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... 

This Father's Daughter

She was 50. Prior to being transported to our ER, her only complaint had been for non-traumatic elbow pain over the past two weeks. She was on no medications and had no significant medical history.

She was at home, preparing to visit her doctor for a scheduled visit, when she collapsed. Because she didn't drive, her elderly father had planned on swinging by to pick her up. He had just called and spoken to her minutes earlier to let her know he would be there shortly.

He arrived at her front door and knocked. No answer. He rang the doorbell. Again, no answer. Panic set in. This was not like his daughter to not greet him when she was expecting him. He knocked again, harder. Nothing. He kept his finger pressed to the doorbell, hoping his daughter would hear its continuous ringing and come to the door. She didn't. He tried turning the doorknob, but it was locked. He banged his aging shoulder against the door. It didn't budge.

He remembered the spare key she had given him months ago. "I'll never need this," he had said, trying to give it back, but his daughter had insisted he put it in his glove compartment. He stepped off the concrete porch pad and ran down the sidewalk, back to his pickup truck to retrieve the key. He found it, hidden under a pile of napkins.

Returning to the door, he struggled to fit the key into the lock. As a father, he knew something was wrong, very wrong. With trembling fingers, he finally succeeded in properly jamming the key into the door's lock. He turned the doorknob, barely breathing now, his mind racing of the possibilities he would encounter.

The door opened. He stepped into the small kitchen and yelled his daughter's name. No response. He listened to hear if the shower was running, but it wasn't. He strained his ears for anything, any sound of activity that would reassure him he was overreacting.

That's when he heard the moan. It was garbled and low, guttural almost. He followed the sound into his daughter's bedroom. That's where he found her, lying on the floor, beside the telephone nightstand.

He tried to rouse her, but he couldn't. Knowing something was terribly wrong, he dialed 911. Waiting for the prehospital team to arrive, he sat down on the floor beside her, caressing her head. Talking quietly to his daughter, he filled her ear with the promises that everything would be okay. It had to be, since they were all each other had.

The ambulance team arrived. After briefly interviewing her father and performing an exam, they prepared the daughter for transport to our emergency department. They were concerned that this patient may have had a stroke. They offered the elderly father a ride in the ambulance, with his daughter, but he decided to follow them in his pickup.

In the ER, the prehospital radio went off. They reported that a 50 year-old woman with a sudden onset of right-sided weakness and garbled speech was being transported to our facility. There had been no signs of trauma. Confirming that the time frame was adequate, a stroke alert was called in preparation of this patient's arrival. She would be a perfect candidate for tPA therapy if she did indeed suffer a stroke that was not hemorrhagic.

I, with the rest of our ER team, waited for this patient's arrival in Room 26. In three short minutes, she was being wheeled through our ambulance bay doors and down our hallway. Quickly, we were able to slide the patient from the prehospital stretcher to our hospital cot, all the while listening to the medical report given by one of the paramedics.

Her vital signs revealed that her blood pressure was quite high. She had no fever, her respirations were slow and erratic, and her pulse was normal. On exam, she had a flaccid right side, was nonverbal except for her occasional moaning, and teetered between some minimal form of consciousness and being unresponsive. It appeared that this patient had suffered some catastrophic brain event.

We emergently intubated this patient, both to protect her airway as well as ensure adequate oxygenation to her ill body. After a repeated exam by the neurology team, the patient was hurried to the CT scanner to determine the extent of her stroke.

While she was out of our department, escorted to CT by our nurse, the respiratory therapist, and a neurology resident, I went to the family room to speak to this patient's father. I was accompanied by our social worker and nursing supervisor.

I knocked on the door, opening it slowly to reveal a gentleman in his mid-seventies, tearful and distraught, running his hands through thin wisps of graying hair as he sat in the corner wing-backed chair. He had the look of a hard-working, honest man, dressed in a pressed flannel shirt and brown Dickie pants. He was alone.

"Sir," I said quietly, after introducing myself and my team, "I'm so sorry about what you are going through. Can you tell me what happened or anything that might help us with your daughter's care?"

With great detail, he told me about their plans to visit her family doctor that morning regarding her elbow. He was not aware that she had any medical problems. "She's a hard worker, that one. Never had time to be sick, really." He shared how he went to pick her up, only to find her collapsed beside her bed prior to his calling the ambulance. I listened intently, watching this father struggle to be stoic in his misery.

After maybe five minutes, a faint knock on the family room door preceded one of our nurses stepping in and interrupting our conversation. "Dr. Jim," she said, "can you come here, please."

