The Boss

Even before entering his room, I could hear my next patient yelling as I stood in the hallway. "No," he screamed. I heard a woman's voice murmur back. "I don't care. I won't eat it." The woman's voice, again, said something that I couldn't understand. "I hate it!" the patient screamed again. "You can't make me!"

Before taking that first big leap into the unknown, I knocked on the frame of the door. I entered. And there, sitting Indian-style on the cot, his arms crossed, with a big pout resting across his face, sat my next patient. A five y.o. little boy, chunky and sulky, in a huff, refusing to eat the spoon of vanilla pudding his mother was holding to his lips.

The nurse, apparently on her knees wiping up a glass of spilled orange juice, looked back at me. Her rolling eyes told me all I needed to know about this room.

The mother put down the spoon as I approached her with my hand extended. "Hello, maam," I said, "I'm Dr. Jim. I'll be working with Nurse Michelle to take care of your son today." She smiled as we shook hands. I then turned my attention to the patient. "Hello, Scottie," I greeted him, "how are you? It looks like you don't like vanilla pudding, huh? Me either." A blatant fib on my part, all for the sake of bonding.

Scottie stared me down, giving me his best angry look. I held my hand out to him to shake, but all he did was turn his attention from my face to my hand, probably willing it to explode. "No!" he exclaimed, either in answer to my question about vanilla pudding or in refusal to shake my hand. Either way, I hadn't made a friend.

I focused my attention back on Mom, who had since taken a corner seat to rest. "Maam," I said, "what happened that brought you here to our emergency department with Scottie?"

Mom explained that Scottie had been diagnosed with juvenile diabetes just a few short months ago. Since this diagnosis, they have been struggling to find the right balance between his medications and diet. Unfortunately, Scottie has also been acting out. He typically got three shots of insulin a day, prior to meal time. And on multiple occasions, after receiving his shot, he refused to eat the food placed in front of him, instead demanding a McDonald's Happy Meal. Of which the family, in exasperation, eventually allowed. "Thank goodness we live near a McDonalds," Mom said, as if this was the answer.

It seemed that Scottie was the boss. King of the house. Ruler of the roost.

Tonight, after receiving his dinner dose of insulin, Scottie again refused to eat supper. "I want a cheeseburger!" he had exclaimed, per Mom. And then, before they could run and get Scottie his demands, Scottie went unconscious. Paramedics were called and rushed to the house to find Scottie's blood sugar low--45. They squeezed oral glucose packets into his mouth while attempting to start an IV, and soon Scottie was back with a finger stick of 115. They transported him to our facility.

"Scottie," I asked him, "you don't want to get rushed here to the emergency room again, do you?" He nodded his head "no." "Then you need to eat what Mom gives you after your insulin shot. Do you understand?"

He stared me down. I stared him down. And he stared me down some more, before finally yelling, "I want a cheeseburger!" Supposedly, his aunt and cousin were heading on in with a Happy Meal soon.

Nurse Michelle, in her best attempts, had ordered Scottie a tray. When it arrived, I went back into his room to see how he was doing. No Auntie with the Happy Meal yet, but his tray was one of the best collections of hospital food I have ever seen. Chicken noodle soup, cake, apple juice, french fries, a peanut-butter and jelly sandwich, soda, peaches, potato chips, and chicken tenders. There were no dietary discretions as we struggled to keep his glucose level up.

Unfortunately, there was no cheeseburger. "The grill is down," Michelle explained, shrugging her shoulders.

Guess how much of this delicious tray Scottie ate? Not one bite. Not one drink. Out of defiance, I'm sure. Despite our coaxing attempts, this kid appeared to call the shots. And it was obvious we weren't going to change his behavior in this one ER visit. I eyed up those chicken tenders, though, sitting on a plate under a lid, and said a silent prayer that they would still be on the tray after Scottie was discharged. Michelle, it seemed by her intensely focused eyes, was claiming the fries.

