Future Hopes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A hero.

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

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

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

Sister, Sister

Good day, everyone. Briefly, it is that time of year when the prestigious Medgadget Medical Blog Awards are upon us, and I have humbly been chosen as a finalist in the Best Literary Medical Weblog category for 2010. If you enjoy my blog and posts, especially from 2010, I would greatly appreciate your support for this award. Simply click on the highlight above and go vote for StorytellERdoc! As always, thanks for reading and especially for your support! Now, on to the post...

I rolled open the sliding glass door of Room 33, pushing aside the privacy curtain as I entered into the treatment room to see my next patient. By the nurse's triage note, she was a woman in her mid-thirties who presented to our emergency department with a history of leukemia and a recent complaint of bruising.

Running through my mental checklist prior to entering, I was hopeful that this patient was actively undergoing chemotherapy, which would be the best explanation for her bruising (low platelets as a result of her medications). If she was in remission and not actively receiving chemotherapy, however, the bruising could signify, among other things, a return of her leukemia. The bruising might just be letting us know that her bone marrow was ill and not able to produce healthy, viable cells.

Sigh. I thought back to Christmas Day a few years back when my mother, in remission from her leukemia, nicked her fingertip while cutting a dinner roll at the kitchen sink. A little nick of bleeding that we struggled to control. "It's back, Jim," Mom had said, knowing the truth, sadness creeping into her eyes as she watched me dress her cut. I, playing the dutiful son, reassured her that all would be okay when, in truth, it turned out not to be.

Stepping into this patient's room, then, I was prepared for the worst but hoping for the best.

Two women greeted me as I walked into the room--the patient, sitting upright on her cot, wearing a flimsy hospital gown and loose-fitting pajama bottoms, and a woman of similar age sitting beside the cot in a hospital chair. They were obvious sisters, resembling each other quite strongly. Especially when they smiled their warm smiles.

"Hello," I said, walking up to the patient and taking her hand in my gloved ones as I absorbed her appearance, "I'm Dr. Jim. A pleasure to meet you, maam." She was fatigued-appearing, trying to smile the listlessness from her face. Despite her attempts, she looked so very tired. Her eyes were hazel and apprehensive, closely watching me study her. Her skin was smooth, maybe a touch pale, and her cheekbones gaunt. Her lips were slightly dry. The hospital gown loosely hung from her shoulders.

I turned to her sister, introducing myself to her as well. As it turns out, she was the older of the two. She, like her ill sister, had hazel eyes that, perhaps, sparkled a bit more, reflecting her bigger reservoir of energy. Her skin was creamy rather than pale. Where her sister was gaunt, this woman's face was healthy, lacking her sick sister's bony jawline and cheekbones. Her smile, the obvious family trait, was as genuine as her sister's. Looking at her sister, it was easy to imagine what the patient might look like on a typically healthy day.

For all the similarities, though, there existed two glaring differences between these siblings. Whereas the healthy sister had beautiful, coarse chestnut hair, the patient wore a black and yellow bandanna to her eyebrows, obviously covering her hair loss. The other thing? The patient's arms and upper chest were covered by varying stages of bruises--older, yellowish-brown ones to younger angry, purplish ones. The ravages of battling a malignancy.

"Maam," I said to Lisa, the patient, "are you actively on chemotherapy for your leukemia or are you currently in remission?" I held my breath in anticipation of her answer.

Lisa hesitated before answering. "I guess both, Doctor Jim," she said. "I am currently in remission but still take maintenance chemotherapy." In many cancer therapies, there is both an "induction" phase and "consolidation" phase of chemotherapy. Induction therapy is the aggressive initial round(s) of chemotherapy, whereas consolidation (think of maintenance) typically is started after the cancer has been halted or significantly "beaten back" by the induction round.

"Do you know which chemotherapy regiment you are on, Lisa?" I asked, relieved and happy with both of her answers to my questions. Her bruising, I suspected, was most likely due to low platelets from her medicines.

She nodded her head no. "I can never remember the long names of them."

