I walked into Room 28 to examine a woman who had presented to our emergency department with complaints of abdominal pain. She had initially been examined by our chief resident, who was under my supervision for this particular shift.
Unfortunately, this patient was a "frequent-flier," presenting to our ER multiple times in the past few years. Complicating the matter, she spoke no English. Despite our offers to provide a translator during her visits, she refused. Every time. Instead, she placed that responsibility on her ten year-old daughter's shoulders.
My resident was somewhat flustered by this patient. For one, her multiple visits to our ER were always for chronic issues that, despite significant past work-ups, never amounted to any significant findings. Secondly, the language barrier. When a patient and a physician do not share a common language, there is always a concern that some important fact or angle may be overlooked. In addition, this patient had now been in our country for a few years. During that time, wouldn't you expect her English skills to advance a little bit? I can't picture myself living in France for two years and not learning some French. Yes, no, wine. Those words would roll off my tongue in the first week. This patient, for whatever reasons, seemed to have not made much effort in learning even basic English words.
Which leads us to my resident's biggest frustration. The daughter. And the burden placed on her to translate for her mother. If the patient had come to our ER over thirty times in the past few years, how many times do you think the daughter had been with her? Even conservatively, if the daughter had accompanied her mother on half of those visits, it's still too much. In addition, most of her mother's visits were regarding abdominal pain. Some of the questions asked during history-taking can be very sensitive and specific with this complaint and, yet, the mother wouldn't answer a question unless it was through her daughter.
I walked into the room to find a laughing patient sitting upright in her cot, watching TV. Despite her loose hospital gown, I could appreciate this woman's large size. She appeared very comfortable, though, and in no acute distress. Her daughter sat in a corner chair, also smiling as she looked upward at the TV. She was beautiful. Dark hair, dark eyes, long lashes, and dangling pink gemstone earrings that swayed with her laughter. She wore a pink Hannah Montana sweatshirt. Looking up at the TV, I was not surprised to see the channel was set to The Hannah Montana Show on the Disney channel.
"Hello," I said, holding out my hand to the patient and shaking hers, "I'm Dr. Jim, and I'll be treating you today with Dr. Mary, whom you just met. How are you?"
The patient looked from me to her daughter, who translated everything I had just said. When her daughter was done, the patient turned back to me and silently nodded. I continued focusing on the daughter, holding out my hand and walking around to the other side of the cot where she sat. "You are her daughter?" I asked. She nodded. "What is your name, honey?" "Annabelle," she answered, shyly.
"Annabelle," I said, "we appreciate you being here today to help us with your mother's care. Would your mother want us to call a translator instead, though?" Annabelle translated my words for her mother and returned her mother's response to me. "Absolutely not," Annabelle said.
"Okay, then, Annabelle," I said, "I will ask you all my questions and you can, in turn, ask your mother, okay? If there are any questions you don't feel comfortable with, just tell me and I will call in a translator."
Even this, Annabelle translated for her mother, who's return response, through Annabelle, was "There is no question that my daughter has not already heard."
So, I asked away. Fever? Nausea? Vomiting? Diarrhea? Where is the belly pain? Similar to past episodes? Chest pain? Trauma? I kept it short and sweet. Finally, I briefly asked about any urinary problems or vaginal problems. Annabelle didn't even flinch, asking her mother my questions and relaying her mother's answers. She was a translating pro, albeit at the age of ten. Practice makes perfect, I guess.
After the questions, I performed a physical exam that was stable and unremarkable for any abnormalities. I reviewed a new set of vital signs, also normal. This was all similar to what my chief had found. This patient's blood and urine work had returned prior to my exam, even, and I was armed with the knowledge that all of those results were normal as well.
I explained the results of my exam and the testing to Annabelle, who in turned spoke to her mother about it. The mother seemed genuinely happy. I explained that I was going to call her family doctor and review the results of our exam and testing and would expect her to follow-up for her chronic abdominal complaints in the morning with him. She agreed.
Before leaving, I focused on Annabelle. "You were so helpful today. Did anybody give you any stickers yet? Or a popsicle?" Annabelle didn't answer me but, instead, turned her face from me and toward her mother and started talking in their native language. It took me a minute to realize that she had thought those last questions were directed toward her mother.
"No, no, no, honey," I said, interrupting her and laughing. "Annabelle, I was asking you those questions. Did you get any stickers or a popsicle for being such a big help with your mother's care today?"
"No, Doctor Jim, I didn't," she replied, shyly gazing to the floor with her eyes. Her voice, in English, was quiet and faint; in her native language, fluent and guttural and husky.
"Well, Annabelle, your mother and we are sure lucky to have you translate for us. Thank you very much. Let me go get you some thank-you stickers, okay?" She nodded yes to my words, smiling now, her secondary teeth perfectly white and evenly lined. Her smile lit up the room.
I left the room, hearing Annabelle's explanations to her mother grow faint as I walked down the hallway. While my chief called the mother's doctor, I perused through our sticker collection and picked out about fifteen or so for Annabelle, including some new kitty-cat ones that I couldn't wait to get rid of (sorry, just not a cat fan here). I went to our employee lunch room, where we keep our popsicles, and grabbed Annabelle a bright blue Italian ice. Who doesn't like blue popsicles, right?
As I walked back into their treatment room, my chief resident was just leaving. "Everything all right?" I asked her. "Everything's good," she assured me, "Dr. Smith is going to see Mrs. Demshonova tomorrow at 9 a.m.
Perfect. I walked in and handed Annabelle her well-earned stickers. "Do you like cats, Annabelle? " She answered with a nod, hurriedly scanning through each of the stickers. "And here," I said, pulling the popsicle out from behind my back, "here is a blue popsicle for all your hard work." She looked at her mother who nodded to her, and Annabelle shyly took the popsicle from my hand. I finished. "It sure was nice meeting you, today. Thanks again for all of your help."
As I began retracing my steps out of the room, Annabelle's mother spoke up. "Excuse me, sir," she said, in broken English. I stepped back in and walked towards her cot, surprised to hear her speaking English. "Yes?" I asked. The patient looked from me to Annabelle, who was devouring the popsicle while rechecking the stickers, and back to me again. "Thank you," she said, grabbing my hand and squeezing it. "Thank you," she repeated again, more softly, for good measure.
"You're welcome," I said, returning her transcending smile with my own simple one.
I walked out of that room and realized that this was a good mother. And Annabelle, of course, a good child. Although I wouldn't expect my ten-year old to translate for me, this patient did. Whether is was cultural or not, I don't know. I do feel confident, though, that this mother wasn't being abusive of Annabelle, she just expected a family member to translate for her. A family member who just happened to be ten-year old Annabelle. Nor do I think the mother deliberately abused our ER with so many visits. Again, I simply think she didn't understand the process of following through with her chronic complaints with her family doctor. What do you think?
The patient and her daughter, after being discharged, walked down the hallway toward the exit door. Holding hands.
I walked back to my chief resident. "They turned out to be quite nice in there, didn't they?" I asked. "Yes, they were," the chief said, happy with the outcome.
Hopefully, she learned a little something besides clinical medicine from this case.
I know I did.
As always, big thanks for reading. I hope you all have a nice weekend. Next post will be Monday, May 17. See you then...
Friday, May 14, 2010
Wednesday, May 12, 2010
Against The Norm
I grew up in a small town. One of seven kids. Raised by parents who represented the expected, traditional roles. Dad worked hard and, with his brothers, became extremely successful in the forestry industry. Heck, he even cut down the presidential Christmas tree one year. Mom kept house and raised us kids quite nicely. The family glue, she was. A sit-down, multi-course meal was enjoyed by the nine of us every night. Roast beef and potatoes, steaks with home-fries and corn, breaded pork chops with green beans and cinnamon applesauce. Who eats like this anymore?
My family was conservative and Catholic. Through and through.
To my parents' credit, expectations were placed on us. Expectations that prepared us for life's many angles and unexpected surprises. Expectations that taught us that life's blanket has many different colored threads interwoven throughout it.
For one, we had to excel in at least one sport. Mine, you ask? Easy. Tennis, which I actually played through college on scholarship. I also loved basketball and baseball. My sister Rosie, although she won tennis districts in doubles a few times, claims to have been the best cheerleader in the family. A sport now, yes, but in her day, a few stomps of the feet and claps of the hands really didn't impress the rest of us. A "stomper," I called her, instigated by the fact that my parents actually accepted this activity as her official sport.
We also had to maintain an A or high B average. My parents batted seven for seven with this expectation. We were taught that discipline and hard work reaps many benefits, especially good grades. And, as expected, we all attended college and graduated. For some of us, books became our very close friends.
We had to be kind and compassionate, to one another and to our fellow-mankind. Mom would perpetually have us kids deliver meals to many of our elderly neighbors. In the winter, we shoveled our neighbors' walks. In the summer, we cut their grass. Without pay. And, more importantly, without complaining. My dad, after hooking up his snow-plow to his pick-up, would plow any driveway in three counties.