I excused myself, leaving the father with our social worker and nursing supervisor. I stepped into the hall. "What is it?" I asked the nurse, herself wearing a worried look on her face.

"The CT scan, it's bad. The radiologist wanted me to get you."

I rushed to our physician work space, pulling up the patient's head CT images on the computer panel while I dialed the radiologist's number. What I saw saddened me. This patient had a significant brain hemorrhage, one that was shifting her brain from its midline and filling her ventricles with blood. The radiologist confirmed what I was looking at--that this patient most likely had a ruptured brain aneurysm. I called neurosurgery and the OR stat, since this patient needed emergent decompression of her brain's swelling and bleeding. Her problems were life-threatening.

I went back to the family room, where I sat down opposite the father. His expectant eyes bore into me. Slowly and deliberately, I explained all of the results to him. He unabashedly cried, his shoulder's shaking. "She's all I have left," he muttered. I was affected by his emotions and, looking at the tearful social worker and nursing supervisor, I knew that I wasn't alone.

We escorted the patient's father back to Room 26, where he was able to sit with his daughter as we awaited the go-ahead from the OR. I hovered in the room with several techs, the patient's primary nurse, and a respiratory therapist, overseeing the quick preparations of getting his daughter ready for surgery. I continued to watch the father, unable to turn away from the deep grief and ache that enveloped him.

This patient was taken to the OR. Thankfully, she made it through her emergent neurosurgery. She remained far from a successful outcome, however, since her following few days after surgery would be fragile and tenuous.

Usually, I follow-up with these types of emergent cases, the types that pull at my heartstrings. But, for this case, I didn't. I couldn't. I thought of this patient and her father frequently, yes, but I couldn't bear to think of this father losing his adult-daughter. I was willing to risk not learning of a possible successful outcome if it meant I also didn't learn of a sad, heartbreaking one.

I recognize what I am doing. I am protecting myself, adding another cement block to that protective shell that surrounds my heart. Building it up. Tearing it down. It is a constant but necessary struggle for each of us in the medical field.

I hope and pray, though, that this patient did well. After all, this father's daughter was all he had left.

As always, big thanks for reading. Next post will be Monday, April 19. I hope you have a great weekend...

Save The Scowl

During yet another busy shift in our emergency department, our staff was on the receiving end of multiple scowls by patients and their families. None warranted, mind you, and none were taken personally. But, nonetheless, it seemed to be the theme of the day.

What started the scowling? Simultaneously, we had three ambulances arrive to our ambulance bay, within minutes of one another. A chest pain patient, a stroke patient, and a trauma patient. Our staff, always ready to rise to the occasion, planned our divide and conquer.

I treated the stroke patient. A 60 y.o. male, normally healthy except for his smoking history, had a sudden onset of slurred speech accompanied by some extremity weakness. His symptoms had started within the past hour and were witnessed by his wife.

"We were sitting in our Lazy-Boys, watching our favorite show, The Wheel of Fortune, when he started having these problems," she said, frightened. "Is he going to be okay, doctor?

We called a "stroke alert." Similar to treating a multiple-trauma patient or an actively-infarcting heart attack patient, we have an emergency response team composed of ourselves, an in-house neurologist, multiple nurses, and the IV team. Our goal? To stabilize a patient, get imaging studies (especially a CT scan), and intervene as quickly as possible. With the right circumstances, we have several treatment options that can reverse such devastating symptoms.

Well, my patient did have a stroke. His CT scans were negative for any hemorrhaging and he qualified for tPA, a clot-buster used very cautiously but effectively to treat ischemic strokes. Simply, this type of stroke is usually caused by an embolus (or clot) that travels to the brain, occluding an artery and preventing blood supply to the brain tissue beyond. tPA can dissolve this clot.

It worked. Within the hour that followed, all of my patient's symptoms resolved.

The cardiac patient went to the cath lab. Unfortunately, the trauma patient died. And, all the while, patients began to back up, waiting for their emergency care. This, I'm afraid, was probably the moment when scowling became an epidemic.

Outside our triage station (the nursing station where a walk-in patient is first greeted and evaluated), patients lying on cots started backing up, lining the hallway. A bad sign that we were getting crowded. Between the patients and their accompanying family members, you couldn't walk down that hallway without having several people give you dirty looks. This, despite them being able to see how we were all rushing around, working hard.