"Let me try," I said, "are you on ara-C and idarubicin?"

Lisa and her sister both looked at me with surprise. "Yes," Lisa said, "those are it. How did you know?" I briefly explained that I had some familiarity with leukemia and the agents used to fight it.

After interviewing Lisa as her sister sat bedside, holding her hand and contributing to Lisa's history, I learned that she had done beautifully with her induction phase of chemotherapy and had quickly entered remission after a few months. Thus far, she had only received one round of maintenance chemotherapy, the week prior.

The amazing thing? Lisa didn't even live in our hometown. She grew up here but was currently living in the South, having returned, with her doctor's permission, to visit her family for an extended weekend. She had no family to help her battle her leukemia in Tennessee and her coming home was the first time she got to see her immediate family since she was diagnosed. "That's alright, though," she said, "I know everybody's prayers are with me."

The supportive sister, sitting beside the bed stroking her ill sister's hand, suddenly burst into sobs. Gasping for air, she tried to talk. "I...wanted...to...come...down, Leeessaaa, but...couldn't..."
What a pivotal moment. Obviously, the healthy sister carried a lot of guilt and pain around for not being physically closer to help her ill sister through her torments. Whether it be kids, a job, or other responsibilities, though, I can only imagine the heaviness the healthy sister endured with each mile she was separated from her sister.

Lisa reached over to her sister and rubbed her hand through her sister's thick hair. "Oh, sister, sister," Lisa said quietly, reflectively, "I know you want to be with me. Trust me, I do. But I'm okay--really, I am. Between my friends, I am well-taken care of."

"But," the healthy sister continued, her face now looking as listless as her sister's, "I want to be there, by your side. It's not fair."

"It never is," Lisa said, "but your daily phone calls and cards and endless prayers have been felt. I promise." Lisa lifted her sister's chin up so that she could gaze into her sister's eyes and slowly, before me, her sister's face gained back its strength and tranquility.

I walked out of the room, aware of the impact of what I had just witnessed. For all the tragic and heartbreaking illnesses that occur in the world, how many of the sufferers endure an unavoidable physical separation from their loved ones and must go at fighting their illness on their own? And can you imagine being a son, a daughter, a brother, a sister, a parent, or a best friend that has to sit on the sidelines, miles away, from someone you love who is suffering with a serious illness? It was obvious these two sisters would have preferred nothing less than to be geographically closer to one another to rely and lean on each other during Lisa's travails.

The magnified pain from both Lisa and her sister, as a result of their physical separation, was a reminder to me of how lucky my family was to be able to "circle the wagons" when one of us got ill. If only everybody could be so fortunate.

I wish that for you and your family if ever the time would come.

Lisa's platelets were low, just as we thought, and she was admitted overnight for several platelet transfusions. I promised her she would be discharged in the morning. She promised me she was going to talk to her sister, reassure her all was okay, and gingerly approach her about being her possible stem cell donor. "Lisa," I said, "that would be wonderful! You know your sister loves you and would be a donor in a heartbeat if your bone marrow matches. I'll keep you both in my thoughts."

And I do...especially for the lesson they taught me that day. Thank you, sister, sister.

As always, big thanks for reading...see you early next week. Jim

Sick-kid Season

I love kids. Always have and always will. And when it comes to sick kids, I feel fortunate to have been trained in a demanding EM residency program where the pediatric emergency department was directly attached to the main trauma center. As a result of such exposure, treating ill kids became as natural to me as treating ill adults. Those little buggers, with their fevers, snotty noses, abdominal pain, and piercing shrills, don't scare me. Some get an "A" for effort, though, pulling out all of the stops in their vain attempt to get me out of their room. Regardless, because of my comfort, I try to see the really sick kids that come through our doors during my shift.

Over the holidays, with the flu season in full swing, I treated many children who were swept up in the epidemic. Some parents simply needed reassurances that they were giving their little Johnnie and Susie all the proper care, while other parents, with their heavy concerns, were right to bring their children in for a workup, including some IV hydration and anti-emetic medication. All-in-all, there was a much heavier flow of pediatrics than what we typically see.