Probably the most interesting expectation placed by my parents, though, was that each of us had to excel at playing a musical instrument. Mine? Classical piano. How's that for you. Ten years to boot. I initially loved playing the piano in elementary school. Around 10th grade, however, I was starting to enjoy it significantly less. Imagine being a teen-ager and having to leave basketball practice early for an hour piano lesson with Sister Mary Catherine, who happened to be the spitting younger version of Sophia from "The Golden Girls." She was tough, but I learned well. Besides other pianists, among us we have an accordian player, a french horn expert, and a clarinet virtuoso.
By appearances, my family looks like the typical, if blessed, American family. Some of us are conservative in our thinking, some of us liberal. Each of us is quick to admit that we had something special and lucky with the childhood cards we were dealt.
Within my siblings, I am probably the most liberal. Does that mean I am Obamafied? Hardly. I'm still a physician working hard in the American system. But I love diversity. I crave diversity. Part of my job's enticement, besides the rewards of helping a patient through an emergent illness or injury, is the social interactions I have with so many different people from so many walks of life. It's a very cool place for me to sit--an appreciation of diversity perched on my left shoulder and my traditional upbringing on my right.
Recently, I wrote a tongue-in-cheek post about men being wimps. It was a spirited and laughable post, although I stand by the elemental truths that us men, with exceptions (of course), are not the stronger of the two sexes when it comes to facing illnesses. Some of the comments from that post questioned if I were stereotyping and, if so, why?
I took a few comments and let them brew in my mind, gathering wisdom with a few passing days. And you know what I realized? I learned that, if anything, I am quite far from the typical, stereotyping person. I don't judge but, rather, observe. Sometimes my observations may not sit well with someone, but that's okay. They are my observations. My experiences.
Flipping that coin, I would be a hard person to stereotype, too. And I like it that way.
I made a mental checklist to prove it. I work out at a gym four days a week while listening to acoustic Sarah McLachlan on my mp3 player. If you looked at me, you would probably think I read history or murder mysteries. Wrong. I just finished two incredibly-written "chick books"--The Help and Saving Ceecee Honeycutt (both of which I would highly recommend). By ninth grade, even, I had read all of Shakespeare's works. Not to say that I don't like a good Patterson book once in a while (all hail Alex Cross). I am both big city and small town. I am both country and a little bit rock-and-roll. Come June, my wife and I will be seeing both Ingrid Michaelson and Cyndi Lauper in concert (I'm a sucker for a strong female voice). I can cut a tree down on a peg fifty feet away and, yet, can successfully pick a perfect room paint color in an instant. I get angry at seeing healthy people my age abuse our country's fine intentions of financial assistance but will fight to have every child, every handicapped person, and every elder adult benefit from my taxes. I am compassionate most always. I will avoid flushing the toilet after one of my prouder productions (if that isn't something to beat on your chest about, what is?). I like a beer but, once in a while, I might have a glass of wine, a vodka tonic, or (gasp) a martini. I enjoy landscaping and washing and waxing cars, playing sports, and teasing the shit out of my family and friends. I can iron and press a dress shirt with the best of them (a necessary talent during the medical school years).
You get the gist. Essentially, I don't want to be pigeon-holed. Ever. Who among us does? Most of us are not a box with four sides. My interests are scattered all over.
Today, at work in the ER, I met an amazing couple. Women who were life-partners. Women whom I initially thought were best friends. After spending several of my rare down-time minutes with them, just talking, it became very evident that they were committed to one another. And they couldn't have been any more fun, this couple, laughing and finishing one another's sentences. As I walked out of their room, I smiled. Big time. I appreciated their diversity and I appreciated my privilege to meet them and learn a little more about the big picture of life from their perspective.
As I sat at my work desk afterwards, I thought about how each of us has an unexpected something about us that, if isolated, could be judged as peculiar or "not normal" by our fellow man. Me included. But what is normal and what isn't? And who made those rules? What people expect from me and what people ultimately find out about me sometimes sit on opposite ends of the spectrum. How cool is that? This very thought is the thing that drives me, inspires me even, to learn more about the people in my life, the patients and families in my ER, and a stranger I may pass in the street.
I observe people and appreciate their differences.
My parents' rules and expectations went with the norm of what I knew life to be. And yet, because of those norms and guidelines, I have interests that extend way beyond the stereotyping and norms as defined by our society. Just what, I'm sure, my parents were hoping to instill with their expectations. If so, they succeeded. And I thank them.
Do any of you have an unexpected something about yourself that goes against the norm? I'll bet each of you have an answer that is three letters, starting with "y" and ending in "s." And Pat and Vanna, I'll take a vowel--"e"--right there in the middle. Am I right? Do I win a prize?
My kids face the same expectations as I did as a child--they all play the baby grand that sits off our foyer, they get great grades, and they play two or more sports. They are good kids who love music and books and are kind to other people.
Hopefully, that's not against the norm. But if it is, I'll gladly keep things the way they are.
It worked for me.
As always, big thanks for reading. Especially this one. A change of pace in sharing some of myself. Next post will be Friday, May 14. See you then.
My family was conservative and Catholic. Through and through.
To my parents' credit, expectations were placed on us. Expectations that prepared us for life's many angles and unexpected surprises. Expectations that taught us that life's blanket has many different colored threads interwoven throughout it.
For one, we had to excel in at least one sport. Mine, you ask? Easy. Tennis, which I actually played through college on scholarship. I also loved basketball and baseball. My sister Rosie, although she won tennis districts in doubles a few times, claims to have been the best cheerleader in the family. A sport now, yes, but in her day, a few stomps of the feet and claps of the hands really didn't impress the rest of us. A "stomper," I called her, instigated by the fact that my parents actually accepted this activity as her official sport.
We also had to maintain an A or high B average. My parents batted seven for seven with this expectation. We were taught that discipline and hard work reaps many benefits, especially good grades. And, as expected, we all attended college and graduated. For some of us, books became our very close friends.
We had to be kind and compassionate, to one another and to our fellow-mankind. Mom would perpetually have us kids deliver meals to many of our elderly neighbors. In the winter, we shoveled our neighbors' walks. In the summer, we cut their grass. Without pay. And, more importantly, without complaining. My dad, after hooking up his snow-plow to his pick-up, would plow any driveway in three counties.
Probably the most interesting expectation placed by my parents, though, was that each of us had to excel at playing a musical instrument. Mine? Classical piano. How's that for you. Ten years to boot. I initially loved playing the piano in elementary school. Around 10th grade, however, I was starting to enjoy it significantly less. Imagine being a teen-ager and having to leave basketball practice early for an hour piano lesson with Sister Mary Catherine, who happened to be the spitting younger version of Sophia from "The Golden Girls." She was tough, but I learned well. Besides other pianists, among us we have an accordian player, a french horn expert, and a clarinet virtuoso.
By appearances, my family looks like the typical, if blessed, American family. Some of us are conservative in our thinking, some of us liberal. Each of us is quick to admit that we had something special and lucky with the childhood cards we were dealt.
Within my siblings, I am probably the most liberal. Does that mean I am Obamafied? Hardly. I'm still a physician working hard in the American system. But I love diversity. I crave diversity. Part of my job's enticement, besides the rewards of helping a patient through an emergent illness or injury, is the social interactions I have with so many different people from so many walks of life. It's a very cool place for me to sit--an appreciation of diversity perched on my left shoulder and my traditional upbringing on my right.
Recently, I wrote a tongue-in-cheek post about men being wimps. It was a spirited and laughable post, although I stand by the elemental truths that us men, with exceptions (of course), are not the stronger of the two sexes when it comes to facing illnesses. Some of the comments from that post questioned if I were stereotyping and, if so, why?
I took a few comments and let them brew in my mind, gathering wisdom with a few passing days. And you know what I realized? I learned that, if anything, I am quite far from the typical, stereotyping person. I don't judge but, rather, observe. Sometimes my observations may not sit well with someone, but that's okay. They are my observations. My experiences.
Flipping that coin, I would be a hard person to stereotype, too. And I like it that way.
I made a mental checklist to prove it. I work out at a gym four days a week while listening to acoustic Sarah McLachlan on my mp3 player. If you looked at me, you would probably think I read history or murder mysteries. Wrong. I just finished two incredibly-written "chick books"--The Help and Saving Ceecee Honeycutt (both of which I would highly recommend). By ninth grade, even, I had read all of Shakespeare's works. Not to say that I don't like a good Patterson book once in a while (all hail Alex Cross). I am both big city and small town. I am both country and a little bit rock-and-roll. Come June, my wife and I will be seeing both Ingrid Michaelson and Cyndi Lauper in concert (I'm a sucker for a strong female voice). I can cut a tree down on a peg fifty feet away and, yet, can successfully pick a perfect room paint color in an instant. I get angry at seeing healthy people my age abuse our country's fine intentions of financial assistance but will fight to have every child, every handicapped person, and every elder adult benefit from my taxes. I am compassionate most always. I will avoid flushing the toilet after one of my prouder productions (if that isn't something to beat on your chest about, what is?). I like a beer but, once in a while, I might have a glass of wine, a vodka tonic, or (gasp) a martini. I enjoy landscaping and washing and waxing cars, playing sports, and teasing the shit out of my family and friends. I can iron and press a dress shirt with the best of them (a necessary talent during the medical school years).
