Scratching Below

He was a good-looking guy, my next patient.  Even before walking into his treatment room to introduce myself, I had overheard the nurses talking about him in their nursing station.  "Did you see those brown eyes of his?" his primary nurse said.  "And that hair," added a tech, "so wavy and thick."  "I like his smile," added a second nurse, one who had helped settle this patient after he arrived by ambulance.  I could only have imagined the argument between the nurses as to who would get to be this patient's primary nurse.  I had no doubt that lots of pillow fluffing, extra blankets, repeated exams and vitals, and a turkey sandwich were all in his future.

The aggressive, single, newly-graduated nurse won out.  Secretly, I had my money on her.

I walked into the room to find a gentleman in his mid-twenties, sitting upright in his cot, in a properly worn hospital gown (I had no doubt the nurse helped him put it on correctly).  He seemed tall, six-foot maybe, and weighed around a buck eighty.  He was thick-shouldered and clean-cut, in good shape, his brown hair appearing recently-cut.  He was modern and hip--tattoos poking out from the sleeves of his gown.   

The nurses were right, of course, he was a good-looking guy.  In fact, I would have even agreed with their assessment that this patient could have modeled at one point.  More for Land's End or Eddie Bauer, though.  He would have had to imbibe in plain chicken breasts and no carbs for months to make it into a Hollister or American Eagle ad.

Good-looking or not, this patient was in our ER to be treated.  And doing a quick, cursory once-over, I could tell that all was not right.  This patient's brown eyes were dilated, tracking my every move, his deer-in-the-headlights glances matching his nervousness.  He was breathing rapidly as well, fidgeting with the pulse-ox monitor clipped to his finger.  Before I could approach him and introduce myself, his anxiety was revealed in his rapid-fire speaking.  "Are you the doctor," he blurted out.  "Yes, sir," I answered, "I am your doctor today.  I'm Dr. Jim."

He paused to take me in, looking me up-and-down.  I remained quiet during his assessment of me.  Finally he spoke.  "Do you work out?"  Of all the questions and comments I was prepared for, this one surprised me.  "Yes, sir, I work out.  You, too, I take it?"  He nodded his head yes.  Obviously, physical appearances meant something to this patient.

I decided to gain control of this interview.  "Mr. Nalstead," I asked, "what brought you to our ER today.  What can we do to help you?"

"I think I'm having a heart attack, Doc."

"Why do you think that?" I asked him.  "Are you having chest pain?"  He certainly didn't come across as a patient at risk of having a heart attack.

"No," he answered, "but I'm having a hard time breathing.  And sometimes I get palpitations, like my heart is going to pound out of my chest."

I reviewed his cardiac risk factors with him.  The patient admitted to smoking and his father was being treated for hypertension but never had a heart attack, himself.  "What are you doing when you develop this 'hard time breathing?'" I asked him.

"Usually I'm just sitting, Doc, and thinking."  "About?" I asked.  He continued.  "About my kids."  "How many do you have?" I asked, guessing, from his age, one or two.  "Three," he answered.  I wasn't too far off.

"How old are they?" I continued, interested now in his social history.  And although it is hard, after working in the ER for so many years, to catch me off-guard, this patient's answer did.

"They are 22 months, 19 months, and 16 months."  He paused, staring at me, waiting to see what my reaction would be.  I wore my poker face, though.  I'm sure he was anticipating what my next question would be.  I was no Ob/Gyn, but even I could figure out that this scenario was not possible with just one mother, one woman.

After asking him, he admitted to me that "I had gone through a pretty rough period, yeah."  He had three children to three women.  In a remarkably short period of time.  Currently, none of the three mothers of his children would let him see his kids.  Whenever he thought about his kids and his lack of involvement in their lives, he started the rapid breathing, the nervous tremor, and the heart palpitations.  Raising my suspicions for an anxiety disorder.

I dug deeper.  As it turns out, this patient had had a pretty miserable childhood.  A piss-poor father-figure.  A mother who cut him down repeatedly.  Alcohol and drugs since his early teens.  Prison time.  Although he denied any recent alcohol or drug abuse to me, I suspected he was teetering on using again.  It was a vicious cycle that needed to be broken.  And he knew it.

After doing some baseline tests to make sure he was clinically sound, I sat back down with him. His testing results, I assured him, were excellent.  "So you don't think I'm having a heart attack, Doc?" he asked me.  "I'm sure," I reassured him.  We talked a little further about how he had to break his cycle of behavior, though.  "You have to," I repeated, sternly, "if not for you, then, for those three little kids out there in our community who don't know their father's love."  My words must have gotten to him--I saw the glistening brown eyes well-up before tears spilled onto his cheeks.

We offered him counseling.  He took it.  We offered him a follow-up appointment with a family doctor who was accepting patients.  He took it.  I offered him a short-term prescription for a few anxiolytics.  Six pills.  He took it.  He asked me about my social life--and I shared with him that I was married with three kids.  "Are they fun?" he asked.  I simply nodded my head "yes."  In my mind, though, I imagined my life without my kids, a thought that made me shudder. 

The patient stared me in the eyes.  "I want to do this, Doc.  I want to be a good father to my kids."  By all appearances, he appeared sincere in wanting to break the cycle he was caught up in.  I could only hope.

I left his room, after my last recheck, thinking about all of this patient's problems, problems that were buried deep below a good-looking exterior.  On the inside.  Hidden from anyone who didn't take the time to uncover the true essence of his person.  An exterior that didn't match our society's standards of what we suppose a good-looking person has within them. After all, if a woman is beautiful or a man is good-looking, why would they have any internal turmoil?  Why would we think anything but their outer beauty would be matched by their inner beauty?  What do they have to be upset about?  How could they have any problems?

It goes back to the common thought--physical beauty is temporary, spiritual beauty remains forever.  We are all guilty of judging a book by its cover, aren't we?  I know I am, despite my awareness of trying not to.  However, I have learned, with time, that I find much more pleasure from a book by opening it.  Pretty, pretty cover, maybe.  But what are the words saying inside?

Thankfully, this patient reminded me that, yeah, I am in my mid-forties, and my body and looks might be fading a bit (some characters in my life would probably argue more than "a bit"), but I have inner peace.  I am loved.  I give love.  If you make me look like an ogre, but guarantee me my love and inner peace, I will take that deal and run with it.

I walked back to my desk.  His primary nurse approached me.  "Hey," she said, "is it okay if I discharge Mr. Nalstead?"  I nodded my head "yes" to her, adding "He is a pretty nice guy, isn't he?  I hope he can turn his life around."

She looked at me like I was crazy.  "Are you kidding," she said, "he has been in jail and has three kids to three different women!  I'm not up for instant motherhood!"  She chuckled at her words. I was surprised, this response coming from her, when just a few hours prior she had been thinking this guy was the most glorious specimen to come from the human race.

Scratch below the surface...

As always, big thanks for reading.  And a big thank you for your patience with my frequency of posting... 

The Barn Door Is Open

One of the things that continually amazes me, intrigues me even, about medicine is the scale of personalities that exist within our community.  From the obnoxious "know-it-all" to the warm-hearted "everybody's friend" types, you can find just about any recipe for a personality among us.  Take a dash of kindness, a pinch of self-doubt, a teaspoon of over-eagerness, and a dollop of sharp wit, and viola, you may have this nurse during your next visit to the ER.