We repeated Scottie's finger stick as he continued pouting, sitting on his bed Indian-style, and were surprised to find it only at 50. "Here," Michelle said, cutting open several packets of liquid glucose, "you need to take all of these, Scottie, or else I'll have to poke you for an IV." Miraculously, Scottie devoured all three packets. "Mmmm," he said, smacking his lips and wiping his face with his shirt-sleeve.

Great, now the kid was getting hooked on glucose packets instead of real sustenance.

As we repeated his finger stick (98), his aunt and cousin walked into the room with the McDonald's Happy Meal. With that familiar greasy smell trailing them. Scottie jumped from the cot, barely able to contain himself, stepping up to his aunt and snatching the meal from her hands. No "thank you." No smile. No gratitude. He just turned back to his cot and ripped open the box of food, unwrapping the burger and finishing it in just minutes. After that, the fries. And finally, he slurped his Coke until the glass was gone.

He was good to go.

Before discharge, I pulled Mom out into the hallway. "Mom," I said, "his disease is lifelong and serious. You need to take the control from Scottie and gain it back. It appears he is calling all the shots right now."

She nodded in agreement. "I know, I know," she said, "my friends and family say the exact same thing. It's just..." Here, she broke down a little before finally continuing. "It's just that it's not fair that he had to get this diabetes crap, you know?" Now I nodded my agreement, thinking back to having those familiar feelings when my son was diagnosed with his malignancy.

"I know," I said, "it seems so unfair when a child gets a serious illness like this. But you need to show him, by example, that this is conquerable if he follows the rules. Eating a McDonald's Happy Meal isn't following the rules. Letting him make demands and granting them isn't following the rules."

She agreed again, and assured me that she would try harder in her discipline. She also promised me that she would keep the morning appointment we made for Scottie with his endocrinologist.

I wished her luck. She was the mother of a child recently diagnosed with a long-term illness. She deserved a break and some time to figure things out on her own schedule. I hoped she could see, though, that her actions would significantly affect how well her son would respond to his situation.

I hoped, too, that someday again, she would be the boss.

As always, big thanks for reading. I hope you have a great weekend...

No Baby Yet

Despite the weighted concern and anticipation that enveloped Room 21, I was greeted with two genuine, hopeful smiles. Innocent smiles, actually. Smiles that unassumingly revealed a faith and confidence that life would be fair and good to them.

From the moment of our introductions, I liked this youthful couple, both just entering their twenties. She was the patient, sitting upright in her treatment cot, her legs fully-extended in front of her and nervously crossed at the ankles. She was thin but strongly built, her athleticism exposed by her muscular tone. Her angular jaw and full cheekbones were framed by the pixie-cut of her light brown hair. Her blue eyes sparkled.

He stood beside her, to the right of her cot, holding the hand she offered him. He was tall and pudgy, several times nervously swiping at the sheen of worry revealed by his forehead. His blondish hair was haphazard and messy. His face was average, muted, nothing quite as striking as his girlfriend's, and yet his brown eyes burned with a fierce intensity.

They had presented to our ER with a a significant concern. The patient was pregnant, barely nine weeks, and had started having abdominal cramping and vaginal spotting approximately thirty hours before they arrived. "Now I am bleeding so much, it almost seems like a period," she shared, looking from me to her boyfriend before looking back to me again. Her face was expectant, almost willing me to tell her that everything would be fine. That this bleeding and cramping was not out of the ordinary.

Unfortunately, I couldn't speak those words.

"How far along are you?" I asked them. "Nine weeks and two days," the boyfriend answered. Such exactness already answered my next question. "Is this your first pregnancy?" They both nodded yes. The excitement and magic that accompanies a first pregnancy is unbridled and elicits many memorable moments--including ticking off each day of the forty weeks. I could picture this couple's calendar hanging on the wall in a small, canary-yellow kitchen with old white appliances, an "x" drawn through each passed day.

"You really want this baby, don't you?" I asked, trying to learn about this couple, after I had finished with my pertinent medical questions.

