was that.

I entered Miss Claire's room one last time, explaining to her the disposition and follow-up plan. I assured her that I was quite pleased with her test results. "If you're pleased, then I'm pleased, Dr. Jim."

"I am pleased, Miss Claire," I replied, before hesitantly continuing. "It was a pleasure meeting you today, maam. A privilege, really. And whatever you do, don't ever lose that smile of yours."

After our goodbyes, Miss Claire shuffled down the ER hallway toward the exit, her discharge papers in hand. I lingered in the hallway, watching her leave, appreciating her warm greeting to every person she passed, whether it was a faint "hello" or a friendly nod of her head. Or both. I smiled to myself, watching the wonders of her kindness in action.

What a beautiful individual.

Golden smile and all.

As always, big thanks for reading. A special thanks to Dr. Kevin, from KevinMD.com, for kindly requesting and reposting one of my earlier works yesterday. I am honored. Have a great weekend. See you Monday, May 3...

Another Notch In The ER Cot

I know there is a "mile-high" club for airplane travelers who are, to say the least, adventurous and daring. But is there a club I don't know about that involves an ER treatment room and the flimsy cot in it?

The other day, during another busy shift, I walked into Room 31, ready to treat a new patient. What I walked into, however, caught me off-guard. In fact, I think I blushed. And after everything I've seen and treated in the ER over these past years, to get me to blush is a major accomplishment.

Lying in the cot, covered by a thin papery sheet, was a very "loving", shall we say, young couple. They were in the midst of some passionate maneuvering--four tangled arms wrapped around one another, shirts rumpled and pulled up, shoes kicked off to the side of the cot, and mussed up hair. My timing couldn't have been better. Lucky me. A front row ticket to an amateur peep show.

Maybe in my twenties, I would have been more enamoured about this situation but, to be honest, I'm in my early forties now--the only thing I felt was a little frustration. And, guessing from my warm cheeks, embarrassment. Well, some wonderment too--who in their right mind looks around an emergency treatment room and gets "in the mood?" Is it the gowns? At least this explained why the room curtain and sliding door were closed.

I cleared my throat and skipped my usual greeting. 'What's going on in here?" I asked, trying to sound like my father, stern and all-knowing.

Surprised, the girl sat up. "Oh my gosh," she giggled, hardly embarrassed, "we got a little bored after waiting for so long to be seen."

"I'll tell you what. I'm going to step out of this room for one minute, and when I come back in, I expect you to both be presentable. If not, you will both be escorted out of the ER by security. Do I make myself clear?"

They both nodded their heads at me, the middle-aged doctor who interrupted their cheap thrills.

I walked back to the nurses' station shaking my head. I wasn't buying the bored routine. Each patient room has its own television, complete with a remote control and more cable channels than I get at home. Each room also has a filled magazine rack and its own telephone for local calls. We even have available wireless internet if someone is so inclined to bring in their laptop with them. Outside of a pillow, a warm blanket, and a two-day old turkey sandwich with fresh lemon jello, what more could a waiting patient want?

Obviously, some privacy. And some form of birth-control.

I found the nurse for Room 31 and after making her aware that our patient had just been actively trying to get pregnant in our ER, we both walked back to the room together. Maybe, we joked, they would name the baby after one of us.

The curtain and sliding doors were both open. We walked into the room. The twentyish male companion was sitting meekly in the corner chair, the patient in the treatment cot. They were both dressed.

This time, I introduced myself and their nurse. "So," I said, after introductions, "which one of you might be the patient? Because from what I walked in on earlier, I would think that neither of you is sick enough to visit us in our ER."

After some putzing around, we got to the reason. The patient, it turns out, had missed her period and came to our ER for a pregnancy test. Yes, I am being serious. She got sent to the ER's acute-care side instead of our express wing after telling the triage nurse she had abdominal pain, thinking it would get her seen faster when, in fact, it tripled her wait time. The triage nurse, trying to move things along, had ordered the pregnancy test and some basic blood work.

There must be a higher power--her pregnancy test was negative.

This whole scenario, though, got me thinking that maybe there was some club I wasn't aware of, a club that nobody filled me in about since they know I work in the ER. This isn't the first time I've caught a couple fooling around in a cot. It's happened before and I would be disillusioned to think it wouldn't happen again. The common denominator, though, seems to be that they are all younger people, ranging from their late teens into their twenties.

I guess that rules my wife and I out. Initially, after catching this last couple, I had started making plans to take my wife to our ER to spend the night and find out what we were missing. And I was going to splurge, yessirree. No regular treatment room for my honey. I was going to get us one of those big trauma rooms with the really sturdy cot. Warm blankets. Cable TV. Pack our own sandwiches and pillows. Get a baby-sitter for the kids. All I had to do was register one of us, embellish some medical symptoms, give our insurance information, and the room would be ours.

"Hey honey," I would have said, "pack up your suitcase and jump in the car. I'm taking you on an overnight excursion. You don't need to pack a nightgown, either. Where we're going, they have plenty of them." If those prospects didn't intrigue her, what would? "Oh yeah," I'd add, "don't forget our insurance cards!"

In the midst of all this planning, though, it hit me--I probably wouldn't get a good night's sleep in the ER sharing a trauma cot with my wife. And, as I think I mentioned, I am in my early forties now. I held both my hands out and weighed the situation. A good night's sleep at home versus joining some obscure "notch in the ER cot" club. I yawned as I thought about it and with my yawn, the answer came quite easily.

So, this brings me back to my original question. Is there an ER club similar to the "mile-high" club that I don't know about? Do I really want to know? And does it have a nickname? I do like "notch in the ER cot" but I made that up on the fly--I would hope the name would be something better and more original than that.

Finally, if any of you are members to either club, keep it to yourself. I don't want to know. Now, if you'll excuse me, I'm going to get a good night's sleep.

As always, thanks for reading...next post will be Friday, January 8th. Let me know if you think of any good nicknames...

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!