Me?  I'd like to think that I am a straight-shooter, the furthest orbit away from the central pedestal that so many doctors feel they deserve to be perched on.  Their livelihood depends on this precarious position.  Mine doesn't.  I ask my team to call me Jim.  I don't wear a white coat during a shift (except in the family room, where I insist on a higher level of decorum to be followed). I welcome anyone to question why I am doing something in a certain way.  I am kind and compassionate.  I love to laugh and smile among the infectious camaraderie of a good team during a rough shift   

However, I am human, too, which means I sometimes need to really fight myself during a crazy shift or odd patient-encounter to avoid cynicism, sarcasm, anger, or disappointment.  Although rare, I have had some breaking moments.  For example, to have a patient with a top-of-the-line cell phone, decked out in a designer outfit and $300 dollar running shoes, with a pack of cigarettes hanging from their pocket demand (in an irate, demanding manner) a free ride home and free prescription fills is still something I struggle with, although my answer remains the same.  "No."  And patients who have attained their medical degree via a ten minute Google search prior to their ER visit, trying to dictate the course of their treatment, can test my limits in a weaker moment.

My idols, those inspiring physicians I've encountered through my career, seem to be the "regular Joe" doctors who have a quiet confidence and a humble self-assuredness combined with a normalcy of expected kindness and respect.  They don't want their coffee brought to them, they don't want everybody to bow at their feet, and they don't feel the need to brag and show-off their endless knowledge base (a pet peeve of mine--I'd rather one show me how good they are, through their actions, rather that waste their words by telling me).  They just want to be a friend, a mentor, a good person defined by their entire world, not just their world of medicine.  Their greatness as a physician is simply an extension of their excellence as a human being.

It is a fact I stress with our residents.  "Don't emulate just one of us," I say, "but rather, skim from each of us the characteristics you want to carry with you throughout your life, your career."  I reiterate that none of us, their mentor physicians, are perfect.  We are all human.  I can only hope that they choose to combine hard-work, compassion, and humility among their other qualities.

If I ever decide to pursue a big head and an uppity view, though, about my professional accomplishments, I think I will fail miserably.  Too many times through the day I am humbled by reminders that I am nothing special.

Case in point?  Just last week, during another busy shift, I was standing in front of the counter of Room 22.  In the treatment cot lie Mr. Smith, his mental status dwindling and his extremity weaknesses gaining.  His wife, expectedly concerned and apprehensive, sat in a corner chair just a few feet to my left, watchful of her husband and our treatment team.  Her worried look, her disheveled gray hair, her furrowed brows, her dilated pupils, the way she edged her body forward on her seat, utilizing but a few inches of its support, all spoke of her love of her husband.  Of her inherent sense that something was terribly wrong.

And she was absolutely right in her suspicions.  Mr. Smith's CT scan had confirmed a significant intracranial bleed, a stroke of devastating proportions.  A stroke that limited us, between his previous strokes and extensive medical history, in our aggressiveness.  Together, the ER nurse and I had walked into the room to share their grim news with them while we contacted the neurology and neurosurgical teams.

"Mr. and Mrs. Smith," I spoke, quietly and gently, yet urgently, "I have some disheartening news.  It appears that Mr. Smith has had another stroke, this one quite involved within the entire brain."  We talked at length about the findings, our plan of action, of how aggressive they wanted our team to be, despite our hands being tied from this CVA's severity.

Mrs. Smith took the news much better than I expected, her acceptance belying her body's expressions. While her husband floated in and out of awakeness, she explained their position.  "We were told last time that the next stroke could be the final one.  It appears we have arrived at this final one, yes?"

I couldn't help but like Mrs. Smith.  Her inner strength was simply astounding.  I nodded "yes" to her, but added "Let's at least have the specialists see your husband and make their recommendations to you."

Now she nodded "yes."  "But," she added, "neither of us want heroic measures."

I understood.  "I'm just going to remain here with you a few minutes," I said, "if that's alright, while we wait for the specialists to arrive."  Although the ER was busy, I wouldn't let that fact prevent the nurse and I from providing a few minutes of necessary companionship.

And then, it happened.  Another realization of my humanness.  After removing my supportive arm from around Mrs. Smith's shoulders, I stepped back to the front of the counter, bowed my head, and cupped my hands in front of me.  I looked to the floor, to my brown Clark clogs, as I started to say a silent prayer for this family.

Instead of finishing my prayer, though, I became distracted.  Thoroughly and completely.  Because there, in this extreme moment of crisis, in the middle of my wishful thoughts for this family, I noticed my zipper.

My wide-open unzipped zipper.  How long had it been down?  I shuddered at the thought that my zipper may have been this way for several hours and through several other patient encounters.

Not only was my zipper open and lingering at its lowest possible point, but its edges were widely gaping, exposing my hunter green, 3% spandex and 97% cotton, boxer briefs.  My hip-huggers were there for the world to take in at possibly one of the most inopportune moments.  "Hello," they screamed, "look at me.  Look here!"  Ugh!  For some unexplained reason, I remember thinking the situation would have been better had I chosen to wear my tighty-whities that day.

Slowly, I tried to cover this embarrassment with my cupped hands, but to no avail.  I shifted my legs back and forth, trying to see if the sway of my motion might magically reacquaint my zipper edges.  No go.  I looked up at the nurse, who was oblivious to my predicament, and Mrs. Smith, who was not.  She was focused on my every move. It didn't help, either, that she was sitting in her chair, eye-level of my indiscretion.  Secretly, I think she was quite entertained by my distraction.  Heck, I'd go so far to say that she enjoyed watching me squirm of embarrassment.

Suddenly, though, she looked me in the eyes, her eyes sparkling with amusement and yet glistening with sadness.  I returned her gaze.  We both remained quiet. All was okay.  I abandoned any sense of correcting the situation and remained leaning against the counter.  Graciously, she turned her head from me and refocused on her husband.  As did I.  As was the nurse this entire time.

By the grace of God, I got paged overhead for a phone call.  Probably the neurologist, I thought.  I excused myself from the room and rushed to my physician station, where I yanked up my zipper before attending to any other tasks.  Later on, as we do in our twisted ER ways, the team would have a hearty laugh at my expense.

Yep, I'm human.  I put my underwear on just like the next person.  As do every one of my fellow physicians. Oh, and my zipper will occasionally fail me and that's okay.  How can one possibly get an exaggerated ego with that in mind?

I will remember Mrs. Smith and her quiet resolve, her inner strength, in the face of such a crisis.  And I'm sure she will remember me, too, but, unfortunately, not for the same reasons. 

I hope my residents take my words to heart and emulate the best I have to offer.  Which, during that shift, was this advice--never, ever go into a patient's room without checking your zipper first!

Otherwise, I'll just keep preaching kindness and compassion.  And, oh yeah, humility...

As always, big thanks for reading.  I hope this finds you all well.  On HHI for the week and having a grand ol' time.  Any embarrassing medical stories you'd like to share?  Please do... 

What To Do

Briefly, I want to thank Dr. Billy Goldberg and Dr. Christopher McStay, emergency medicine physicians from NYU, for being gracious and entertaining hosts during my Sirius XM interview with them on Doctor Radio the Thursday morning of April 7th.  To their producer, Melanie, a huge kudos for your cool kindness and for seeking me out for this interview.  I am honored by this flattering experience.  You have played a part in making this small town boy's dreams approach his reality...    