Walking into Room 22, then, thanks to an alert by the nurse, I knew I was about to face another sick child. "This one is 'punky', Doc," she had said, "he hardly flinched when I started his IV." Never a good sign.

I quietly pulled back the curtain to the room and entered, finding a fatigued two-year-old boy sprawled on his back on the medical cot with his cotton sheet kicked into a ball at his feet. His oversized hospital gown had one loose tie in front, opened to reveal his skinny frame. His blond bangs were sweaty, matted to his forehead, and his skin was pale. Before introducing myself to his parents, I walked up to him and felt his forehead with the back of my hand. He was "burning up," as we say and, more importantly, didn't even shrug to a stranger's touch.

I shifted my focus to his parents, walking up to the young mother sitting in a chair alongside her son's cot. She looked as wiped-out as her son, the livelihood of her existence threatened by her son's illness. She was tearful, a mother's angst clearly etched into her face. I took her right hand in the both of mine, squeezing it reassuringly. "We'll get him feeling, better," I said, nodding to her sleeping son as I spoke. She dabbed her eyes with a Kleenex and gave me a feeble smile.

Next, I walked up to the father, his disheveled baseball cap barely clinging to his head as he paced three steps back and forth in a tight corner of the room. We shook hands and I held his gaze for a few extra seconds, trying to silently reassure his concerns. He, like the mother, was young, worried, and quite upset over his son's circumstances. He looked me in the eyes and took a deep breath. "Can you really make him better, Doctor?" he asked, a glimmer of hope escaping his watchful eyes.

"Let me talk to you both, do a thorough exam of your son, and order some tests and treatment for him, okay? But yes, I do think we'll get your son to feel better by the time we are done treating him." Their son looked like several other patients we had recently treated for influenza.

Between the two of them, I learned that they were first-time parents and married. Although neither of them were ill, their son went to daycare two days a week, where they thought "a bug" was going around. He had been born full-term and was up-to-date on his immunizations. This was his first major illness, barring a few past ear infections. Over the past few days, they watched their son eat and drink less, urinate less, become less active, and start a fever that they couldn't control. Eventually, all of their son's symptoms worsened and became boggled in their minds, totally confusing them (like any first-time parents) as to what symptoms were most serious and needed addressed immediately.

That's where we came in.

After a thorough exam on this patient, I had no suspicions for focal illnesses (such as pneumonia, bronchitis, or strep throat) on this patient. His temperature was quite high (103.7) and he appeared clinically dehydrated, so we treated him with a Tylenol suppository, aggressive IV hydration, and some IV Zofran, a God-sent anti-emetic that helps control nausea and vomiting. Then we sat back and waited--one, to see how the child would respond to our interventions and two, to review the results of our blood and urine tests as they returned.

Within the hour, I was walking into my work station with another patient chart only to find Dad standing at the counter, waiting to talk to me. He was smiling.

"He's doing better already?" I asked. "Come take a look," Dad said, practically grabbing my hand and pulling me towards his son's room.

We got back to his son's room and, before opening the curtain, the father stepped aside, sweeping his arms as if welcoming me to step into his home.

Pushing aside the curtain, I was extremely happy to find their son sitting upright in bed, licking an Italian ice while watching a cartoon on the TV. He looked at me with apprehension, turned to his mother who gave him a reassuring wink, before turning his attention back toward the TV, continuing to lick his popsicle. He was a new kid.

The mother jumped from her chair, then, and rushed me, giving me a big, grateful hug. "I can't believe how good he looks," she said, muffling her words into my shoulder. "Yes," I said, happily agreeing with her, "he looks great!" She left my side and went back to her cot-side chair, sitting clumsily down before wrapping her hands back around her son's torso. Her face held the most genuine expression of thankfulness and love that could ever be.

Within the next hour, as the patient's labs returned with adequate results, the nurse and I took turns going into the room to educate the parents and answer their questions.