You get the gist. Essentially, I don't want to be pigeon-holed. Ever. Who among us does? Most of us are not a box with four sides. My interests are scattered all over.
Today, at work in the ER, I met an amazing couple. Women who were life-partners. Women whom I initially thought were best friends. After spending several of my rare down-time minutes with them, just talking, it became very evident that they were committed to one another. And they couldn't have been any more fun, this couple, laughing and finishing one another's sentences. As I walked out of their room, I smiled. Big time. I appreciated their diversity and I appreciated my privilege to meet them and learn a little more about the big picture of life from their perspective.
As I sat at my work desk afterwards, I thought about how each of us has an unexpected something about us that, if isolated, could be judged as peculiar or "not normal" by our fellow man. Me included. But what is normal and what isn't? And who made those rules? What people expect from me and what people ultimately find out about me sometimes sit on opposite ends of the spectrum. How cool is that? This very thought is the thing that drives me, inspires me even, to learn more about the people in my life, the patients and families in my ER, and a stranger I may pass in the street.
I observe people and appreciate their differences.
My parents' rules and expectations went with the norm of what I knew life to be. And yet, because of those norms and guidelines, I have interests that extend way beyond the stereotyping and norms as defined by our society. Just what, I'm sure, my parents were hoping to instill with their expectations. If so, they succeeded. And I thank them.
Do any of you have an unexpected something about yourself that goes against the norm? I'll bet each of you have an answer that is three letters, starting with "y" and ending in "s." And Pat and Vanna, I'll take a vowel--"e"--right there in the middle. Am I right? Do I win a prize?
My kids face the same expectations as I did as a child--they all play the baby grand that sits off our foyer, they get great grades, and they play two or more sports. They are good kids who love music and books and are kind to other people.
Hopefully, that's not against the norm. But if it is, I'll gladly keep things the way they are.
It worked for me.
As always, big thanks for reading. Especially this one. A change of pace in sharing some of myself. Next post will be Friday, May 14. See you then.
Monday, May 10, 2010
I'm Going To Die!
Occasionally, a patient will come into the ER with a profound sense of foreseeing their immediate death. A foreboding that, despite their complaints and physical findings not matching up, death might be knocking on their door.
I'm not talking about how some people think they may die young. Or that they may die a tragic or traumatic untimely death. Haven't we all had that thought at one time or another? Rather, I'm talking about that patient who is lying in their cot, looking somewhat stable, piercing into your eyes with their frantic own. "Please don't let me die," they say, before you can even begin to sort out their history and perform a physical exam.
This kind of talk and behavior, as you can imagine, may be quite unsettling, both for the patient and the providing medical team. In most circumstances, that dramatic foreshadowing deserves some attention.
Recently, an elderly male had been rushed to our emergency department from the radiology department, where he had been undergoing an outpatient, IV contrast-enhanced MRI. After the MRI nurse had pushed his contrast into his IV catheter, the patient began flailing and screaming.
"I can't breathe!" Help me!" "I'm going to die!"
The MRI nurses looked for a rash. They found none. They listened to his heart and lungs. They sounded good. They reviewed his extensive MRI checklist but found no documented allergies of suspicion.
"I'm going to die!" the patient yelled again. His frantic nature became contagious and, within a few minutes, the patient was being wheeled into our department. Room 21.
I remember hearing the concerning page overhead. "We need a doctor in Room 21, stat." As luck would have it, I was just walking out of Room 22, the next-door room, after explaining some results to that patient. I hurried into Room 21 before the page was even finished.
Entering, I found an elderly male, 75 maybe, in a loosely-tied hospital gown, sitting upright in his cot. "Are you the doctor?" he asked, focusing his worrisome eyes on me. As I nodded yes, I glanced up at his cardiac monitor, which was showing a stable cardiac rhythm, good oxygenation on room air, and a slightly elevated respiratory rate. As I was looking, an automatic blood pressure reading had cycled and that, too, was normal.
"Help me, doctor," he exclaimed, his eyes remaining fixed on mine, his voice cracking, "I'm going to die!" To add a dramatic flair, one of the overhead fluorescent bulbs began flickering its last hurrah, casting intermittent shadows on the patient's face. An interrogation room atmosphere.
I quickly introduced myself, shaking this patient's hand, as I listened to a brief overview given by one of the two nurses. As she finished, I still hadn't heard what I wanted to hear--a solid reason for this patient's words and behavior.
It was time to interrogate. "Sir," I said, "has anything like this ever happened to you before?" No, he replied. "Are you having chest pain or calf pain with this shortness of breath?" No. "Have you had any recent cough or cold symptoms?" Again, no. "Any trauma or falls?" Nope. "Have you ever had any allergic reactions that may have caused a similar reaction?" You guessed it, no.
I was told this patient's brother, whom he lived with, was going to be escorted to Room 21 shortly. I looked forward to talking to him. In the meantime, I did a thorough exam on this patient and found nothing remotely concerning. He had no rash. He had no wheezing or stridor. He had normal heart sounds.
"Sir," I asked him point-blank, "do you have a history of anxiety or nervousness?" He shook his head "no." "On any new medicines?" Another nod "no."
Even though we approached this patient as a possible allergic or anxiety reaction, based solely on his MRI-department history, he still warranted a thorough work-up, because of his age and several cardiac risk factors.
We ordered a stat EKG, a portable chest x-ray, blood work, including some screening cardiac enzymes that would elevate if there were any concurring ischemia to the heart, and a d-dimer, a blood marker that, if positive, raises one's suspicion for a blood clot.
The patient's brother still hadn't arrived by the time I reviewed the patient's EKG and chest x-ray, both normal. I had someone go look for him as I reviewed the patient's blood work results, hot off the presses. Surprisingly, normal.
I was in Room 21, explaining all the good results to the patient, when a smiling, elderly man was escorted into the room by one of our techs. If you took away the patient's nervousness and sense of dread, this arriving man would have been what I imagine this patient to look like. Obviously, it was the patient's brother.
Being told that his brother had finished in MRI, this man had gone to the cafeteria to grab a bite while waiting for an official discharge. The brother had not been told of the situation in the MRI suite.
"So Frank," the brother spoke, shaking his disapproving head, exasperated, "you did it again, huh?"
"Did what?" Frank asked, now glancing sideways out of his eyes at me.
"Have another nervous attack," the brother said. "I told you to make sure you told everybody you have anxiety and are on medication for it. You didn't, did you?"
I looked incredulously at Frank, who now fully avoided eye-contact with me. I looked at the brother. "I point-blank asked your brother if he had anxiety or nervousness and he told me 'no.'"
"Of course," the brother said, "he always denies it. But he has about five or so attacks a day. He seems to be more and more preoccupied with dying these days. " He looked at his brother, the patient, before turning back to me and continuing. "Did he tell you he was going to die?"
I shook my head "yes." The nurse shook her head "yes." Frank, even, shook his head "yes." "Well," Frank's brother continued, "I hear that about five times in a day. Frank gets all worked-up, insisting that I will be living alone by the end of the day." The brother hesitated, as if he was going to add a quirky little comment to that last statement, but bit his tongue.
"How does Frank look to you now?" I asked the brother.
"Like he always does," the brother replied. That reply was music to my ears. Frank looked at his brother, piercing eyes and all, and spoke quite dramatically. "That's enough, Elmer."
Elmer wasn't intimidated. "You're right, this is enough." I stepped out of the room only after refereeing the minor argument that ensued. And ordering some Vitamin "V" for Frank.
It turns out that Frank had held his morning medications, including his valium and anti-depressant, in preparation of his MRI. Unfortunate, since some people without anxiety still require an anxiolytic to get through MRI testing. After a social service consult, I called Frank's family doctor with a report of what happened and, more importantly, to get a follow-up appointment for the next day.
The family doctor was surprised that, somehow, Frank's medications and history of anxiety were not conveyed to the MRI staff, which could have preempted an ER visit. It made me think, though, that if you point a finger, four are still pointing back at you. The family doctor had ordered the test and knew this patient better than anyone else. I would have assumed he would have alerted the MRI team to Frank's recent bouts of anxiety.
"May I ask," I questioned, still a little perplexed, "what was the reason for Frank's MRI?"
"Oh, sure," his doctor replied, "it was a brain MRI to rule out any recent or remote stroke activity. He's been getting real forgetful lately."
So, as it turns out, the forgetful patient forgot to share his anxiety issues.