It was my birthday.  Because I wasn't home with my wife and kids, eating cake and being silly and opening presents, reminding them over and over again that it was my special day, I was just a little bit sulky while ho-humming it, struggling to make it through my odd 5 pm to 3 am shift in the ER.  This, despite a birthday cake, balloons, several cards, chocolate, and many hugs and birthday wishes from my fellow coworkers, my friends.

I needed an encounter to remind me of my blessings.

As I sat at my computer in the physician station thinking this thought, I felt a sudden light tap on my shoulder.  "Excuse me, Dr. Jim," a nervous voice spoke, slightly quivered and breathy, "would you be able to see one of my patients?"  I turned to find one of our newer hires, a young energetic nurse who had just graduated from nursing school the previous year and was fresh off of her ER orientation, speaking.  I liked her.  I liked her eagerness, her good attitude and her priorities of providing excellent, all-around patient care.  I hadn't been, though, in a serious patient situation to really see her abilities and knowledge tested.

"Hi Chris," I said, "what can I do to help you?"

She spoke quickly as I stood from my chair and we began walking.  It was a woman in her late fifties, Room 22, one of Chris's patient rooms.  She had come in by ambulance and her clinical picture was making Chris nervous.  "Her blood pressure is really low and I can't seem to maintain her oxygen levels.  She looks bad."  She had been sent from her group home to an outpatient clinic appointment because "she didn't look good for a few days."  From the outpatient clinic's alarming find of this patient's condition, she had been sent to us.

"Oh," Chris added, right before we entered the room, "I have to tell you--she has severe MR (mental retardation) and she can't tell you anything.  All of her extremities are contorted, too."

As with most patients in this situation, I expected to find a three-inch information binder, usually maroon, sitting on the counter.  There was no binder.   I also expected an aide, familiar with the patient and her history, to be sitting in the corner chair or, better yet, standing at the patient's bedside.  Again, no aide.

The only people in Room 25, besides the patient, were a tech and another nurse helping Chris settle this patient.  Where was the binder?  Where was the aide?

Uh oh.  "A young woman came with her from the office, but said she had to go move her car and would be right back," Chris said, shaking her head.  "That was ten minutes ago.  She didn't leave us a binder or tell us anything."  Sadly, it would be over an hour before this aide came "right back," and our team was now in a struggle to get any information that we could on this patient.  What was her baseline condition?  We didn't know.  Had she been ill recently?  What was her past medical and surgical history?  Sorry, no information there.  Was her resuscitation status DNR (do not resuscitate) or was she a full code?  Did she have a living will?  Who was her power of attorney?

Don't know.  Don't know.  And don't know.  We were at a loss for any viable information.  At least we had a name, though.  That was a start.

I walked up to this patient's head, slightly forward-flexed at her neck off the pillow.  Her eyes were open, brown and dilated, a little reddened at the sclera, and she appeared to be trying to focus on something.  Anything.  Her skin was pale, ghostly white, dry and wrinkled.  Her hair was wispy gray, brushed straight back over her crown, a little greasy.  She was in a gown, but her pants still needed to be removed.   As Chris had warned, her upper extremities were rigidly flexed at both her  elbow and wrist joints.  Her legs were a little more pliable, resting in a flexed position but easily straightened at the knee.

I brushed some stray hairs from her forehead to her crown, resting my hand on her head. "Maam," I said, bent over and talking into her ear, "my name is Dr. Jim.  We are going to take real good care of you, okay?"  Her eyes found mine but, other than a brief blink, didn't give me any indication of her awareness.

I looked at her concerning blood pressure, 74 systolic over 40 diastolic.  Her heart rate was adequate, 88.  Her respiratory rate was quickened, 24, and her oxygen level was low at 89% on two liters of oxygen via a nasal cannula.  She appeared to be struggling for a deep breath.

"Chris," I said, "open up the fluids and give her two liters of normal saline.  Switch her cannula to a non-rebreather mask at 15 liters of oxygen."  As Chris did this, I did a brief primary exam, followed by a more intensive secondary exam, all the while paying attention to this patient's fragile vitals.

This poor soul, this patient without a history, was dry.  Very.  Her tongue was cracked and fissured.  Her skin was tenting, lacking hydrated elasticity.  Her urine from a foley insertion was scant, darkly-colored, and strongly odiferous.  Her heart was regular, thankfully.  Her lungs, though, had diminished air movement through them, with accompanying sounds of rhonchi and wheezing, suspicious for pneumonia.  Her abdomen was soft.  She didn't appear to grimace with my deep palpations.  Her rectal exam was positive for blood.  A rectal temperature recorded hypothermia at 95 degrees fahrenheit.  Her extremities had faint pulses but their skin coloring was as pale as her core.  Her body was frail and struggling.

This patient was septic, plain and simple, infection threatening to overtake her entire body.  Hypothermia.  Low blood pressure.  Low oxygenation levels.  Suspicion for dehydration.  Suspicion for pneumonia.  Suspicion for a urine infection possibly spread to the blood stream.  An unclear mental status change from an unknown baseline.  And, add to that, a suspicion for a GI bleed.

We ordered our workup.  Blood cultures and blood work.  EKG.  Chest x-ray.  Urine work and cultures.  We continued aggressive IV fluids while covering the patient with a warming "bear-hugger." We started immediate IV antibiotics, gave her breathing treatments, and put her on additional respiratory supportive measures.  With rhythmic purpose, I observed Chris and our ancillary services kick up the care.

Still, we had no information.  No binder.  No aide.  We searched for her group home's number and address.  We had called the outpatient clinic but, since she was a new patient and was so critical, they had not wasted much time delving into this patient's past before sending her to us.

We proceeded as if this patient was a full code.  We had to--it's what you do in these circumstances.  Initially, the patient did okay, responding to our fluids and respiratory interventions.  Her oxygenation picked up to 95%, and her blood pressure increased, 98/62.  But still, she looked fragile.  Pathetic, even, in her misery.  My gut instincts, usually spot-on, told me to be ready for this patient to crump at any moment.

And she did.  Her condition took a turn for the worse at the very moment we succeeded in contacting her power-of-attorney, her concerned brother.  After talking to him, we followed his wishes of doing everything in our power to improve his sister's critical state.  She was a full code.  He sounded quite reasonable and was hurrying to our hospital to be with his sister at her bedside.  Quickly, to stabilize the patient's breathing concerns, we emergently intubated her and connected her to a vent.  Despite sedating and paralyzing her, however, her arms remained quite contracted while her legs and neck relaxed.  We started medicines to elevate her dangerously low blood pressure.  We started central lines and arterial lines to continue giving IV fluids and monitoring vitals.

Then, concerning results began to roll in.  Acute kidney failure.  Severe dehydration.  Significant pneumonia on x-ray.  Low red blood cell counts, probably from a GI bleed, requiring transfusions.  Skewed electrolytes, including a high postassium.  Infected urine.  

She would need an ICU admission, which we pursued and obtained.  She would need emergent dialysis.  She would need critical care from a variety of sub-specialties in attempts to improve her condition.  She would need continued life-saving medications and interventions.  She would need a lot of good energy and a little luck to come back from being so ill.  Hopefully, we started her on the right path.