How frequently are they supposed to use Tylenol and ibuprofen?
What doses of Tylenol and ibuprofen are they supposed to use?
How should they use the Zofran prescription we'd be sending them home with?
What type of fluids should they give their son?
What foods would be okay to reintroduce back into his diet?
How much sleep should they let their son get?

It's easy to see how confusing it can get the first time your child has a serious illness. Their questions for us were endless and repeated several times, but we, in the medical field, all know that education and knowledge is most empowering to recover from an illness. Our patience in the parent's education is paramount. Besides making sure each of their questions were answered, we also wrote down their instructions for them to take home.

By the time we were ready to discharge this patient, he was a new kid, running around his room, drinking watered-down juice, coloring the staff pictures, and covering himself in the stickers we gave him.

To us, another successful but predicted response to our interventions with a child with the flu. To the parents, though, this was nothing short of a miracle. The clouds had parted, the rays of sunshine had dispersed before refocusing on the head of their sick child, and the gods had sung. Anyone who has had a sick child recover knows these feelings of exhilaration that follow the many pangs of doubts that haunt us during our child's illness.

I've been there...have you?

The nurse and I stood together at the counter and watched this young family walk out of our ER after being discharged. Three big smiles, plus two more if you count ours.

It was another good day in the ER...

As always, big thanks for reading. I appreciate the nominations and support for the 2010 Medgadget awards for best medical weblogs...thank you, thank you. I hope this finds you well...

My Buddy, For Always

A few months back, I had been cleaning out my overflowing desk folders when I happened upon one filled with lots of letters and pictures and cards from my kids. Some older, some more recent. All of them precious.

Of course, despite the folder's bulge and disarray, not a single thing would be discarded. I wouldn't even think of it. And in a Clark Griswold moment (when he was sitting alone in his house attic watching old family videos) , I leaned back in my office chair and began to rummage through the collection, slowly being taken back to moment after memorable moment of my children's childhoods thus far. Deep sighs, silent smiles, and bittersweet emotions rushed me.

Yes, time certainly does fly by. Darn it all. If only a rewind button or a pause button had been invented to control the pacing of our lives, I'm certain that we would all be pushing it frequently. Shamelessly. Without abandon. Heck, I could almost guarantee my finger would be calloused from my efforts.

While reviewing the collection that sat in front of me, though, I was reminded time and again of one giant thought--that I am a lucky guy. A very, very lucky guy. Two beautiful daughters and one resilient son. Kind and compassionate, all of them. Various notes printed in crayon and colored pictures documenting the world from their view were soon scattered all over my desk, my lap, and taped to my office walls.

What follows is one of the pieces, currently hanging on my office book shelf, that I am allowed to share with you, courtesy of my son, written several years ago as a homework assignment in third grade for Mrs. F. My heartfelt thanks from me to her. And to heck with grammar and punctuation and new paragraphs. The beautiful childlike cursive and use of "my dad" ten times is all I really needed.

My Inspiration

My Inspiration is my dad because he teaches me things I need to know. He also helps me when I need him or if I get hurt my dad is there to help. My dad is a great cook and my favorite thing he makes are egg whites. My dad helps me in my baseball skills and helps me in other sport. My dad has helped me so much in my fort in the woods. My dad drives me places I need to go like baseball practice and baseball games. At night my dad would come in my room and say goodnight. Then we would play this game. My dad works so hard so we can do things we want to do like go on vacation. My dad helps me clean up the yard when my mom says to clean the yard by myself. When I grow up I want to be just like my dad.

Cole in 3-F

As soon as I had read this piece, I stood from my office chair and hurried myself into our foyer, to the northern wall, where my favorite picture of my buddy and I was hanging in an antique frame among the numerous other framed pictures. I stood on my tiptoes, barely reaching its lower border, until I successfully lifted it from its hanging nail.

I returned to my office and sat back down, focusing on the picture. Immediately, I was taken back ten years to the beautiful North Carolina coastline. To our family vacation. To a healthy Cole. To the summer before Cole would spend a full year on his induction chemotherapy to beat his illness.