I walked back into Frank's room to explain his follow-up plan, only to find Frank and Elmer both calmed down, watching a baseball game on TV. "So I'm not going to die, Doctor Jim?" Frank asked one last time.
I shook my head no. "Sorry, Frank, not today you aren't."
Not on my shift, anyway...
As always, big thanks for reading...I hope everyone had a great weekend. Next post will be Wednesday, May 12. See you then...
I'm not talking about how some people think they may die young. Or that they may die a tragic or traumatic untimely death. Haven't we all had that thought at one time or another? Rather, I'm talking about that patient who is lying in their cot, looking somewhat stable, piercing into your eyes with their frantic own. "Please don't let me die," they say, before you can even begin to sort out their history and perform a physical exam.
This kind of talk and behavior, as you can imagine, may be quite unsettling, both for the patient and the providing medical team. In most circumstances, that dramatic foreshadowing deserves some attention.
Recently, an elderly male had been rushed to our emergency department from the radiology department, where he had been undergoing an outpatient, IV contrast-enhanced MRI. After the MRI nurse had pushed his contrast into his IV catheter, the patient began flailing and screaming.
"I can't breathe!" Help me!" "I'm going to die!"
The MRI nurses looked for a rash. They found none. They listened to his heart and lungs. They sounded good. They reviewed his extensive MRI checklist but found no documented allergies of suspicion.
"I'm going to die!" the patient yelled again. His frantic nature became contagious and, within a few minutes, the patient was being wheeled into our department. Room 21.
I remember hearing the concerning page overhead. "We need a doctor in Room 21, stat." As luck would have it, I was just walking out of Room 22, the next-door room, after explaining some results to that patient. I hurried into Room 21 before the page was even finished.
Entering, I found an elderly male, 75 maybe, in a loosely-tied hospital gown, sitting upright in his cot. "Are you the doctor?" he asked, focusing his worrisome eyes on me. As I nodded yes, I glanced up at his cardiac monitor, which was showing a stable cardiac rhythm, good oxygenation on room air, and a slightly elevated respiratory rate. As I was looking, an automatic blood pressure reading had cycled and that, too, was normal.
"Help me, doctor," he exclaimed, his eyes remaining fixed on mine, his voice cracking, "I'm going to die!" To add a dramatic flair, one of the overhead fluorescent bulbs began flickering its last hurrah, casting intermittent shadows on the patient's face. An interrogation room atmosphere.
I quickly introduced myself, shaking this patient's hand, as I listened to a brief overview given by one of the two nurses. As she finished, I still hadn't heard what I wanted to hear--a solid reason for this patient's words and behavior.
It was time to interrogate. "Sir," I said, "has anything like this ever happened to you before?" No, he replied. "Are you having chest pain or calf pain with this shortness of breath?" No. "Have you had any recent cough or cold symptoms?" Again, no. "Any trauma or falls?" Nope. "Have you ever had any allergic reactions that may have caused a similar reaction?" You guessed it, no.
I was told this patient's brother, whom he lived with, was going to be escorted to Room 21 shortly. I looked forward to talking to him. In the meantime, I did a thorough exam on this patient and found nothing remotely concerning. He had no rash. He had no wheezing or stridor. He had normal heart sounds.
"Sir," I asked him point-blank, "do you have a history of anxiety or nervousness?" He shook his head "no." "On any new medicines?" Another nod "no."
Even though we approached this patient as a possible allergic or anxiety reaction, based solely on his MRI-department history, he still warranted a thorough work-up, because of his age and several cardiac risk factors.
We ordered a stat EKG, a portable chest x-ray, blood work, including some screening cardiac enzymes that would elevate if there were any concurring ischemia to the heart, and a d-dimer, a blood marker that, if positive, raises one's suspicion for a blood clot.
The patient's brother still hadn't arrived by the time I reviewed the patient's EKG and chest x-ray, both normal. I had someone go look for him as I reviewed the patient's blood work results, hot off the presses. Surprisingly, normal.
I was in Room 21, explaining all the good results to the patient, when a smiling, elderly man was escorted into the room by one of our techs. If you took away the patient's nervousness and sense of dread, this arriving man would have been what I imagine this patient to look like. Obviously, it was the patient's brother.
Being told that his brother had finished in MRI, this man had gone to the cafeteria to grab a bite while waiting for an official discharge. The brother had not been told of the situation in the MRI suite.
"So Frank," the brother spoke, shaking his disapproving head, exasperated, "you did it again, huh?"
"Did what?" Frank asked, now glancing sideways out of his eyes at me.
"Have another nervous attack," the brother said. "I told you to make sure you told everybody you have anxiety and are on medication for it. You didn't, did you?"
I looked incredulously at Frank, who now fully avoided eye-contact with me. I looked at the brother. "I point-blank asked your brother if he had anxiety or nervousness and he told me 'no.'"
"Of course," the brother said, "he always denies it. But he has about five or so attacks a day. He seems to be more and more preoccupied with dying these days. " He looked at his brother, the patient, before turning back to me and continuing. "Did he tell you he was going to die?"
I shook my head "yes." The nurse shook her head "yes." Frank, even, shook his head "yes." "Well," Frank's brother continued, "I hear that about five times in a day. Frank gets all worked-up, insisting that I will be living alone by the end of the day." The brother hesitated, as if he was going to add a quirky little comment to that last statement, but bit his tongue.
"How does Frank look to you now?" I asked the brother.
"Like he always does," the brother replied. That reply was music to my ears. Frank looked at his brother, piercing eyes and all, and spoke quite dramatically. "That's enough, Elmer."
Elmer wasn't intimidated. "You're right, this is enough." I stepped out of the room only after refereeing the minor argument that ensued. And ordering some Vitamin "V" for Frank.
It turns out that Frank had held his morning medications, including his valium and anti-depressant, in preparation of his MRI. Unfortunate, since some people without anxiety still require an anxiolytic to get through MRI testing. After a social service consult, I called Frank's family doctor with a report of what happened and, more importantly, to get a follow-up appointment for the next day.
The family doctor was surprised that, somehow, Frank's medications and history of anxiety were not conveyed to the MRI staff, which could have preempted an ER visit. It made me think, though, that if you point a finger, four are still pointing back at you. The family doctor had ordered the test and knew this patient better than anyone else. I would have assumed he would have alerted the MRI team to Frank's recent bouts of anxiety.
"May I ask," I questioned, still a little perplexed, "what was the reason for Frank's MRI?"
"Oh, sure," his doctor replied, "it was a brain MRI to rule out any recent or remote stroke activity. He's been getting real forgetful lately."
So, as it turns out, the forgetful patient forgot to share his anxiety issues.
I walked back into Frank's room to explain his follow-up plan, only to find Frank and Elmer both calmed down, watching a baseball game on TV. "So I'm not going to die, Doctor Jim?" Frank asked one last time.
I shook my head no. "Sorry, Frank, not today you aren't."
Not on my shift, anyway...
As always, big thanks for reading...I hope everyone had a great weekend. Next post will be Wednesday, May 12. See you then...
Friday, May 7, 2010
A Mother's Cry
Every day is a gift...
Initially, this was posted February 17th, and your overwhelming response and compassion astounded me. Thank you. May it remind everyone of the tremendous treasures we have been entrusted with when we become parents.
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 pronouncing 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.
My most heartfelt wishes for every mother, and mother-figure, for a blessed Mother's Day weekend. May your presence in the lives of those you love be cherished. And may unbridled love be returned to you in deserving, infinite amounts. New posts next week...
Initially, this was posted February 17th, and your overwhelming response and compassion astounded me. Thank you. May it remind everyone of the tremendous treasures we have been entrusted with when we become parents.
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 pronouncing 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.
My most heartfelt wishes for every mother, and mother-figure, for a blessed Mother's Day weekend. May your presence in the lives of those you love be cherished. And may unbridled love be returned to you in deserving, infinite amounts. New posts next week...
Sunday, May 2, 2010
Man Up, You Wimp!
As a typical guy, there are several painful illnesses that can hit our brotherhood in an instant. No warning given. No "Get out of jail free" pass, either. Just cruising along, having another fine, healthy day and baam!--suddenly you are lying on the floor in severe distress.
The most feared? A testicular torsion. It can happen spontaneously. It can happen suddenly. And if you are the owner of a testicle or two, it can happen to you. Simply put, the testicle can twist on its supporting ligaments and vessels, in essence cutting off the blood supply while stretching and irritating the supplying nerves. Sounds painful, yes? Excuse me for a second while I wipe my eyes--they're welling up just from talking about this one.
Or better yet? Taking a direct traumatic hit to the groin area. We've all seen the funniest home video shows where Dad takes one to his manhood, only to buckle over and writhe in pain. It's funny, sure, as long as it's not one of us that took the shot. And usually, the laughing female voice we hear is the guy's loving wife or girlfriend, still recording. Explain that one to me! Whatever you do, maam, don't put the camera down to help out your man!