I sat back in my chair after all the action, exhaling a deep sigh while mentally reviewing this patient's ER course.  Our team had done well and I was proud of them.  I was worried, though, for this patient.  Chris came in and spoke.  "Just so you know, the aide returned."  Chris paused and took a deep breath before continuing.  "I let her know we have called the agency and they will be looking into where she had been for the past hour or so.  Now she is teary-eyed and, frankly, she should be.  Oh, and she has the binder if you need to look at it."  Again Chris paused, before finishing.  "Is that okay," she asked with sincerity, "that I called the agency?"

I looked at Chris, smiling at her.  "Chris," I said, "you did good.  It was the right thing to do."  Simple and direct.  Yeah, I thought, we got ourselves a keeper with this nurse.

I didn't meet the brother, although I heard he was a pleasure to deal with.  Loved his sister.  Had her best interests at heart. Disheartened by her turn of health.  He had been escorted to the medical ICU after his arrival, where they were waiting for him.  I couldn't help but wonder, though, what his life had been like to grow up with a severely-handicapped sister.

After things quieted down, when I was alone again at my station, I looked at the computer screen's lower right-hand corner. Yep, the date said it was still my birthday.  Just a few more hours remained.  Suddenly, though, I didn't feel so old.  Or so ho-hum.  Or so out-of-sorts from not being home celebrating with my family.

Instead, I felt appreciation.  For being healthy in my mid-forties.  For being surrounded by cool people in my life.  For knowing I had family at home waiting for me, ready to enjoy my upcoming time-off with me.  For having a sound mind.  For having flexible joints and limbs.  It wasn't lost on me that, by the luck of the draw, this patient's life could have been any one of ours.

Happy Birthday to me.

As always, big thanks for reading.  A big thanks for the numerous birthday wishes, too.  Several key facts have been changed to maintain patient confidentiality within this story, but the essence of the encounter remains true and thought-provoking.  See you in a few days...

Another Birthday

Today is my birthday.  Yep, today.  On this fourth day of this fourth month of this year, I officially have turned 44.  Should I buy a lottery ticket with these numbers?  Something is whispering to me that if I ever had a realistic chance to win, it would be today.  Nah, who am I fooling--I think I'll just keep that errant dollar in my pocket.

44 is an odd age, though.  Am I middle-age?  Am I the new thirties?  Is my life half over?  Or more than half?  That thought makes me shudder.  I look at some of my patients in the ER, those in their 20's and 30's, and in my mind I am dealing with someone in my own age group.  Maybe they have less wrinkles and a fewer amount of life experiences, sure, but otherwise we are the same, aren't we?  That is until they call me "sir," a word I am growing less fond of the older I get.  And suddenly, I am reminded that no, I do not have as much in common with this college student sitting on the treatment cot in front of me as I might have thought.

Still, birthdays are pretty special when you are surrounded in your life by people who make a big deal of them.  Being one of seven kids, I've already received texts by four of my siblings and some nieces and nephews to "have a great day."  The phone calls will follow tonight, with multiple renditions (mostly bad) of the song "Happy Birthday" sung to the answering machine or myself.  When my mother was alive, she and Dad would always call and sing "Happy Birthday" in harmony from their two different receivers, Mom carrying the high notes and Dad trying to blend his deep, husky off-tune baritone to compliment her.  Since she passed on, Dad still keeps this tradition alive.  It is bittersweet, to say the least, to have Dad call and sing a solo "Happy Birthday" to me.  A big sigh typically follows, and longings for my mother's missed presence follow that.  The beauty in this, though, is that over the two years prior to Mom's lost battle to leukemia, we recorded every "Happy Birthday" sung by them to my family.

My kids and wife, though, are the real reason the excitement level in our house today is immense.  For the past week, there has been whispering between she and my kids that suddenly stops when I enter a room.  There has been hushed huddling in front of the desktop computer, a flurry of hands blocking the screen's view when I walk into the office.  There have been shopping trips to the mall, the kids returning with big grins on their faces and filled shopping bags held behind their backs.  "Don't look, Dad!"  has become the newest greeting in our house.  Tonight I will eat my favorite cake, chocolate from scratch (which includes a cup of coffee) topped with mounds of creamy peanut frosting, made lovingly by my wife from Mom's recipe.

So today, then, is the day.  My 44th birthday.  I was woken up with hugs, warm and heartfelt and accompanied by morning breath.  And chimes of "Happy Birthday, Dad!"  There is no better sweetness in this world than hearing these fluent, tender words from your children's innocent mouths.  Birthday wishes from my wife, too.  A flurry of activity followed as they got ready for school.  A grab of my hand by my youngest, who lead me to the dining room table to proudly show me the presents that await my opening.  Their homemade cards and homemade gift wrap make my smile double.

Then, too suddenly, the buses came to take my kids to school.  My wife left in the SUV to work her school-related job.  And, just like that, all of the excitement contained within our four walls just minutes earlier dissipated, a big balloon of happiness and anticipation popped... to be filled up again upon their return.  I go to sit alone in my office.

I have the morning and afternoon off, but work an odd evening into morning shift tonight.  So I sit here in my silent home, giving up the hope that cranked techno music from Robyn on YouTube will bring back all of that excitement.  It didn't.  Instead, a life lesson smacks me in the ass.  Hard.

My birthday and this swirling excitement that comes with it is not just because of the day.  Or the cake.  Or the presents.  It is because, simply, on this day, I am reminded of just how blessed I am to be surrounded by so many people in my life who love and care for me.  The simple texts, the emails, the phone calls, the snail mail birthday cards--all warm hands coming from near and far to wrap themselves around me on this day.  There are no better birthday gifts...

Sitting here, introspective and reflective of my life so far, I find that I am beyond grateful.  Grateful for it all.  The family.  The siblings and parents.  The nieces and nephews.  The cousins.  The friends.  I am a lucky guy.

After all of this, I looked at a brown envelope sitting on my desk, sent to me by one of my best friends through medical school--KT.  To know KT in this life, to have her friendship, is one of those precious gifts I sometimes take for granted.  She is, after my wife and Mom and sisters, one of the most remarkable women that I will ever know.  Her kindred spirit and friendship is unmatched.  And besides, how many other family physicians do you know still make social calls to their patients' homes?

What follows is a cursive note she sent (along with a beautiful book and two birthday cards).

Dear Jim,

     My friend, my brother...how does it feel to you to be celebrating a life so full?  I am acutely aware of the significance this year of similar double digits!
     At 11, I was hiding in the woods with my friends, telling secrets, crushing on Bobby Joe across the street (be still my heart!)  I was a child in a giant's body!
     At 22, I owned the world...I was a college graduate and I was going to medical school!  I was sizzling!  Life was mine to take!
     At 33, I was a mother, in love with my girl, struggling to mesh my original dreams of being a doctor with my dream, unexpectantly better, of motherhood.  I couldn't get enough of my daughter if I ate her!  She was and still is a force in my world!  What a ride I got, eh?
     At 44, I know contentment, really and truly.  But I also know worry...  My life and love has blossomed as my family came to be--a daughter, a son, a dog, and oh yeah, a husband.  I know I am not invisible--my achy hips let me know that every day!  But I am more alive now than ever before.  I have loved, lost, given and gained...
     What will the next half bring?  55?  66?  77? 88? And, oh yeah, I plan on doing 99.  You too?
     So, my brother in this walk...I wonder what you would say about 11, 22, 33, 44?  I think I can guess a few of the emotions.  We have been blessed in love and in friendship, haven't we?

Big hug, Jim!  Have an awesome birthday!  KT

How's that for a birthday gift?