The patient answered. "We do. We've faced a lot of opposition from our families and friends. And this pregnancy certainly wasn't planned." She paused here, looking up at her boyfriend, before continuing. "But, we are both certain we want this."

"And," the boyfriend added, "we just got engaged last week. We might just be throwing ourselves a wedding in the next few months, too." Without letting go of his fiance's hand, he continued to explain that they had dated since their sophomore year in high school. They were certain they had both found their soul mates.

I congratulated both of them on their happiness. Through work, I have seen every imaginable angle that accompanies an unplanned pregnancy and, although their story wasn't new to me, their can-do spirit and enthusiasm for one another and their situation made me think, just maybe, that, with or without this pregnancy, this was a couple that could endure and thrive on their life journey together.

Trust me, though, when I say that I don't get this warm and fuzzy feeling with every unplanned pregnancy. Their commitment was refreshing, plain and simple.

I called in their nurse, Carla, and we performed a pelvic exam. Unfortunately, the patient appeared to have some active bleeding that resembled a typical period. On her bi-manual exam, the opening to her cervix (the lower part of the uterus), which is usually tightly closed during this stage of pregnancy, was loosely open. Things did not look good.

"What do you think, doctor?" the boyfriend asked, unsure where to direct his nervous energy.

I needed to ask one more question before explaining the exam at length. I looked to the patient. "Have you passed any small clots or anything unusual with this bleeding?"

She hesitated somewhat before answering me. "Yes, this morning. That's not good, is it?"

Quite honestly, no--it wasn't good. Not only had her exam concerned me, but her quantitative hCG hormone level, through blood work, had come back barely traceable. Again, at this stage, the level should have returned significantly higher. Every indication was that this patient was not going to have a healthy, full-term pregnancy and was, in fact, actively miscarrying.

"No," I said softly, answering the patient's question, "it doesn't look good. I'm sorry."

It was important for this couple to start connecting the dots on their own terms. Inherently, I had to believe that they knew she was having a miscarriage, and just needed a little guidance and coaxing from my part to start accepting this reality. So I sat there on my stool a minute, silent, absorbing their response.

They both grew glassy-eyed right there in front of me. Remarkably, though, in that split moment where life can make you angry, or defeat you, or make you question everything about yourself after you've received unfair, upsetting news, this couple did an amazing thing.

They didn't get angry. Instead, they wiped one another's tears with caring thumbs. Tenderly. Sweetly. With a maturity and naturalness that belied their years. And, when they were done, they feebly smiled at one another before the boyfriend bent down to envelope his fiance' in a genuine, heartfelt embrace. He whispered in her ear and she nodded at his words.

I looked to Carla, who was watching the couple with the same wistfulness that I felt. One simply could not help but cheer for this young love. Nor could one be in that room and escape the emotional intensity of their love. Despite their youth, they were demonstrating the stuff of which people spend years trying to instill in their own relationships.

When they had collected themselves, I explained everything at length. The patient would need to get repeat blood work in two days. If the hormone level hadn't doubled in that time, or had stayed the same or even dropped, it would be confirmation of our suspicions. Suspicions that were extremely solid, already.

Sitting at my computer station after treating them, out of sight, I heard their familiar voices speak to our secretary on their way out of our department. "Please tell Dr. Jim and Nurse Carla that we appreciate all they did for us today." I rolled my chair through the doorway into their view. "Thank you," I said. "I hope you both have a fantastic future together. You deserve it."

And I meant it. They did deserve a bright future.

As always, big thanks for reading. I hope this finds you all enjoying the last days of summer...

'Tis The Season

Although I have been meaning to post for the past week, the end of summer and a stack of shifts have kept me from fulfilling my intentions. I had no problem posting three times a week during this past school year and can only hope that my writing resumes as the kids return to school and the household takes on a familiar, old calm. Thank you, friends, for your patience.