At least with these afflictions, though, we can't be compared to a woman dealing with the same illness, shaming us with their inner strength. We can carry on and on and never have to explain ourselves and our pain. Or worry about comparisons.
However, the illnesses we do share with the more stoic and stellar species--you know, the ones with two xx chromosomes--are numerous. Chest pain. Abdominal pain of a million etiologies. Migraines. Broken bones. An asthma attack. The list is long. If you came and worked one shift with me, you would find it very evident that a woman is so much more tolerable and less whiny than a man with a similar problem. Almost always. Us guys? Yeah, for the most part, we are big wimps.
A few months back, I had two patients, a man and a woman, present to our emergency department, within an hour of one another, with the same illness. Unrelated, they were both suffering with kidney stone pain. Pain that was sudden. Pain that radiated from the flanks toward their groins. Pain that they both graded a ten out of ten.
Walking into the woman's treatment room, I found a patient with her eyes closed, breathing deeply in and out. Her tight grips on her cot's side rails were her only clue to being uncomfortable. Calmness permeated her room.
After a brief review of her history, which included a previous history of kidney stones, and a primary exam, I offered her some pain medications, in addition to some IV hydration and nausea medicines.
She smiled, taking me up on my offer. "Thank you, Doctor," she quietly said, "that would be wonderful."
After ordering her CT scan, urinalysis, and baseline blood work, I continued into another treatment room, just two doors down from her, to see the male patient.
I heard him before I even walked into his room. Between the cursing, the moaning, and the angry words directed at his wife, I knew he was going to be a difficult patient to manage.
I walked into the room, ready to briefly introduce myself and obtain a bare-bones history and physical, before offering some similar pain relief. I didn't get the chance to do either.
"God-damn it," the patient said, sarcastically, greeting me, "are you the doctor? I'm in pain here." He, by the way, arrived after the previous patient. The drama in the room was suffocating, to say the least.
I assured him that yes, I was the doctor. After a few more obnoxious words, and some dramatic flailing, he refused to tell me anything about what brought him to our ER. Now, I'm all for giving someone a break when they aren't feeling well, but his actions and words were bordering on ridiculous. "I'm not telling you anything f...ing more until I get some God-damn pain medicines," he said, crossing his arms over his chest. If he hadn't been lying in a cot, I know he would have been stomping his feet.
I know that kidney stones can be painful. I've seen enough patients with them to get that. I also know that I never want to have one. But, I also know that pain does not give one an excuse to be as blatantly rude and disrespectful, with the medical team providing care, as this patient was. Sometimes, a patient may forget that we are on their side. At any rate, it's hard to get under my skin and, after walking out of the previous stoic patient's room, this gentleman succeeded in doing just that.
"Sir," I said, "I understand you are in pain, but I won't let you talk to me or anyone else in my presence in that manner. Do you understand?" He eyed me while receiving my direct stare. "Do you understand me, sir?" I repeated. He nodded yes. "If you cooperate, I will be more than glad to help you after I learn what brought you here and perform a brief exam. I'm sorry if you don't understand this process, but that's how it's going to be done." His nurse, standing by his cot, nodded her agreeement.
Translation: Man up, you wimp!
With a little coaxing from his wife, we arrived at an understanding. As I requested, he provided me with the details of his sudden onset of pain. He was home lying on his couch when he suddenly had been overcome with pain in his right flank area. "I know it's my kidney stones again," he said. "It's just like my last one."
After cooperating, he also received pain medications with some IV fluids and nausea medicines. "Finally," he complained to the nurse, "that took forever." Yes, sir. Twelve minutes to be exact, from the time he was placed in his room until the time we pushed his medications.
Ultimately, both patients had results conclusive of a kidney stone via CT scanning. His, three millimeters. Hers, four millimeters. Both stones were in the UVJ, or the uretero-vesicular junction, the distal part of the ureter, the tube that connects the kidney to the bladder. Both stones were near their journey's end. There was no hydronephrosis, or backed-up fluid, to either's kidney.
I walked into the woman's room and explained her results. She looked more at ease, greeting me with a smile as I entered. "Thank you," she said, continuing to be stoic and kind, her grips lessened on the side rails, "for all you did. This was a wonderful experience." She had refused any further offers of IV pain medications. "I'll be fine," she had assured us. I wished her the best, advised her to return to our ER if she had uncontrolled pain or fever, and sent her home with a prescription for pain medication. She would follow with her urologist in a few days.
She had been an absolute pleasure.
Next, I walked into the man's room and to explain his results. He had received several additional doses of pain medication and appeared much more comfortable, although his complaining nature was still evident. "God-damn it," he said, now rating his pain a one out of ten, "why do I have to suffer with these god-damn stones. Why couldn't someone else get them, instead?" I explained to him that his stone was small, was near the end of passage, and that we would be sending him with a script for pain medications. On review of his previous records, he had always passed his stones without complications. I suspected that this would be no different. I referred him back to his urologist for a follow-up appointment in a few days. Yes, I was sharing the love.
I know this is an extreme example of comparing a man to a woman, with many variables to consider (a family history of stones, the size of the stone, an individual's response to pain, age, etc.). Consistently, though, through my career, women have demonstrated to be much more stoic, mature, and admirable in dealing with illnesses than men. You can't change my mind of that. It could be something as simple as the flu, or something as complex as a myocardial infarction. It doesn't matter, really.
My one buddy has a theory--the more screaming and carrying-on from a patient, the less the likelihood of that patient being seriously ill. Likewise, the more stoic a patient, the more serious the illness. At first, I laughed at him and his observation, thinking he was just joking around. "Seriously, Jim," he said, "just think of all the guys we've treated who were crying when we walked into the room." Unfortunately, after this many years spent in the ER, I've seen his theory prove itself true.
What do you think?
I think us men need to toughen up and start spitting out some nails. Or eating black licorice to grow some hair on our chest. Even throw away that certificate for a pedicure and an hour massage. Hide the cologne. Quit watching "Dancing with the Stars." Maybe, just maybe, we should step up and offer to deliver a ten-pound baby, au natural. That might put our pain in perspective.
On second thought, though, maybe I should hope to get a kick in the balls or a spontaneous testicular torsion instead of any other painful illness...that way, I won't be embarrassed or shamed by my fellow womankind when I start my high-pitched screaming in the ER. Or flailing my arms. Or crying...
As always, thanks for reading. Hope your weekend was a good one. See you next time...
The most feared? A testicular torsion. It can happen spontaneously. It can happen suddenly. And if you are the owner of a testicle or two, it can happen to you. Simply put, the testicle can twist on its supporting ligaments and vessels, in essence cutting off the blood supply while stretching and irritating the supplying nerves. Sounds painful, yes? Excuse me for a second while I wipe my eyes--they're welling up just from talking about this one.
Or better yet? Taking a direct traumatic hit to the groin area. We've all seen the funniest home video shows where Dad takes one to his manhood, only to buckle over and writhe in pain. It's funny, sure, as long as it's not one of us that took the shot. And usually, the laughing female voice we hear is the guy's loving wife or girlfriend, still recording. Explain that one to me! Whatever you do, maam, don't put the camera down to help out your man!
At least with these afflictions, though, we can't be compared to a woman dealing with the same illness, shaming us with their inner strength. We can carry on and on and never have to explain ourselves and our pain. Or worry about comparisons.
However, the illnesses we do share with the more stoic and stellar species--you know, the ones with two xx chromosomes--are numerous. Chest pain. Abdominal pain of a million etiologies. Migraines. Broken bones. An asthma attack. The list is long. If you came and worked one shift with me, you would find it very evident that a woman is so much more tolerable and less whiny than a man with a similar problem. Almost always. Us guys? Yeah, for the most part, we are big wimps.
A few months back, I had two patients, a man and a woman, present to our emergency department, within an hour of one another, with the same illness. Unrelated, they were both suffering with kidney stone pain. Pain that was sudden. Pain that radiated from the flanks toward their groins. Pain that they both graded a ten out of ten.
Walking into the woman's treatment room, I found a patient with her eyes closed, breathing deeply in and out. Her tight grips on her cot's side rails were her only clue to being uncomfortable. Calmness permeated her room.
After a brief review of her history, which included a previous history of kidney stones, and a primary exam, I offered her some pain medications, in addition to some IV hydration and nausea medicines.
She smiled, taking me up on my offer. "Thank you, Doctor," she quietly said, "that would be wonderful."
After ordering her CT scan, urinalysis, and baseline blood work, I continued into another treatment room, just two doors down from her, to see the male patient.
I heard him before I even walked into his room. Between the cursing, the moaning, and the angry words directed at his wife, I knew he was going to be a difficult patient to manage.
I walked into the room, ready to briefly introduce myself and obtain a bare-bones history and physical, before offering some similar pain relief. I didn't get the chance to do either.
"God-damn it," the patient said, sarcastically, greeting me, "are you the doctor? I'm in pain here." He, by the way, arrived after the previous patient. The drama in the room was suffocating, to say the least.