I posted the picture above. In case you don't know, I am the one on the right, with the wedgie.

I still look at this picture often, always amazed to think that it was taken at a time when our life was pollyanna, when bad things happened to other people--not to us. I look at my son's little hand, raised up into my own, and feel the surge of the bond from our contact. I carry a sand pail in my right hand, ready to tackle another project together, my buddy and I. Together. Regardless if it entails building a sand castle or fighting a life-threatening illness. I am there for my kids, always.

Finally, look at the view that faced us as we walked forward. The big, big ocean, although only a small part of our bigger, bigger world. The enormity of symbolism in this picture staggers me. Come hold my hand, Cole, I must have thought, I'll take care of you. And together, we head on into the waves, into the roughening path that life sometimes leads us on.

Blindly and unknowing, we walked, but with a strength and a conviction that any obstacle will be faced to the best of our ability.

And although it took a couple hard-fought battles, we won Cole's war. He won his war.

I don't think I need to tell you who my inspiration is...

As always, big thanks for reading. I do cook more than egg whites, I promise. And my wife does help pick up the yard, sometimes (she asked me to let you know--lol). I hope this finds you well and that you are both inspiring and inspired in your own life...

Take A Picture

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

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

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

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

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

So, so pretty.

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

Well, thank you fellas.

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

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

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

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

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

So, so classy.

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

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

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

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

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

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

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

I was never less proud to be an American.

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

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

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

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

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

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

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

The Beaten Path

It has been almost five years since my mother lost her brave war against leukemia. Within this time frame, sadly, some of Mom's familiar traditions have become more of a fond memory rather than a continued reality. For example, although we can all cook a Christmas ham, it was Mom who criss-crossed those seasoning cloves just right on the hind, drowning them again and again with her secret glaze until the browning and flavoring were perfect. And it was Mom who decorated our home and Christmas tree into a welcoming, warm winter wonderland, season after season. Sure, my wife and sisters could probably duplicate her feats, given enough time, but it's just not the same without that extra ooomph of Mom's energy swirling among all the festive activities. Of her love swirling among her family.

The realization (or maybe, rather, fear) that someday my kids wouldn't remember Gramma, with her specialness and unique ways, was so strong, so biting, immediately after her death that I, along with my siblings, worked hard on trying to keep things just the way they were before she died. We tried to arrange the food in the fridge like she did. We continued keeping a pen and paper on the counter in the kitchen, right where she did. We folded towels just right, "like Mom taught us." We changed bedsheets from the cotton variety to flannel and then back during the revolving seasons of each year. We spritzed her perfume in the bedroom, desperately trying to keep her scent fresh. Writing cards, cooking a favorite meal, shopping in excess (with seven kids, if something was on sale, you bought ten of it), calling one another on Sundays...

Not only us kids, but Dad, too, seemed to expend a momentous amount of energy into recreating a surrounding environment much as Mom would maintain. As if somehow, despite Mom's permanent absence, submerging ourselves into a specific physicality of life would sustain our memories and souls.

Wrong.

Slowly, we each learned (at different paces and different depths) that it was okay to create new memories. New traditions. That it was not a betrayal of Mom or her memory to not bake a ham on Christmas or to not fold the towels in tri-fold but rather bi-fold. Memories injected with her presence, I learned, would always make me smile, no matter how things may now be done.

As a result, new traditions have begun to emerge within my family, poking their hesitant faces through the stomped, packed-down soil (laid by moi) and into our sunlight. They are now welcomed whole-heartedly. Fresh Polish sausage and perogies have become our Christmas dinner staple.

Dad, like a few of my siblings, will still occasionally struggle over the exactness of maintaining Mom's traditions. However, he too has gradually learned to let go of some of the uniqueness of these traditions and, instead,"go with the flow." His smiles and good-naturedness seem to walk hand-in-hand with releasing some of that burden. As they say, a remake is rarely as good as the original.

Just like the rest of us, Dad has also created some of his own rituals and traditions. And recently, while visiting him over the holidays, I was reminded of one of his rituals that I hope he never abandons.