That being said, it seems that another return-to-school season is upon us. Advertisement fliers, spam emails, classroom notifications, clothes and sneaker shopping, and the accompanying pressure to squeeze in every last unfulfilled summer moment during these final few weeks are at an all-time high. Fun, yes, but not how I would choose to spend a sunny, warm, lakeside day--fighting off the crowds at the local sporting goods store to buy a heavy-duty, cool-looking knapsack before they run out.

At work earlier last week, then, imagine my surprise when I realized that within the hubbub of excitement of school's return and summer's ending, I missed the approach of yet another season--football season. A season filled with devoted fans and amazing plays and incredible athleticism. And, if you happen to work in an emergency department, you know the other truth--it is a season sometimes filled with unfortunate injuries.

I walked into Room 30 to see my next patient, a fifteen year-old male coming straight to us from his school's football field. His first "official" football practice, full pads included, had just finished. Practice was six hours, from 8 a.m. to 2 p.m.

Somewhere around noon, this patient had taken a hard tackle and had gotten knocked to his left side, injuring his left shoulder. Despite his pads. And despite his pain, the patient had kept quiet about his discomfort and had finished out practice. He hadn't wanted his friends or coaches to think he was "wimping out." When his mother arrived to pick him up, however, he told her his shoulder "wasn't feeling right." That's when they decided to visit us.

The patient was a big, husky boy, from the corn-fed, steak-and-potatoes species. He lay in his cot, on his right side, while his mother and father and younger sister hovered near him. He greeted me with a smile as I walked into the room.

"Hi, Seth," I said, shaking his right hand after introducing myself to his family, "what the heck happened to you on your first day of practice?"

His head, topped with a mop of curly brown hair, shook with disappointment. "I don't know," he answered, his half-boy, half-man voice cracking, "I practiced all summer without pads and today, the first day of practice with full pads on, I get hurt. Go figure."

After reviewing his history and performing an exam, which revealed intense shoulder pain (at the proximal humerus), we sent him for x-rays. While he was gone, I checked in with the family.

"What do you think, doctor?" the father asked me. "Honestly," I replied, "I think he broke it." The parents shook their heads. "I knew we shouldn't have let him play," his mother mumbled before turning to me to explain, "this is his first year doing this sport." It seems he had grown significantly in the past year and wanted to give football a try.

Sure enough, his x-rays revealed a horizontal, transverse (a clean line), non-displaced fracture of his proximal humerus. Although treatment for this type of injury is a minimum of 4-6 weeks of wearing a sling, Seth's football season, by the look on his mother's face, was probably not going to resume after that time.

It's a tough call, this sport. I think of Charles Dicken's famous line, "It was the best of times, it was the worst of times... ," when it comes to football. Although the sport is awfully exciting, it does come with an increased risk of injury. We've all seen those clips of devastating injuries. In fact, I'm sure many of us know someone personally who may have gotten hurt playing this great Americansport. For me, it was my tough, older brother, Johnnie, hospitalized when I was a kid from sustaining a head concussion during a football game. And between me and you, I still don't think he is right (a "little brother" dig there). What to do?

Despite my hesitations, three years ago, when my nine year-old son approached my wife and I about playing, we hmm'ed and hah'ed over our decision. Ultimately, we chose to let him play. Being a good athlete, we watched him successfully play running back the past three years, taking his share of hits but never losing a game during this time. This year, though, he wants a break. And we're fully supporting his decision. Instead of football games, it will be soccer games for him this fall. Somehow, we think watching three of his friends get hurt last year (a concussion, an ankle injury, and blunt abdominal trauma) may have influenced his decision.

I have to be honest, though, I will miss the cheering crowds, the steaming hot dogs, the warm ciders and hot chocolates. I will miss the camaraderie with other parents and the announcer's voice providing the play-by-play and cheap jokes.

And I will miss the football action.