May everyone have a birthday like mine today, where they are reminded of the beauty of the people in their lives.

Now, where are my presents???

As always, big thanks for reading.  May KT see the beauty and specialness in her writing voice here today.  To my family and friends, especially my wife and kids, thanks for making this a special day...I am smiling here.

Underneath

A heartfelt appreciation to the readers who shared their personal stories, both devastating and hopeful, on my last post.  Your courage to share was felt and your words of wisdom were heard...thank you.

Walking into Room 33, my next patient, who had come to the ER complaining of cough and cold symptoms, seemed just as I had expected.  He appeared relaxed on his medical cot, lying back at 45 degrees, facing the room's door, his legs comfortably extended in front of him and his gown tied correctly behind him.  He was a few years shy of middle-age and appeared to be in good physical shape. His sandy blond hair, sprinkled with gray, framed his slightly weathered, apprehensive face.  Between coughs, he managed to give me a faint smile.

"Hello, Mr. Brown," I said, extending my gloved hand and introducing myself, "I'm Dr. Jim.  What can I do to help you in our ER today?"

He coughed before answering in raspy voice.  "I had a bad cold about two weeks ago.  It lasted about a week before going away."  Another cough.  "But now," he continued, after taking a deep breath, "it's back.  Back with a vengeance, actually." Yet another cough.  "I've had three miserable days of this stuff," he said, swirling his hand in front of his runny nose, reddened eyes, and dry lips, "and have tried every over-the counter medicine out there."  Cough.  "I just don't know what else to do."

As he spoke, my senses were acutely attuned to him.  I listened to see if he was speaking full sentences of five or six words or fragmented sentences of just a couple.  I listened for audible wheezing.  I watched to see if his diaphragm and intercostal rib muscles were struggling, under his gown, in their respiratory effort.  I noticed the skin coloring of his arms, the pink of his nails, his reddened, irritated nares, and the slight sheen to his forehead.  I listened closely to his cough, to observe if it was of a dry, hacking quality or a wet, congested effort; whether it came in short, interrupted bursts or was continuous and drawn-out.  I watched to see how quickly he recovered from these coughing spells.      

The patient probably thought that I, standing beside his cot with my stethoscope in hand and a smile on my face, was simply waiting for him to finish his coughing and complete his story.  And I was.  Of course, I was eager to learn of any other input he might share so that we could get him on the right road to recovery. What Mr. Brown didn't probably realize, though, is that as important as his providing a detailed history may be,  these obscure observational moments, wordless and symptom-producing, can provide just as much, if not more, information to a treating physician like myself.  I, for one, would much rather hear the cough than have a patient struggle in his description of it.  Penile discharges, though?  That's another story.

Back to Mr. Brown.  Even without doing my physical exam, I suspected he might be suffering from a community-acquired pneumonia.  "Sir," I said, touching his shoulder, "I'm going to perform a physical exam now."  He nodded his consent.  Starting with his head and taking my time, I closely looked in both of his ears (clear), his eyes (slightly bloodshot from his coughing spells), his nasal passages (angry red with significant turbinate swelling), and his throat (red, no exudates or swelling, mild anterior lymphadenopathy).  His tongue was dry and his breath smelled of neglect, like skipping a brushing.

Moving the exam along nice and smoothly, I next focused on his torso.  "Mr. Brown," I said, "we need to remove your gown so I can listen to your heart sounds and auscultate your lungs."  Trying to help, I untied his gown's back tie while he untied his neck.  Slowly, he pulled off his gown, somewhat hesitantly.  And after he did, I understood his reluctance.

His entire anterior torso, extending from his left shoulder to his chest to his abdomen, was a patchwork of skin-grafting.  Thin, transparent, papery patches of transposed skin were bordered by longitudinal, thickened keloid scars.  Some of the patches were less transparent and more natural-appearing, some of the scars less protruding and more flesh-colored, but it was obvious that multiple skin-grafts from multiple body sites had been a necessary, life-saving event at some point in Mr. Brown's life.

"I know, I know," he said, watching my eyes closely absorb the view of his torso.  "I never remember to mention these skin grafts.  Out of sight, out of mind, I guess."  He was almost too blase, leading me to believe that these physical scars walked hand-in-hand with his mental scars.

"May I ask what happened, Mr. Brown?"

"It happened when I was young, in elementary school.  Believe it or not, I had been playing with matches.  No, not on the playground," he chuckled here, "but in my backyard.  All I really remember is my shirt catching on fire, a lot of pain, the smell of my skin burning, and then my mother's screaming." He coughed a few times, his face mildly grimacing with the effort.

"I'm so sorry, sir," I said sincerely.  Imagine spending a large chunk of your childhood undergoing multiple reconstruction surgeries, missing school and losing friends, at a time when those things matter, in the process.  Being treated differently than the healthy kid standing next to you.  Not to mention the constant pain.  And feelings of lessened-worth.  Too many doctors appointments, no sports, lots of dressings.  I was letting my mind race in that brief minute.

I looked more closely at this patient.  Everything had seemed to change after seeing what was underneath his gown.  And now I understood his symptoms even better.

"Sir," I said, "do these scars restrict you when you need to take a really deep breath?"  He nodded "yes."  I continued.  "And do you get a lot of pain from these scars with your coughing spells?"  "Doc," the man smiled, "I think you get it.  It's been pretty hard with the colds this year, but these scars sure don't make recovering any easier." 

I did get it.  Because of his torso scars, his thorax, when stressed with illness, couldn't expand as easily as yours or mine. His fibrous scars and skin-grafting, lacking pliancy, prevented him from taking as full a breath as necessary.  Kind of similar to being wrapped and squeezed by an anaconda, I would imagine.  His work effort, thus, was increased.  And not exchanging air in the depths of his lungs, because of this momentous effort needed, would set him up to acquire pneumonia.

Not only this, but now I understood why he probably put a lot of effort and time into staying in decent physical shape.  "If I put on even ten pounds," he told me, rubbing the scar tissue around his umbilicus, "I start to hurt right here, from the outward pressure.  It seems any weight I gain goes right to my stomach, of course, and not my ass or legs.  Hell, I'd even take a double chin.  So I really have to be careful with my diet and exercise unless I want to have constant pain."  Talk about the pressure of eating right and hitting the gym.

Me?  I work out just so I will always look better than my brothers.  There is a lot of pressure being the best-looking boy in the family.  Clearly, he had better reasons than me to visit the gym.

After finishing Mr. Brown's exam, we got an x-ray, some baseline blood work, and an EKG.  His WBC count was slightly elevated, going hand-in-hand with a very early consolidated pneumonia viewed on x-ray.  We took no chances--he was placed on a strong antibiotic, given albuterol and atrovent nebulizer treatments and a machine to do the same at home, and, probably most important, he was given a strong cough syrup with hydrocodone to ease the stress that his cough was bringing.  He was quite appreciative upon his discharge, his cough lessened and his breathing a little easier.

"Thanks, Doc," he said, after he was dressed, "this was a good visit."

Meeting Mr. Brown initially, everything was just as I had expected.  Until we removed his gown.  And then, I saw what was underneath--the physical limitations of his body during a time of illness.  And underneath this, I was fortunate to learn of his hidden strengths and stoic fortitude that his life experiences taught him.  He seemed the better man for it.