Several patients later, I walked into a very unforgiving room. Lying in the cot was an elderly man with enough piss-and-vinegar to last me a lifetime. Pacing the room, his son. Sitting in the corner, his wife. They were upset with their wait. They had been sent to our ER by their family doctor (so they said) for a problem that was chronic in nature. Specifically, continued urinary problems from an enlarged prostate. Nothing new, they simply called for an appointment and couldn't get one for a week.

"I don't understand how you can make people wait like this," the patient started, before I even had a chance to acknowledge their delay. After assuring them that we were all working quite hard, I simply focused on this patient's history and physical. All stable. With the delays in care, the triage nurse had ordered a UA and blood work, also normal. I explained in detail my exam and the results of these tests, reassuring the patient and his family that everything looked okay.

Three scowls greeted that news.

Finally, just when I thought the scowls were slowing down, a mother walked out of her child's treatment room, quite gruff, while I was handing a chart to our secretary.

"Can someone give me the access code for the internet? For some reason, I can't sign on," she said, clearly annoyed with her wait, her eyes rolling.

Wait a second. We give out turkey sandwiches and lemon pudding. We pass out warm blankets by the dozen. We reimburse parking. And we even have a TV in each private room. When did we start having available internet access for patients and their families? Did I miss something? Do we have a coffee bar I don't know about, either?

"We don't have internet access in the ER, maam," our secretary answered the mother. "Sorry about that."

The mother bore her angry eyes into us. And scowled. "That's ridiculous," she mumbled, before turning and stomping back into the room.

Eventually, during that shift, we caught up with our patient-load and the scowls lessened. In fact, I might have even seen a few smiles. Always a plus

Truthfully, the scowls don't bother me. Well, okay, maybe just a little. But only because they seem to be accompanied with a sense of entitlement. Yes, I understand that when someone is sick, it might be hard for them to comprehend that their symptoms may be less urgent than the next patient. We aren't minimizing the symptoms, simply prioritizing them. We are an emergency department. We don't ask people to come in. We would never deliberately make a patient wait. The scowls being given to us are for things that we, the ER staff, can't control.

Well, short of getting internet access in the ER, that is.

As always, big thanks for reading...next post will be Wednesday, March 24. Interestingly, as I finished this post, the health reform bill passed...more scowls to come...

"Yoo-Hoo"

As I sat down at my computer station to finish the chart on a patient I had just treated, I heard something quite interesting. A voice, smooth and mellow, was calling out.

"Yoo-hoo."

It was an older woman's voice. I was immediately taken back to when I was a child, in my grandparent's house, standing beneath a small, cottage-shaped clock that hung on the wall. With a new hour approaching, I held my breath, staring up at the clock, its small pendulum swinging beneath, clicking a constant, relaxed beat. Eventually, the clock chimed, a little trap door opened, and a small bird popped out and chirped it's greeting.

"Coo-coo. Coo-coo. Coo-coo." Three times, like clock-work (no pun intended). Standing outside of my memory looking-in, I saw the little boy in his summer shorts, his tanned face framed with shaggy brown hair, smiling as he looked up expectantly at the wooden bird that never failed to mark a new hour.

"Yoo-hoo. Yoo-hoo." The woman's voice snapped me back to the present.

I got up from my chair and followed the yoo-hooing until I was standing at the bedside of an elderly woman with matted soft-grey hair and empty hazel eyes. She clearly had dementia. She looked quite comfortable, though, and was mumbling something to herself between the yoo-hoos.

"Do you need help with something, maam?" I asked, straightening her sheets and tucking her in. "What can I get you?"

"Help me!" the patient screamed, "I need help."

This patient's nurse walked in just then, a younger nurse that I enjoyed working with. She was compassionate, knowledgeable, and hard-working. And apparently, at that moment, frustrated.

"Is everything all right in here, Victoria?" I asked, ready to help.

"Everything's fine. Mrs. Pello has Alzheimer's and was sent by the nursing home because the nurse there thought she was acting 'more demented' today." Victoria gave me a knowing glance. We both recognized the bullshit excuse by the nurse who sent in Mrs. Pello, trying to make her own shift easier. At our expense, of course.

"Anything wrong?" I asked. "You need me to see her?"

"Dr. P. picked up on her. We're just going to get some baseline tests and a CT scan of her head. If it's all good, she'll be heading back soon enough."

"Yoo-hoo," Mrs. Pello called out, yet again.

"On second thought," Victoria said, laughing, "if you can get her to stop yelling 'yoo-hoo' every five minutes, I would appreciate it."