It was during the drive home to visit my father that I explained to my wife that I was struggling to find material to write through the holidays that did not carry too much "heaviness" to it. It seemed all I was observing in the ER were patients and families with too many problems, too much heartache, and too high a level of expectation that we could fix all of their problems. On Christmas day alone, I continued, I had seen several elderly adults, without any complaints, "dumped" off in our ER by family who then immediately left to resume their holiday celebrations. "You'll have to keep Mom a few days," said one son, "so don't call me to come pick her up." After seeing an older gentleman for "trouble walking for ten years," abandoned by his family in our waiting room, I was losing a little faith.

Where was the love?

As we approached my childhood hometown, much like we always do, we turned off the main highway onto a small country road, a road that leads to the cemetery where my mother is buried. Single-lane and winding, my kids love how I beep before each sharp curve to alert an opposing vehicle or pedestrian that we are "coming around the mountain." It is a five-mile country journey that we have grown to love, anticipating the moment when we can pull off the bumpy dirt road and into the cemetery, where Mom is always waiting for our visit, right beside Christ on his crucifix. A visit back always starts this way.

Cautiously, because of freshly falling snow, our vehicle ascended the cemetery's small entrance knoll, turning left and then right and then left again, until we parked alongside the field where Mom is buried. As the kids always do, they hurried from our SUV and ran to Mom's grave stone, appreciating the fresh evergreen wreath, the new plaque, the winter flowers, and the leftover sea shells brought by Gracie the previous summer.

As my wife and I took our time getting out of the vehicle, my wife pointed down to the snow-covered ground and exclaimed, "Jim, do you see what I see?" I looked to where her finger was pointing, to the aisle leading to my mother's grave, but remained oblivious to her point.

"Look at all the other grave sites and aisles leading to them," she continued, "and tell me what you see."

I looked around at the cemetery, paying extra attention to the aisles. They were covered in freshly-fallen snow, hardly disturbed, except for the occasional lone foot prints leading to a stone and back. I looked back at the aisle leading to my mother's grave site. And then I got it--my wife's amazingly simple point.

"Do you see the footprints?" she asked, as I looked down to appreciate the well-worn path made by my father's size 15 winter boots, a path that lead right to my mother. His multiple trips back and forth were evident.

And suddenly, at this very moment during this very holiday season, I had found the love. A diamond of wonder among the sparse holiday rubble of disappointments.

My father will soon be turning 81 and, yet, twice a day, every day for the last five years, he has visited my mother. Through thick and thin. Through sunshine and snowstorms. Through the emerging dawn and the pending dusk. Rearranging fresh flowers, lovingly trimming weeds, and cursingly wiping bird poop for her stone's top. Crossing himself time and again while whispering his prayers. Sometimes, I imagine, wiping a tear from his eye. Sometimes, I'm sure, smiling his big smile while immersed in a warm memory.

And down at my feet, where I stood, was the proof of his five-year tradition--his beaten path leading to and from Mom's grave.

I smiled big, hugging my wife for pointing out this almost-missed moment. How could I have not seen this beaten, well-worn path? I grabbed my cell phone and immediately took several pictures, one included above, although none captured the minute details of each of my father's boot prints. It didn't matter, though. The moment had imprinted itself into my mind, forever.

And suddenly, as I looked toward my wife, who had joined my kids at Mom's grave site, I spun myself around, taking in the magnificent surrounding mountains while breathing in the clean country air. This world of ours made sense--the clarity of things changing, of the constant coming and going of new and old traditions that would continue to feed our wanting souls.

I wonder what traditions my children will continue when they become adults. Me? I know one tradition I hope to someday emulate or be the recipient of...

The beaten path.

To Karen, thanks for pointing out the obvious to me. As always, a big thanks to you for reading...I hope you each had a great holiday season and are enjoying the new year.

Continued Prayers, Wishes, & Hopes

I pulled up my last-year wishes for you and found myself nodding my agreement as I read, finding that the sentiment and spirit are as strong today as when I wrote them one year ago.