I gave this some thought, about how much we all have in common with Mr. Brown.  How we show the world what we think they want to see.  But underneath, don't we all have something we are hiding, just like Mr. Brown?   Something that may even be limiting our full potential?  May it be physical.  May it be mental.  May it be both. More importantly, underneath, buried in doubts, don't we all have more good that we can give this world of ours?  If we just get over our fear of showing... What.  Lies.  Underneath.

Mr. Brown, thank you for trusting me to show me your underneath.  It made a difference.

As always, big thanks for reading.  I hope this finds you having a good week...

Hold A Hand

Our ER case manager and I recently walked out of the family room after having to tell an only-child that his 85 y.o. mother was critically ill. She was so ill, in fact, that she had required emergent intubation for her respiratory distress and was now being sedated and paralyzed. This allowed the ventilator to do all of her breathing, conserving this woman's body of some much needed energy. The patient's worsening circumstances had transpired over the past three hours at her nursing home prior to being transferred to us and, unfortunately, her son had been en route when his mother decompensated in our ER, circling the drain before our very eyes. Thus, he never got a chance to visit with her before her intubation.

As we left the family room to go back to the patient's room and continue medical management, the case manager and I walked in silence, affected by the situation at hand. I had tried to hold off this patient's intubation for a few minutes, hoping that her son might soon arrive to exchange a few words with his mother, but it didn't happen. Because the patient's living will had requested that she be a "full code" (my understanding was that she lived a fulfilling, independent life), all efforts would be employed in attempt to save her life and help her through this medical crisis. We had intubated her successfully and aggressively began her medical management.

Suddenly, the case manager stopped smack-dab in the middle of the hallway and spoke to me. "You are amazing in that room, do you know that?" I looked her in the eyes, trying to see if she had picked an inopportune moment to hassle me, to tease me the way that us ER co-workers sometimes do to lighten such heavy, burdensome moments.

She was being serious. "After introducing yourself and shaking this son's hand, you sat down on the couch beside him, touched his shoulder, introduced the rest of us, and asked him how he was doing before slowly, in words he could understand, explaining everything that had been done so far to save his mother's life."

"Yeah," I said, "so?"

She continued. "Did you not feel the tension in that room? And somehow, after you were done delivering the worst of the news, the room felt hopeful, at peace. You could see the son's face slowly accept the news you were giving him. You eased his worries by instilling that we were doing everything we can to help his mother, without falsely elevating his hopes."She paused here, taking in a deep breath. " You showed him that you cared."

"Doesn't everybody do this, though?" I said, knowing the answer before I finished asking.

The case manager laughed in a regretful, wistful kind of way. "Are you kidding? You would be appalled at some of the ways I've seen bad news delivered in that room. No introductions. No sitting down. Blurting out the bad news without any preparation to the family. Leaving without addressing any of the family's questions. Jim, you need to teach more doctors how to act and speak more appropriately in that room."

By now, we had started walking again and were standing outside of the patient's room. The son was going to be escorted back in just a few minutes.

Not one to gloat over getting a compliment, I walked back into the room and continued helping my senior resident with this patient's care. It was, once again, a thing of beauty to watch our team methodically go about each of their responsibilities and, as a result, we were soon rewarded with this patient's condition stabilizing. She was still very sick, but at least the son could now spend some time at her bedside. Which turned out to be a blessing as, in the end, this patient passed on that same evening.

Later on that night, at home, after tucking in my kids and a glass of wine in hand, I was giving much thought to our case manager's words. Just a few weeks prior, during a night shift, a nurse supervisor who had accompanied me in the family room spoke similar words to me when we were done. "The way you approach patients and their families is remarkable," she had said. I may have blushed, but her words were greatly appreciated and I viewed them as the ultimate compliment.

Why isn't everybody at their best, especially in that room? I thought to myself, though, becoming a little annoyed. When did medicine become so shifted to view patient's and their families as "its" and not as human beings, as "hes" and "shes"? When did we abandon learning patient's names and their life story? Of taking a little more time in their treatment room? When did compassion and kindness sneak out the window and rush, rush, rush sneak in. When did the the quantity of patients one treats replace the quality of care given to each individual patient, defining, in some peoples' eyes, a better physician?

Sadly, most of us in medicine know that answer. With the increasing struggles of our profession, from insurance cutbacks to legal threats, from hospital cuts of personnel to the shifting thought that patients' rights outstrip our own, medicine isn't the field it once was when I signed up for a career twenty years ago. Especially in the ER, it is now common for us to be 4-6 hours behind every day, patients now relying on us not only for emergent care but for treatment of their chronic illnesses as well as maintenance medications. Can you see the frustrations? This quantity has potential to impede on our quality, to cut into the time we spend with each patient and their family.

I recently gave an hour lecture to our residency physicians regarding kindness and compassion. I started it with a tragic video of 9/11, scenes playing out to Sarah McLachlan's "Arms Of An Angel." We then watched a synopsis of the Columbine tragedy before I started talking. There was nary a dry eye. "See this devastation, this grief, involved in such atrocious acts?" I asked the residents. "What makes this grief and loss any different from that which you will encounter in a patient's treatment room or our ER family room?" A dropping pin could be heard in the room. Grief is grief, I reiterated. Loss is loss. Death is death. Respect is necessary. Kindness and compassion are a must. Addressing such concerns, I assured the residents, is one of the most important jobs they will ever face. Put the time in and learn how to view this responsibility as a privilege and not a burden.

This lecture was never finished. Before my time was up, only half of the slides had been presented. Instead, we had spent a great deal of time talking about personal techniques on how to interact with patients and their families and how to deliver devastating news. My residents shared personal stories of their best and worst experiences. It was clearly evident that some of them were quite comfortable in their roles, while others struggled with this part of their jobs. This hour lecture on kindness and compassion had gone from the category of "light and fluffy" to receiving the respect it deserved. From the feedback of the residents, they were appreciative and definitely more cognizant of their roles in treating patients and their families.

As karma sometimes dictates, a few nights later, while reading Cutting For Stone, a brilliant fiction novel by a brilliant writer, Abraham Verghese (he who also happens to be a brilliant man of medicine), I happened upon a collection of words on page 519 that left me with goosebumps. In the novel, Dr. Thomas Stone, a leading liver transplant specialist, reads a letter from a mother of a trauma victim that he had treated. It follows:

Dr. Stone--

My son's terrible death is not something I will ever get over, but perhaps in time it will be less painful. But I cannot get over one image, a last image that could have been different. Before I was asked to leave the room in a very rough manner, I must tell you that I saw my son was terrified and there was no one who addressed his fear. The only person who tried was a nurse. She held my son's hand and said, "Don't worry, it will be all right." Everyone else ignored him. Sure, the doctors were busy with his body. It would have been merciful if he had been unconscious. They had important things to do. They cared only about his chest and belly. Not about the little boy who was in fear. Yes, he was a man, but at such a vulnerable moment, he was reduced to a little boy. I saw no sign of the slightest bit of human kindness. My son and I were irritants. Your team would have preferred for me to be gone and for him to be quiet. Eventually they got their wish. Dr. Stone, as head of surgery, perhaps as a parent yourself, do you not feel some obligation to have your staff comfort the patient? Would the patient not be better off with less anxiety, less fright? My son's last conscious memory will be of people ignoring him. My last memory of him will be of my little boy, watching in terror as his mother is escorted out of the room. It is the graven image I will carry to my own deathbed. The fact that people were attentive to his body does not compensate for their ignoring his being.