I assured him that yes, I was the doctor. After a few more obnoxious words, and some dramatic flailing, he refused to tell me anything about what brought him to our ER. Now, I'm all for giving someone a break when they aren't feeling well, but his actions and words were bordering on ridiculous. "I'm not telling you anything f...ing more until I get some God-damn pain medicines," he said, crossing his arms over his chest. If he hadn't been lying in a cot, I know he would have been stomping his feet.
I know that kidney stones can be painful. I've seen enough patients with them to get that. I also know that I never want to have one. But, I also know that pain does not give one an excuse to be as blatantly rude and disrespectful, with the medical team providing care, as this patient was. Sometimes, a patient may forget that we are on their side. At any rate, it's hard to get under my skin and, after walking out of the previous stoic patient's room, this gentleman succeeded in doing just that.
"Sir," I said, "I understand you are in pain, but I won't let you talk to me or anyone else in my presence in that manner. Do you understand?" He eyed me while receiving my direct stare. "Do you understand me, sir?" I repeated. He nodded yes. "If you cooperate, I will be more than glad to help you after I learn what brought you here and perform a brief exam. I'm sorry if you don't understand this process, but that's how it's going to be done." His nurse, standing by his cot, nodded her agreeement.
Translation: Man up, you wimp!
With a little coaxing from his wife, we arrived at an understanding. As I requested, he provided me with the details of his sudden onset of pain. He was home lying on his couch when he suddenly had been overcome with pain in his right flank area. "I know it's my kidney stones again," he said. "It's just like my last one."
After cooperating, he also received pain medications with some IV fluids and nausea medicines. "Finally," he complained to the nurse, "that took forever." Yes, sir. Twelve minutes to be exact, from the time he was placed in his room until the time we pushed his medications.
Ultimately, both patients had results conclusive of a kidney stone via CT scanning. His, three millimeters. Hers, four millimeters. Both stones were in the UVJ, or the uretero-vesicular junction, the distal part of the ureter, the tube that connects the kidney to the bladder. Both stones were near their journey's end. There was no hydronephrosis, or backed-up fluid, to either's kidney.
I walked into the woman's room and explained her results. She looked more at ease, greeting me with a smile as I entered. "Thank you," she said, continuing to be stoic and kind, her grips lessened on the side rails, "for all you did. This was a wonderful experience." She had refused any further offers of IV pain medications. "I'll be fine," she had assured us. I wished her the best, advised her to return to our ER if she had uncontrolled pain or fever, and sent her home with a prescription for pain medication. She would follow with her urologist in a few days.
She had been an absolute pleasure.
Next, I walked into the man's room and to explain his results. He had received several additional doses of pain medication and appeared much more comfortable, although his complaining nature was still evident. "God-damn it," he said, now rating his pain a one out of ten, "why do I have to suffer with these god-damn stones. Why couldn't someone else get them, instead?" I explained to him that his stone was small, was near the end of passage, and that we would be sending him with a script for pain medications. On review of his previous records, he had always passed his stones without complications. I suspected that this would be no different. I referred him back to his urologist for a follow-up appointment in a few days. Yes, I was sharing the love.
I know this is an extreme example of comparing a man to a woman, with many variables to consider (a family history of stones, the size of the stone, an individual's response to pain, age, etc.). Consistently, though, through my career, women have demonstrated to be much more stoic, mature, and admirable in dealing with illnesses than men. You can't change my mind of that. It could be something as simple as the flu, or something as complex as a myocardial infarction. It doesn't matter, really.
My one buddy has a theory--the more screaming and carrying-on from a patient, the less the likelihood of that patient being seriously ill. Likewise, the more stoic a patient, the more serious the illness. At first, I laughed at him and his observation, thinking he was just joking around. "Seriously, Jim," he said, "just think of all the guys we've treated who were crying when we walked into the room." Unfortunately, after this many years spent in the ER, I've seen his theory prove itself true.
What do you think?
I think us men need to toughen up and start spitting out some nails. Or eating black licorice to grow some hair on our chest. Even throw away that certificate for a pedicure and an hour massage. Hide the cologne. Quit watching "Dancing with the Stars." Maybe, just maybe, we should step up and offer to deliver a ten-pound baby, au natural. That might put our pain in perspective.
On second thought, though, maybe I should hope to get a kick in the balls or a spontaneous testicular torsion instead of any other painful illness...that way, I won't be embarrassed or shamed by my fellow womankind when I start my high-pitched screaming in the ER. Or flailing my arms. Or crying...
As always, thanks for reading. Hope your weekend was a good one. See you next time...
Friday, April 30, 2010
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...
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...
Wednesday, April 28, 2010
Double Crack
There are occasions, in the midst of examining a patient, when I am caught off guard by some meaningless observation or physical finding.
For example, I never would have guessed that an 80 year-old grandmother named Bertha would have a tramp stamp. But, a few weeks ago, there it was, a four-leaf clover tattooed right on the small of grandma's back. It distracted me from appreciating her diamond-studded nose-ring, I'll tell you. A few days later, I treated a very pretty college student who made me wince when she shook my introduction hand within her own man-hand. And, on the same shift, I treated a college guy who didn't have one hair on his entire body, thanks to an overactive Gillette razor. Not one. Heck, even the 50 year-old conservative business man surprised me with his bilateral nipple piercings (I am thinking "ouch" even as I type that). Impressive what a double-breasted suit can hide.
These physical findings rarely play any part in treating a patient or making a diagnosis. They are simply observations that happen to be noticed during the course of a thorough physical exam. Nothing judgemental. No prejudices. Just an aspect of a patient's physicality that jumps out at you when you aren't expecting it. To each their own, I say. Whatever makes you happy and isn't harming the next fellow human being.
I think anyone who does a patient exam can relate to these surprises, though. If nothing else, these findings keep me on my toes. If truth be told, I like these unexpected discoveries--these little secret gems that a patient would probably not commonly share with his fellow man. Seriously.
Picture it. "Um, yeah, Darryl," I imagine a patient confessing at a tavern, an empty pitcher of Guinness sitting between him and his good friend, "I need to tell you something. I have seven toes on my right foot. And, I have your wife's initials trimmed in my chest hairs." Yeah...I don't think so. Lucky me, though--I get to discover those initials when I auscultate this patient's heart.
The other day, I was privy to one of my more favorite observations. Like a rare bird, the sighting of one of these is few and far between. In fact, I can count on two hands how many times I've seen this characteristic in my career. It was very exciting.
I can just picture you now, sitting on the edge of your seat, saying to yourself, "What is it? What did he see?"
Okay. I'll spill. It was the famous (drum roll, please)... "double crack."
Walking into Room 31, I had no reason to suspect that I would, in a few short minutes, be giddy over seeing another double crack. It had been a few years, easy, since my last sighting. And, to be honest, this patient did not fit my usual perception as to who would possess the double crack.
I introduced myself to this patient. A very nice person who had been suffering with some dizzy spells and a chronic cough. Nothing major, but just enough of an annoyance that, after a few weeks, he wanted to be "checked out." After a satisfactory interview, we moved on to the physical exam. Vitals were reviewed. An HEENT exam was normal. Throat and neck, good. The heart, steady and strong with a regular rhythm and no murmurs appreciated.
And then...the spotting of the double crack.
After listening to the patient's heart, I had the patient, who was in a gown, sit up in his cot, leaning forward so that I could auscultate his lungs from a posterior approach.
I had my stethoscope in my ears, listening as I had the patient take several deep breaths in and out, when I casually glanced down along the patient's mid and lower back. And there it was, the double crack, staring back at me, waiting for me to discover it's existence.
To explain the double crack, I am taken back to the first time I had to explain to my giggling kids, at a local zoo, why the baboons' bottoms were bright red. You know that color--the inflamed, captivating shade of a deep, rich sunset. "It's just part of being a baboon," I told them. No other explanation, really, was needed. The baboons' bottoms were what they were. And, as I told my kids, I don't even know if the baboon knew his own bottom makes a bright-red firetruck look dull.
Note to self--don't forget to do a google search on the baboon's red ass.
But, just like the baboon's ass, it is very hard for me to take my eyes from the double crack. And to explain why it exists? I can't. It just does.
So, as I tracked along this patient's vertebrae with my eyes, I spotted his double crack in the lumbar region. Whether it was the way this patient's skin folded, or the way the patient sat, or the way his supporting muscles ran longitudinally along his spinal column, or just where his body decided to deposit some extra fat, I really couldn't tell you. But, when I had this patient sit up in his cot, the sides of his lower back tissue folded up to meet at the mid line, creating a perfect replica of an ass crack.
I kid you not.
Starting around the upper lumbar area, the deep fold ran the length of the lower back, ending just before the tailbone region. There, a gap of about two inches of regular anatomy existed, giving good pause between the impostor crack and the beginnings of the patient's real buttock's crack. Yep, the real crack poked out of this patient's droopy underwear, challenging the impostor crack to a face-off. I couldn't have picked the better crack. Deeply creased and pressed together, that impostor crack looked like the real thing. Perfection, almost.