My continued prayers, wishes, and hopes for you and yours...have a Blessed and Happy Holidays.

Another holiday season is upon us. For all the unbridled joy and excitement that surrounds us, however, there is an uneasiness within my core that seems to seed itself every year. I don't think I am alone.

I have seen enough heartache through the year to know that joy and excitement can be very temporary. Can you even imagine wrapping presents only to return them after the holiday season because of an untimely death, never having the chance to give them? Over the holiday season, especially, heartache seems to magnify itself into a swirling tornado ready to touch down on so many lives. I've seen a lot of energy spent outrunning that tornado.

So, for all the happiness, I still can't help but be reminded of how hard these upcoming days will be for so many. My heart goes out to them. Especially the children.

How do I remember the important things in my life? And not just over the holidays, but every day? I know I have been blessed in my life. When I think of these blessings, none of them have to do with material things but rather things that spiritually feed my soul. Companionship, loyalty, kindness, and love. And more love. These make me a better person.

So, in the spirit of this holiday season, I share just a few of my prayers, my wishes, and my hopes with you.

I pray for my family, my friends, and those in the world that are in need. I pray that my son remains in remission for another five years, and another five years after that. I pray that my mother can look down on my family and smile. I pray she knows the power of her prayers, asking a forgiving God to show my son mercy and take her in His arms instead when they were both battling their malignancies. I pray that I can be gracious in adversity, always.

I wish for my family, my friends, and those in the world to know love, to embrace kindness, and to step outside the box and give more of themselves. I wish for endless hugs. I wish for good health. I wish for every child to know warmth in their heart and comfort in their soul. I wish for peace.

I hope that the ripples from compassion will disperse beyond our wildest imaginations. I hope that random acts of kindness multiply. I hope that thoughts of others will replace thoughts of ourselves. I hope that we all remember that we are in this together. I hope that your joy, your happiness, and your excitement is not temporary but rather infinite.

I pray you have a wonderful holiday season. I wish for all your expectations to be fulfilled. I hope the most important presents you will give this holiday season are gifts you can give each day through the year.

Happy Holidays...

As always, big thanks for reading... To my amazing readers...I truly hope this holiday season is blessed and happy for you and all the people in your lives.

Defining Emergency

Emergency, as per the all-knowing Webster, is defined as an unforeseen combination of circumstances or the resulting state that calls for immediate action. Furthermore, an emergency is also defined as an urgent need for assistance or relief.

These definitions sound pretty spot-on, right? When thinking about emergency room settings, even, one can easily correlate the words of Webster to what one would necessitate to be a situation requiring emergency medical treatment. A trauma. Broken bones. A heart attack. A stroke. A seizure. Respiratory distress. A cardiac arrest. The list goes on and on and on. When a critical illness or injury occurs, then, we should all be thankful that we live within a society where emergent, life-saving medical care is available.

Lately, though, it seems the system meant to provide this care is being bogged down by questionable decision-making. Instead of providing emergent care, it seems I spend at least half of my emergency room time now playing doctor to chronic illnesses. To pain control issues. To mildly elevated blood pressure readings. To months of nonspecific weaknesses and fatigue. To office appointments sent to the ER because "we are overbooked today." And our ER is not alone. I hear the frustration of my colleagues and see first-hand how overworked most of us who provide health care in the ER setting have become.

A month back, I was in the middle of a very busy shift. Several patients with chest pain (one requiring immediate catheterization), two patients with respiratory distress (one from skipping dialysis and one from a COPD exacerbation), and three patients from a motor vehicle collision presented almost simultaneously to our ER. Within minutes, all of these critical patients had been treated with efficient, appropriate life-saving care. The team on deserved kudos for doing their job well and making a difference in these patients' outcomes.

Walking back to the nursing station, then, I was surprised to find our secretary being berated by a gentleman in his thirties at the counter. His voice was loud and menacing. His face was pinched with anger. His fists were clenched by his side.