Brilliant. Simply and utterly brilliant. Thank you, Dr. Verghese.

We need to bring back kindness and compassion. We need to fix the medical field as it now exists so we can begin, again, to pay attention to that which is most import--the patient and their families. With kindness and compassion at the forefront.

Enough said.

As always, big thanks for reading. If you have had any experiences, either as a patient or as a family member sitting in that family room, that may enlighten us readers and make us better at what we do, please share...

For The Love Of Ruby

I have to admit, I wasn't one to really appreciate the offbeat behaviors and attachments that otherwise seemingly normal people develop with a family pet. I mean, really, have you ever seen a pet owner kissing their dog, tongue-to-tongue? Or letting their kitty-kitty-kitty lick them all over their face? Or letting their pet gerbil nibble the lettuce off of their nose? I'm surprised at the lack of short-term memory some of these owners must have to not have remembered watching their pet lick themselves...everywhere...just a few minutes before their face bath. I'll repeat myself...everywhere. I still cringe to think that before licking their owner's face, a dog may have been going to town on his anus. And that's just the boy dog.

It wasn't just the licking, though, but also that foreign language that I couldn't quite grasp. "Here, Muffy," the cat owner might say in a baby-talk voice, "come give your mommy a big kissy-kissy here on my lips." At least with the baby talk with a human baby, you eventually come to the conclusion that it will cease when the kid turns one, maybe two. An end is in sight, yes? But with cats? I don't think so. I think one is looking at 10-20 years of baby talk, minimum, with a pet cat. God forbid the day I scratch a dog behind the ears and whisper "goochie-goochie-goo." No way, no how--not for me.

I grew up around pets, yes, but they were at my grandparent's farm and they were outdoor pets. Besides several pigs, lots of chickens, and a little house full of rabbits, several cats and dogs were also part of the lot. They remained outside, though, and were well taken care of with their own private houses and feeding stations. We talked normal English to them. We pet them and fed them regular pet food from the 50 lbs. bag. They didn't wear designer outfits but, instead, relied on their genetics to thicken or shed their hair, depending on the season. The names rush me now--Sweet Pea, Prince, Trixie--and they were all awesome dogs, my buddies actually, when I was visiting for an afternoon or overnight. I don't think the dogs minded their lack of indoor living, judging by their playful run through the gorgeous, rich, adventurous farmlands.

So, with this upbringing, it seemed a little off to me that so much energy would be spent by an owner on making their pet so extremely comfortable within an indoor setting. Wouldn't the pet hair all over the floor and clothes be a deterrent enough? I've seen my share of ER patients with their clothing covered in pet hair. Cringe-worthy, I tell you.

Enter Ruby. Our family pet. Our yellow lab. I have to chuckle when I call her "yellow," though, because, if anything, she is actually pure snowy-white.

Most important? She spends the majority of her time indoors. Yes, I know, I'm eating crow. But she has single-handedly changed my way of thinking when it comes to indoor pets.

Five years ago, in March, our Ruby was born. Around the same time that Ruby was born, my mother passed away. Like any other family who has suffered a loss, try as we might, a certain "funk" seemed to linger around our house. Smiling was, at times, a chore. Sad realizations of Mom's death would interrupt happy moments. We needed to change things up.

My wife and her sister had a suggestion. Maybe it was time for us to get a family dog, something we had considered in the past but rejected. Sandy's family had two beautiful labs, both from the same breeder. This particular breeder focused her attention on two of the dogs' attributes--their gentle, mild disposition and their beautiful white coat. And she would not sell a person a dog unless she approved of them and the home her dogs would be joining.

Yeah, I'll think about it, I thought to myself. The breeder didn't have any available pups from the upcoming litters, giving me some available thinking time. Or so I thought. Because a few days later, Sandy called to say that the breeder had an about-to-be-born litter with one more pup than was supposed, confirmed by ultrasound.

"June said the pup is yours if you want it," Sandy said, exciting our family at the prospect.

Thus, the process began. First, we had to be interviewed by the breeder, June, a gruff woman with a heart of gold, whose profound love for her dogs was very evident. She, thankfully, felt that us receiving one of her puppies was meant to be. After a successful interview (brow-glistening included) and tour of her comfortable home, she led us to her enclosed back porch and the most beautiful litter of pups imaginable. And there, jumping on her hind paws and trying to get our attention, was our Ruby. Leaning into the enclosure, trying to climb out to us. The kids were sold. My wife was sold. And me? Standing there looking at the wrinkly, yelping little bundle of goochie-goochie-goo that so quickly took to our family, I knew I was hooked. Even if I hadn't been, I knew I was outnumbered.

Ruby, named for Mom's birthstone, came home with us in early May. Five years ago. Lifting that "funk" that had clouded our air for the whole spring.

Yeah, the carpets now get shampooed and vacuumed more frequently. Yeah, my socks have white fur stuck to them occasionally. Yeah, sometimes a leftover snack will disappear off the kitchen counter. Yeah, sometimes stepping in a pile of poop in the yard is annoying. Yeah, sometimes our house smells like wet dog after a walk in the rain. Worse, I've had to learn that dogs have gas just like humans.

And you know what? Who cares. Really, for all the love and smiles that she has brought to our lives, Ruby can certainly shed and traipse some dirt through the house occasionally. All it takes is one look at Ruby cuddling with the kids at bedtime to know that some things are worth the inconvenience. She is, quite simply, an important part of our family--our fourth kid, even.

So yeah, I've talked the (baby) talk. "Where's my Ruby, Ruby, Ruby?" you might hear me say when I get home from work. Without shame. That might be me on my knee, kneeling at her face level, tickling her ears while I whisper "We love you, Ruby." That would be my eyes, gleaming, as I throw the tennis ball and she chases it down, returning it at my feet.

My favorite thing about Ruby, though? Late at night, while we are all sleeping, she does her rounds, nudging open each of the kid's bedroom door and checking on them. Even my wife and I are included in her rounds. And if she suspects anything unusual, she can be found lying at the base of our stairs, ready to protect us as necessary. Otherwise, you'll find her randomly sleeping in one of the bedrooms, at the foot of the bed, every night. Snoring and farting. And fitting in beautifully.

Many of our family and friends now have indoor pets, most of them making adjustments similar to us, and we are happy to be included in this group. And, patients that come in with hair on their clothes no longer make me cringe. Well, except for the frail, elderly woman who has the hair of ten cats clinging to her wool sweater. Excuse me while I go sneeze...okay, I'm back. But I can easily picture these patients, in their home, cuddling up to their pets, their smiles bigger and better than any medicine I might possibly prescribe.

If you ever wondered about or considered an indoor pet, but opted out, reconsider. I am living proof of the convert that exists in all of us.

Happy 5th Birthday, Ruby! We hope you like your raw-hide presents and doggy-cake!

Now...get over here and give me a big kissy-kissy...

As always, big thanks for reading. This post is dedicated to my sister Rosie's little Havanese, Maggie, who will only drink bottled water and snack on mini-marshmallows! And my sister Susie's dog, Knuckles, who was the king of all self-lickers! LOL Have a good weekend...

Macys Or Mom

I walked towards Room 22 to see my next patient, an elderly woman who was found lying on the kitchen floor of her private home. She lived alone. Because of her advancing dementia, she was unable to provide any history as to how long she had been down or the circumstances that lead to her being on the floor. Unfortunately, due to the strong smell of stale urine and feces that permeated the hallway outside of her room, it was a safe assumption that she had been down for quite a while.