Thus, the double crack.
I had the patient take a few extra breaths, relishing my sighting while I made sure the patient had good air movement within his lungs.
Like the baboon and his fiery red ass, I don't think this patient knew what he was in possession of. Maybe a good thing, really. I sure wasn't going to tell him.
Could I even bill for that diagnosis? Any coders out there? Acute double crackitis. Code 191.22.3?
I came home that night and looked at my lower back in the mirror. I sat down. I stood up. I rotated. I side-bended. Nope, no double crack on me. I even made my wife look, but she couldn't spot one, either. Darn it. I secretly wanted my own double crack.
"Sorry, Jim," she said, laughing, "you'll just have to suffer through life with one crack."
I guess I'll just have to make myself an appointment to get a tramp stamp.
As always, big thanks for reading (and in this case, tolerating my silly, indecent humor). The well ran dry from a busy weekend, so I took Monday off. Thanks for understanding. See you Friday...
For example, I never would have guessed that an 80 year-old grandmother named Bertha would have a tramp stamp. But, a few weeks ago, there it was, a four-leaf clover tattooed right on the small of grandma's back. It distracted me from appreciating her diamond-studded nose-ring, I'll tell you. A few days later, I treated a very pretty college student who made me wince when she shook my introduction hand within her own man-hand. And, on the same shift, I treated a college guy who didn't have one hair on his entire body, thanks to an overactive Gillette razor. Not one. Heck, even the 50 year-old conservative business man surprised me with his bilateral nipple piercings (I am thinking "ouch" even as I type that). Impressive what a double-breasted suit can hide.
These physical findings rarely play any part in treating a patient or making a diagnosis. They are simply observations that happen to be noticed during the course of a thorough physical exam. Nothing judgemental. No prejudices. Just an aspect of a patient's physicality that jumps out at you when you aren't expecting it. To each their own, I say. Whatever makes you happy and isn't harming the next fellow human being.
I think anyone who does a patient exam can relate to these surprises, though. If nothing else, these findings keep me on my toes. If truth be told, I like these unexpected discoveries--these little secret gems that a patient would probably not commonly share with his fellow man. Seriously.
Picture it. "Um, yeah, Darryl," I imagine a patient confessing at a tavern, an empty pitcher of Guinness sitting between him and his good friend, "I need to tell you something. I have seven toes on my right foot. And, I have your wife's initials trimmed in my chest hairs." Yeah...I don't think so. Lucky me, though--I get to discover those initials when I auscultate this patient's heart.
The other day, I was privy to one of my more favorite observations. Like a rare bird, the sighting of one of these is few and far between. In fact, I can count on two hands how many times I've seen this characteristic in my career. It was very exciting.
I can just picture you now, sitting on the edge of your seat, saying to yourself, "What is it? What did he see?"
Okay. I'll spill. It was the famous (drum roll, please)... "double crack."
Walking into Room 31, I had no reason to suspect that I would, in a few short minutes, be giddy over seeing another double crack. It had been a few years, easy, since my last sighting. And, to be honest, this patient did not fit my usual perception as to who would possess the double crack.
I introduced myself to this patient. A very nice person who had been suffering with some dizzy spells and a chronic cough. Nothing major, but just enough of an annoyance that, after a few weeks, he wanted to be "checked out." After a satisfactory interview, we moved on to the physical exam. Vitals were reviewed. An HEENT exam was normal. Throat and neck, good. The heart, steady and strong with a regular rhythm and no murmurs appreciated.
And then...the spotting of the double crack.
After listening to the patient's heart, I had the patient, who was in a gown, sit up in his cot, leaning forward so that I could auscultate his lungs from a posterior approach.
I had my stethoscope in my ears, listening as I had the patient take several deep breaths in and out, when I casually glanced down along the patient's mid and lower back. And there it was, the double crack, staring back at me, waiting for me to discover it's existence.
To explain the double crack, I am taken back to the first time I had to explain to my giggling kids, at a local zoo, why the baboons' bottoms were bright red. You know that color--the inflamed, captivating shade of a deep, rich sunset. "It's just part of being a baboon," I told them. No other explanation, really, was needed. The baboons' bottoms were what they were. And, as I told my kids, I don't even know if the baboon knew his own bottom makes a bright-red firetruck look dull.
Note to self--don't forget to do a google search on the baboon's red ass.
But, just like the baboon's ass, it is very hard for me to take my eyes from the double crack. And to explain why it exists? I can't. It just does.
So, as I tracked along this patient's vertebrae with my eyes, I spotted his double crack in the lumbar region. Whether it was the way this patient's skin folded, or the way the patient sat, or the way his supporting muscles ran longitudinally along his spinal column, or just where his body decided to deposit some extra fat, I really couldn't tell you. But, when I had this patient sit up in his cot, the sides of his lower back tissue folded up to meet at the mid line, creating a perfect replica of an ass crack.
I kid you not.
Starting around the upper lumbar area, the deep fold ran the length of the lower back, ending just before the tailbone region. There, a gap of about two inches of regular anatomy existed, giving good pause between the impostor crack and the beginnings of the patient's real buttock's crack. Yep, the real crack poked out of this patient's droopy underwear, challenging the impostor crack to a face-off. I couldn't have picked the better crack. Deeply creased and pressed together, that impostor crack looked like the real thing. Perfection, almost.
Thus, the double crack.
I had the patient take a few extra breaths, relishing my sighting while I made sure the patient had good air movement within his lungs.
Like the baboon and his fiery red ass, I don't think this patient knew what he was in possession of. Maybe a good thing, really. I sure wasn't going to tell him.
Could I even bill for that diagnosis? Any coders out there? Acute double crackitis. Code 191.22.3?
I came home that night and looked at my lower back in the mirror. I sat down. I stood up. I rotated. I side-bended. Nope, no double crack on me. I even made my wife look, but she couldn't spot one, either. Darn it. I secretly wanted my own double crack.
"Sorry, Jim," she said, laughing, "you'll just have to suffer through life with one crack."
I guess I'll just have to make myself an appointment to get a tramp stamp.
As always, big thanks for reading (and in this case, tolerating my silly, indecent humor). The well ran dry from a busy weekend, so I took Monday off. Thanks for understanding. See you Friday...
Friday, April 23, 2010
The Complacent Eyes
I walked into Room 35 to find a three year-old lying on the hospital cot. Her father sat alongside her bed, whispering softly to her. The patient appeared quite tired, wiped-out even, and if it weren't for her complacent eyes tracking my every move, I would have thought she might be sleeping.
She was visiting our ER because, after a few days of cough and congestion, she had developed a fever. 102.2. Not such a big deal, usually, for a healthy child. Unfortunately, this child was not healthy.
She had leukemia. Acute lymphocytic leukemia (ALL), to be exact. And because she was currently receiving chemotherapy, a fever with an immunocompromised system could signify tremendous trouble for her.
Because of my experiences with my middle child, Cole, who sadly spent two of the first six years of his life battling his own life-threatening illness with multiple chemotherapies, I was well-aware of the concerns of this family. Besides the concerns, I was also well-aware of the lessons of bravery and love, of sadness and heartache, that came with this child's illness. Immeasurable. Five years after our own journey, I can easily see that I am a better man and a better physician from our experience. A better human being, actually.
I knew how to help this family through this crisis.
This beautiful little girl, with her brown, wavy, returning hair, had been diagnosed with ALL last summer, following symptoms of significant fatigue. She had been transferred to Children's Hospital, where she had a mediport placed and began an aggressive regiment of chemotherapy, high-dose steroid therapy, and prophylactic antibiotics. And, happily, she responded well. Her chemotherapy, just eight months after her diagnosis, had just been reduced to the maintenance phase. Instead of receiving IV chemotherapy every week, she now only needed to receive it once a month. The steroids, the antibiotics, and the oral chemotherapies were continued on their regular schedule.
So, her fever--where did come from? The typical cough and cold symptoms had passed through their house. Mom first, then Dad, and then this patient's younger sibling. Against offered prayers, she was the last to get the runny nose, the congestion, and the coughing. Ten hours before arriving at our ER, she had developed a concurrent low-grade fever that steadily climbed until her presentation for treatment.
Dad brought his precious daughter to us, entrusting us to do right, while Mom stayed home with the younger sibling. He walked through our ER entrance, explained to our triage receptionist and nurse what brought him and his daughter to our ER, and was immediately escorted from our busy waiting room, where his daughter might be exposed to other illnesses, to an isolation room. The door was shut and reverse isolation warnings were placed. Until we learned the status of her immune system, we would take no chances of this little girl getting exposed to any further illnesses.
Anyone who wanted to enter Room 35, while this little girl was being treated, would need to don a mask and gloves and a sterile gown. That included myself, the nurses, the IV team who would access her port, the radiology techs who would take her portable chest x-ray, and our phlebotomists.