"Whoa," I said, walking up to him, standing between him and the secretary, "what seems to be the problem, sir?"

"We've been waiting two hours to be seen by a doctor!" he exclaimed. "What the hell is going on around here?"

Are you kidding? All he had to do was look for himself to find the organized commotion that was occurring in our ER setting. What followed was the briefest of conversations.

"Sir," I asked, "what brought you to our ER today?"
"My daughter's left ear is hurting her."
"For how long?" I asked.
"Two hours," he replied.

Two hours of ear pain? I get it--maybe he was worried about his daughter. I would be as well. But my daughter would also have gotten Tylenol and Advil and watched her daddy patiently wait for their turn to be treated once the dire situation had been explained. Better yet, we would have probably waited until the morning when a call could be placed to her personal physician.

I explained to him that we had multiple critical patients brought to us and we would be with his daughter as soon as possible. "We're all trying our best, sir," I added, "but you're going to need to be a little more patient."

The father stared me in the eye. I stared back. Finally, he blurted out what he had been thinking to say. "Well, then," he spoke, sarcasm dripping from his pathetic words, "try harder." It didn't end there, though. He continued. "This is bullshit waiting two hours to be seen."

Before I could respond, he turned his back and huffed himself back into Room 27 where, the nurse shared with me, his eleven year-old daughter comfortably sat watching TV. "And," the nurse added, "I had already explained to him why they were waiting to be seen."

After this, one of our regulars who had been to our ER over 200 times (since we started tracking in March of 2006) arrived via ambulance. Then a gentleman carrying a big bottle of Mountain Dew was escorted from his ambulance, by foot, into our ER because his main complaint was "I just want to take a nap and was too far from my apartment." Next, an asymptomatic patient with elevated blood pressure for three years, non-compliant with her medications for financial reasons (yes--I noticed the pack of cigarettes hanging from her purse), was sent to us from her family doctor to be cured on the spot. "Go right to the ER," she was told.

Can you appreciate the obviousness of the long waiting times in the emergency department? Although we all pride ourselves on providing expedient care, a four to six hour wait is sometimes the reality for some of our noncritical patients.

As if to hammer the point home, my last patient during my shift that night (I was working 5pm to 3am) was a sixteen year old female who had presented to our ER, via ambulance at 2am, with her mother.

I walked into her room to find this patient and her mother both lying in the cot, laughing while watching TV, the patient in no obvious distress. I introduced myself to them before I started asking questions. "What can I do to help you tonight? What brought you to our emergency room?"

The girl looked at her mother and started giggling, my first sign that she would survive whatever her ailment may be.

"Well," she said shyly, "I've had some burning when I pee for about a week. And," she added, not done "I have something gross leaking from down there (she swept her hand towards her pelvis as she spoke)." Upon further questioning, I learned that she had been diagnosed with a yeast infection from her family doctor one month ago but failed to get her prescription filled. I also learned that she was sexually active with not one, but two partners. Unprotected.

I was disheartened. "What made you come to the ER at 2am when these symptoms have been going on for over a week?" I asked, hoping there was some rhyme or reason to her seeking out emergent care at this time. There wasn't. Her answer to my question--"Why not?" I didn't even approach her on why she came in by ambulance. Some things are better not known, I guess, especially at 2am.

I'm not sure this is the system that was imagined when emergency departments started gaining favor in our society. Don't get me wrong, though. I, like all of my colleagues, are 100% committed to providing respectful and appropriate care to anyone who shows up in our department, whether it be a critical, life-threatening illness or a chronic "nuisance," so to speak.

I can only hope that people will be patient and understanding as we all cope with the evolving changes that seem to be occurring with our health care system. And my hat is off to all the medical folks who work hard, day after day, treating our fellow mankind as best we can within this currently accepted system. Because, even as bogged down as we can sometimes become, what an awesome privilege we have in meeting and greeting and treating our fellow kind. Of helping them out in their time of need.

Salute!!!

As always, big thanks for reading. I wish a blessed holiday season to each and every one of you...