Not yet fully aware of how disheartening this patient's case would be, I opened the room's partially-closed glass door before sliding back the room's privacy curtain. I stepped into this patient's room as this patient stepped into my consciousness.

What I stepped into was sad. No, heartbreaking. The patient, rolled onto her left side by our staff and lying fully exposed on her treatment cot, was being tenderly wiped and cleaned by two of our ER nurses, one standing behind the patient while the other stood in front. Despite the slightly-dimmed room lights, I could appreciate the momentous task these nurses had of cleaning the hardened stool and human waste from this patient's neglected body.

I looked to unflappable Charlene, the nurse standing in front of the patient, who was shaking her head in frustration. "This is bad," she said, "really bad." She went on to explain that the patient was found by her two children, a son and daughter, on the floor of her kitchen, conscious but covered in human waste. Her own. The prehospital team believed she had been down at least several days. According to Charlene, the paramedics, our local experts on witnessing the best and worst of living conditions, said that this patient's home was among the worst conditions they had ever encountered. "There were multiple mounds of strewn garbage, numerous puddles of drying urine, and smeared feces everywhere you looked," Charlene said, repeating their words.

I shook my head. Although I hadn't yet learned the particulars to this patient's social situation, I had seen my share of elderly patients who were brought to our ER for treatment after they had been discovered incapacitated in their home, whether ill from a trip and fall or, worse, a catastrophic medical event like a stroke or heart attack. Unfortunately, they might sometimes lay there for several days, alone and possibly in pain, frightened of never being found.

The thought of a patient suffering in this manner always makes me shudder.

Descriptions of poor living conditions sometimes accompanied these patients, as well, but none to the degree that Charlene described. "Seriously, Dr. Jim, the prehospital team said that feces was even smeared on the kitchen counter." Maybe this patient simply struggled after going down, making a bigger mess of things.

I briefly observed this patient's body--her frailness, her thin, cachectic limbs, her slightly protruding belly, her transparent pale skin, her matted-down silvery hair, her deep facial wrinkles--before walking towards her head and squatting down to her face level, ready to introduce myself. "Maam," I said, caressing the right side of her face as I spoke, "I'm Dr. Jim and I will be taking care of you today." The patient stirred as I continued to stroke her face. And then, quite suddenly, she opened her eyes, searching eyes of hazel brown, that stared back into mine. After sizing me up, she gave me a big, confused, wondrous smile, the familiar smile of a good-natured dementia patient.

"Do you hurt anywhere, maam?" I asked, beginning my exam while the nurses continued to clean her. "No," she said feebly, shaking her head. I looked in her ears, her mouth, her nose. I listened to her heart, her lungs, her abdomen. I palpated every part of her body, rotating and flexing her joints to make sure she had no clinical evidence of fractures.

Outside of the obvious signs of dehydration and her frail body breaking down at her pressure points, I was happy not to find any obvious signs of injury or acute medical illness. Now, we could pursue a thorough heart and brain workup (including a head CT to rule-out a stroke) as well as several clearance x-rays and some additional urine and blood studies. More importantly, social services could be called to pursue further information on this patient's living conditions and social situation.

It was near the end of my physical exam on this patient, though, when I began to see the situation more clearly. As the nurses continued to clean the patient and I stood beside the patient auscultating her abdomen, the room's curtain flew back and a very meticulous, very well-dressed, very put-together woman hurried into the room. She was middle-aged.

"May I help you, maam?" I asked, pulling my stethoscope from my ears as both nurses looked toward the woman, taking her in as I'm sure I had done.

"Yes, I'm her daughter," the woman answered with severe enunciation, taking a corner chair while nodding towards the patient. I waited briefly for her next question, a question that never arrived--"How is my mother doing?"--while taking in her neatly highlighted hair, her pressed wool pants, her polished heels, her matching argyle blazer, the multiple bands of gold that hovered on her neck and wrists, her ring-covered fingers, her painted face. I looked back at the patient, now rolled to her other side, and back at this daughter again.

The dichotomy of the situation was startling.

I leaned against the wall, giving the situation a few minutes to play itself out. The nurses continued their diligent work, occasionally glancing at the daughter, while the daughter continued to sit comfortably in her corner chair. And watch. I didn't expect her to offer her help bathing her mother. And she didn't. I had hoped that she might offer to hold her mother's hand, though, or whisper some encouragement in her ear. But she didn't. No moments of tenderness or love ever came.

Finally, I went up to this daughter and introduced myself and the two nurses. "Can you please tell me what happened with your mother?" I asked, eager to hear what she could contribute to her mother's story.

"Well, we, my brother and I, hadn't heard from Mother for a couple nights, so we called her. When we got no answer, we went over to her house and found her on the kitchen floor."

"Any signs of trauma?" I asked. "No," she answered. "Any blood?" "No." "Was your mother awake when you arrived?" "Yes." "Did she complain initially of any pain or have any difficulty breathing?" "No."

After finishing my questions, none with answers that would change our treatment plan, I asked this daughter about the living conditions the paramedics had described.

"Oh, that," the daughter said, blase, "we think Mother may have tried to get back up several times and failed, creating such a big mess." I nodded my head, hoping this was the extent of it, hoping that there wouldn't be anything more to this story when social services investigated. But, by Charlene's account, the paramedics had said the whole house was in disarray, not just the kitchen. "My brother is over cleaning Mother's house now as we speak," the daughter added.

I continued. "And your mother has dementia but lives alone, I see?" She nodded 'yes.' "Why hadn't anyone seen her for at least a couple days? How often do you check on her? Who cooks and cleans for her?"

The daughter shifted in her chair. "Well, either my brother or I go over every day, but both of us were busy and thought the other had been over. We were wrong. We have a cleaning maid and meals delivered, too, but not on weekends."

Although most of the answers seemed adequate, something still made me uncomfortable about this case. Something I couldn't put my finger on. At this point, though, I saw this daughter's eyes glisten. "Maam," I said, acknowledging her first signs of compassion, "I'm sorry if these questions might upset you, but they must be asked. Your mother's health and care depend on your answers." She nodded her understanding.

After a few more minutes of talking with the daughter, I said goodbye to both her and her mother, but not before thanking the nurses for yet another awesome job of patient care. They are worth far more than what their paycheck reflects. I made a conscious decision to leave the rest of the social questions to our case management team and focus on the patient's medical care.

Unfortunately, the patient's kidneys had begun failing her, both from her moderate dehydration and from being clogged with muscle-wasting metabolites (rhabdomyolysis). She was admitted, obviously, for further medical care before ultimately being placed into a safe nursing home environment. She would never again be left alone at home.

I refuse to sit in judgment of this daughter. And the son I never met. But in my line of work, a healthy dose of suspicion is sometimes what the doctor must order. So I did. I have to trust that our system works.

I have several friends who recently lost their fathers. Just last week, my brother-in-law suddenly lost his mother. My world is filled with people who, regretfully, have lost one or both parents. Who have lost their spiritual guiders. Who would give anything to have just a few more minutes with their deceased parent. Who would do things a bit differently than this patient's family, I'm sure.

I know I would.

As always, big thanks for reading. This post is dedicated to those who give of themselves to benefit an elderly person in their lives. May your kindness and compassion be returned tenfold...see you again in a few days.