"I kind of like it," I said. "It reminds me of a coo-coo clock my grandparents had when I was a kid. She sounds just like the little bird that popped..."

I was interrupted by Mrs. Pello. "Help me! I need help!" Her sudden outburst had caught Victoria and I both by surprise. Then, without pausing, Mrs. Pello continued. "Yoo-hoo. Yoo-hoo."

"Just wait," Victoria warned me, both of us chuckling, "you might like it now, but after a few hours of this, I'm not so sure."

Well, little did I know at the time, but Victoria had hit the nail right on the head. Mrs. Pello's loud "yoo-hoo" was methodical and rhythmic, an audio alarm that was set to go off every five minutes, interrupting our workday. Unfortunately, her door had to be left open so that the nurses in their station could keep a close eye on her. And the risks of sedating her outweighed the benefits. So her yoo-hooing would just have to be accepted for a few hours.

Soon after meeting Mrs. Pello, a middle-aged man, who had collapsed at home, was brought into our ER and placed in the room next door. His right side was completely flaccid (no muscle strength) and he had a facial droop. An obvious stroke. A stroke alert was called and we emergently intubated this gentleman, hooked him up to a ventilator, and aggressively treated his escalating blood pressure. This patient was critical.

And then, suddenly, in the midst of treating this crisis, there it was. "Yoo-hoo. Yoo-hoo." It was clear and resounding. Everyone who was involved in treating our stroke patient did a quick pause. "Yoo-hoo." Mrs. Pello had added another one for good measure.

"Come on, people, back to work," I said, reminding them of our task at hand.

"What the hell was that?" the neurologist and neurosurgeon asked me, intrigued. "You really don't want to know," I said, grinning. My ER team, including Victoria, was shaking their heads, obviously trying to stifle their laughs. Swiftly, we transferred the stroke patient to the OR for emergent surgery after his CT scan revealed a large hemorrhagic stroke--blood on the brain.

Unfortunately, treating the stroke patient delayed Mrs. Pello's own head CT and she continued to sit in her room, waiting. "Yoo-hoo." Yep, about every five minutes.

At another point, as a family passed by Mrs. Pello's room while being escorted to their treatment room, she started screaming out "Help me! I need help." The family's eyes widened from fright. The staff, immune to the cries, didn't even budge to help, which I'm sure thoroughly impressed this family. They had to have thought of high-tailing it and heading to another ER. Someplace where the doctors and nurses cared.

Eventually, though, Mrs. Pello went over to the radiology department for her head CT. We all cheered, looking forward to a few minutes of silence. Unfortunately, not even five minutes had passed before we got an urgent call from the CT tech. "Can someone come over right away? Mrs. Pello is screaming for help." Oops, someone forgot to warn the tech of Mrs. Pello's outbursts.

She returned from her CT scan and, thankfully, all of her workup was normal. She had been in our emergency department for approximately four hours. Well, not approximately. More like exactly! Even those of us not involved in her care were celebrating her finished work-up and immediate plans to be transferred back to her nursing home. However, due to several ongoing emergencies, it would be one more hour of waiting until the ambulance service arrived to take her back. "Yoo-hoo."

Even though I wasn't treating her, I couldn't help but go into Mrs. Pello's room several more times to make sure she was comfortable. You see, not only did her "yoo-hoo" trigger a wonderful childhood memory of that coo-coo clock, but Mrs. Pello herself reminded me of my grandmother, an amazing and fiercely-independent woman who also was stricken with dementia.

Victoria was dead-on right. After five hours of "yoo-hoos," Mrs. Pello's voice had lost most of its charm and smooth, mellow tones. Now, her cries were simply annoying. Our staff gave her a wonderful farewell, lining up in the hallway to witness her be escorted by the ambulance team back to her nursing home. I think they were just making sure that there would be no screw-ups--that Mrs. Pello was actually leaving. Do not pass go. Do not collect $200. Just get the heck out!

Me? Well, of course, I was missing Mrs. Pello and her "yoo-hoos" five minutes after she was discharged. It was too quiet! And truth be told, I don't think I was alone. I think we all were suffering from yoo-hoo withdrawal.

So, I took a deep breath, calmed my fears, made my voice smooth and mellow, and did it.

"Yoo-hoo."

Update: One week later...
Good news...you can hardly see my black-eye anymore. I just wish someone had warned me that Victoria knew karate!

As always, a big thanks for reading. The next post will be Monday, February 15. Happy Valentine's Day to all of you...

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