So, this is how I met my brave little patient and her father, wrapped in a sterile, disposable, pale-yellow gown, with a blue mask clinging over my mouth and rubber gloves snugly fitting my hands. Hardly a welcoming outfit, but necessary.
"Good morning, Meghan," I said, speaking through my mask, watching the little girl's eyes slowly follow my movements, "I'm Dr. Jim. And I am going to help you feel better today, okay?" I looked for a little spark in those complacent eyes, but, sadly, there was none. Between her fever, not feeling well, and probably expecting to be poked and prodded, she looked miserable.
After talking with Dad, he with the heartfelt smile and calming voice, I performed my exam on Meghan, who appeared so fragile and tiny lying within the cot's hospital blankets. She had an obvious cough, somewhat wet. Looking in her ears, I found a whopping left ear infection. Crusty nares. A patent, non-reddened throat. Her heart and lung exam was perfect. No abdominal pain. Her extremities were unremarkable. Most importantly, she had no rash.
Interestingly, her mediport was not near her collarbones, or clavicles, where I usually find them. Instead, it was on her right lateral mid-abdominal section. "They had a hard time placing one up by her neck," Dad said, "so they put it there instead." The mediport is basically a little pin cushion, placed under the skin, with tubing that is inserted and anchored to a larger vein. When accessed with a needle, it can be used to administer fluids or medications and withdraw blood. Basically, it functions as a permanent IV. After a successful outcome, the mediport is removed, leaving a battle scar about 1-2 inches long.
My son has two, one near each collarbone. Two battles. We won that war.
With Meghan, we accessed her mediport and obtained blood to check her white counts and for cultures. We obtained a urine specimen to check for infection. We performed a chest x-ray. After all of that, we administered a dose of IV antibiotics and a dose of Tylenol.
Happily, her test results returned in her favor. Her chest-ray was negative, absent of any infectious findings. Her urine results were clean--no infection. And her blood counts? They were low, as we expected from her chemotherapy, but not dangerously low. She had a sufficient immune system to fight off this infection.
I called her hematology/oncology team and shared our workup and findings with them. Meghan had the same team as my son, and I was familiar with the person on the other end. They were appreciative of our efforts and we arranged Meghan to be seen by them in two days.
I walked back into her room, smiling, ready to deliver some good news for a change. I no longer needed my gown, my gloves, or my mask. Hopefully, Meghan would be able to see my happiness for her, plastered all along my face's edges. I had a bounce in my step.
If I thought I was happy with her results, seeing Meghan after we gave her fluids, antibiotics, and Tylenol simply made me ecstatic. She was a different child. A beautiful, smiling, interactive toddler was sitting upright in her cot, playing with stickers, eating a blue Italian ice, and watching a funny cartoon on the room's TV. Her fever had obviously broken. And looking at Dad, ten years had been erased from his face.
For a split moment there, I forgot about Meghan's fight for her life.
And in this moment, a spark had returned to her complacent eyes.
After spending some enjoyable time with both Meghan and her father, I walked back to my hallway desk, lost in my own thoughts, suddenly thinking about the five years that have passed since my son's complacent eyes regained their permanent spark. And I said a few silent prayers. One for my son. One for Meghan. And one last one, for every child who's eyes have lost their spark.
May they someday get it back.
As always, big thanks for reading. May your weekend be a great one. See you Monday...
She was visiting our ER because, after a few days of cough and congestion, she had developed a fever. 102.2. Not such a big deal, usually, for a healthy child. Unfortunately, this child was not healthy.
She had leukemia. Acute lymphocytic leukemia (ALL), to be exact. And because she was currently receiving chemotherapy, a fever with an immunocompromised system could signify tremendous trouble for her.
Because of my experiences with my middle child, Cole, who sadly spent two of the first six years of his life battling his own life-threatening illness with multiple chemotherapies, I was well-aware of the concerns of this family. Besides the concerns, I was also well-aware of the lessons of bravery and love, of sadness and heartache, that came with this child's illness. Immeasurable. Five years after our own journey, I can easily see that I am a better man and a better physician from our experience. A better human being, actually.
I knew how to help this family through this crisis.
This beautiful little girl, with her brown, wavy, returning hair, had been diagnosed with ALL last summer, following symptoms of significant fatigue. She had been transferred to Children's Hospital, where she had a mediport placed and began an aggressive regiment of chemotherapy, high-dose steroid therapy, and prophylactic antibiotics. And, happily, she responded well. Her chemotherapy, just eight months after her diagnosis, had just been reduced to the maintenance phase. Instead of receiving IV chemotherapy every week, she now only needed to receive it once a month. The steroids, the antibiotics, and the oral chemotherapies were continued on their regular schedule.
So, her fever--where did come from? The typical cough and cold symptoms had passed through their house. Mom first, then Dad, and then this patient's younger sibling. Against offered prayers, she was the last to get the runny nose, the congestion, and the coughing. Ten hours before arriving at our ER, she had developed a concurrent low-grade fever that steadily climbed until her presentation for treatment.
Dad brought his precious daughter to us, entrusting us to do right, while Mom stayed home with the younger sibling. He walked through our ER entrance, explained to our triage receptionist and nurse what brought him and his daughter to our ER, and was immediately escorted from our busy waiting room, where his daughter might be exposed to other illnesses, to an isolation room. The door was shut and reverse isolation warnings were placed. Until we learned the status of her immune system, we would take no chances of this little girl getting exposed to any further illnesses.
Anyone who wanted to enter Room 35, while this little girl was being treated, would need to don a mask and gloves and a sterile gown. That included myself, the nurses, the IV team who would access her port, the radiology techs who would take her portable chest x-ray, and our phlebotomists.
So, this is how I met my brave little patient and her father, wrapped in a sterile, disposable, pale-yellow gown, with a blue mask clinging over my mouth and rubber gloves snugly fitting my hands. Hardly a welcoming outfit, but necessary.
"Good morning, Meghan," I said, speaking through my mask, watching the little girl's eyes slowly follow my movements, "I'm Dr. Jim. And I am going to help you feel better today, okay?" I looked for a little spark in those complacent eyes, but, sadly, there was none. Between her fever, not feeling well, and probably expecting to be poked and prodded, she looked miserable.
After talking with Dad, he with the heartfelt smile and calming voice, I performed my exam on Meghan, who appeared so fragile and tiny lying within the cot's hospital blankets. She had an obvious cough, somewhat wet. Looking in her ears, I found a whopping left ear infection. Crusty nares. A patent, non-reddened throat. Her heart and lung exam was perfect. No abdominal pain. Her extremities were unremarkable. Most importantly, she had no rash.
Interestingly, her mediport was not near her collarbones, or clavicles, where I usually find them. Instead, it was on her right lateral mid-abdominal section. "They had a hard time placing one up by her neck," Dad said, "so they put it there instead." The mediport is basically a little pin cushion, placed under the skin, with tubing that is inserted and anchored to a larger vein. When accessed with a needle, it can be used to administer fluids or medications and withdraw blood. Basically, it functions as a permanent IV. After a successful outcome, the mediport is removed, leaving a battle scar about 1-2 inches long.
My son has two, one near each collarbone. Two battles. We won that war.
With Meghan, we accessed her mediport and obtained blood to check her white counts and for cultures. We obtained a urine specimen to check for infection. We performed a chest x-ray. After all of that, we administered a dose of IV antibiotics and a dose of Tylenol.
Happily, her test results returned in her favor. Her chest-ray was negative, absent of any infectious findings. Her urine results were clean--no infection. And her blood counts? They were low, as we expected from her chemotherapy, but not dangerously low. She had a sufficient immune system to fight off this infection.
I called her hematology/oncology team and shared our workup and findings with them. Meghan had the same team as my son, and I was familiar with the person on the other end. They were appreciative of our efforts and we arranged Meghan to be seen by them in two days.
I walked back into her room, smiling, ready to deliver some good news for a change. I no longer needed my gown, my gloves, or my mask. Hopefully, Meghan would be able to see my happiness for her, plastered all along my face's edges. I had a bounce in my step.
If I thought I was happy with her results, seeing Meghan after we gave her fluids, antibiotics, and Tylenol simply made me ecstatic. She was a different child. A beautiful, smiling, interactive toddler was sitting upright in her cot, playing with stickers, eating a blue Italian ice, and watching a funny cartoon on the room's TV. Her fever had obviously broken. And looking at Dad, ten years had been erased from his face.
For a split moment there, I forgot about Meghan's fight for her life.
And in this moment, a spark had returned to her complacent eyes.
After spending some enjoyable time with both Meghan and her father, I walked back to my hallway desk, lost in my own thoughts, suddenly thinking about the five years that have passed since my son's complacent eyes regained their permanent spark. And I said a few silent prayers. One for my son. One for Meghan. And one last one, for every child who's eyes have lost their spark.
May they someday get it back.
As always, big thanks for reading. May your weekend be a great one. See you Monday...
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