As I am finishing this post, I am reminded of a local high school football star who I treated a few years back. He was one of several children of a single mother who had gotten a full scholarship to one of our prestigious private schools to play football. Unfortunately, he had come to our ER, with his mother and coach, after sustaining a head injury during football practice. "They said," his mother voiced, love and concern dripping from her words as she stood trembling beside her son's cot, "that he was knocked out cold for five minutes." The coach, who had witnessed the injury, nodded his agreement.

Fortunately, this respectful, young man, he with the caring mother, did not show any significant injury on his CT scan. Because of the significance of his impact, his loss of consciousness, and his flattened, groggy affect, however, I did not want him to practice or play any football for at least two weeks, until he was cleared clinically and with cognitive testing by his private doctor. Another head injury layered on top of this one could potentially have had a catastrophic outcome.

The coach took the news worst of all. "He has several college scouts coming this Friday to watch him play." I shook my head "no." Call me conservative or overly-cautious, I don't care. I didn't want this young man taking another hit like the one that brought him to us. At least not in the near future.

The patient took the news quite well, but it was his mother that I was most impressed by. "Doctor," she said with earnest, "I promise you that Tyler will not be playing for the next few weeks. It is more important for me to have my son around for a long, healthy life than it is for him to play a few risky weeks of football. No victory is worth those odds." She turned to the coach. "If those scouts want him bad enough, they can come back another time."

Wise woman. Wise words.

I followed him the rest of the season via the sports section in our newspaper. As Mom had promised, Tyler didn't play for those two weeks. Tyler did, however, go on to have a full recovery and receive a full Division I football scholarship.

To all the football players, coaches, and fans, I salute you with a personal toast. To you, I wish the merriest and healthiest of football seasons.

As always, big thanks for reading. C, thanks for the kick in the pants via email today. I hope you all have a great weekend.

The Decisions We Make

It had been a high-speed motor-vehicle accident. One car. A twenty-something male driver without passengers. No seat belt. And now, this same driver had no movement from his waist down and no sensations below his mid-abdomen.

According to bystanders, he had been driving his sedan dangerously fast, some estimates of nearly 100 m.p.h., before losing control. The car veered off the roadway to the right, flipping mid-air before smacking head-on into a magnificent tree. It was unclear if the driver had been thrown from the vehicle or eased out of it by witnesses at the scene.

The prehospital call came from an experienced paramedic who's shallow, rapid breathing and abbreviated sentences clearly defined the dire circumstances of this patient. "We are bringing you a male patient, approximate age twenty, involved in a single-car MVC (motor vehicle collision). The patient's vital signs are stable. He has no, I repeat--no, leg movements and cannot feel us touching him on his abdomen." The paramedic took a deep breath before she continued. "The patient also has priaprism."

"Is the patient talking?" the charge nurse taking the radio call asked.

"If it weren't for the forehead laceration and his neurological deficits, you wouldn't even know this guy was in an accident," came the reply.

From this short conversation, we were able to garner some very important information. One, the patient had an obvious spinal cord injury. With his leg weakness and loss of sensation below the abdomen, we could assume that the level was somewhere in the thoracic or lumbar area. Two, his vital signs were stable, which went against an injury above T6. A spinal cord injury above this area can result in neurogenic shock, where the patient may exhibit extremely unstable hypotension and bradycardia. The paramedic had told us the patient's vital signs were stable. And three, this patient had priaprism--a persistant erection that, in this circumstance, was indicative of a spinal cord injury.

It was not sounding good for this patient.

We prepared the trauma room for this patient's impending arrival. He was being flown directly to our facility from the scene of the accident, about an hour away by car. Just minutes by chopper. A trauma alert was called, which ensured that the CT scanner was vacant and ready, that the trauma team would respond and work hand-in-hand with our ER team, that respiratory therapists would bring a ventilator and intubation trays, and that all other services were placed on high-alert to immediately respond as needed.

Within minutes, the chopper landed on our parking garage rooftop and the patient was rushed into our department, Trauma Room 18. Surpisingly, just as the paramedic has described, he did not appear to be acutely ill or injured upon first impressions.

He had sandy brown hair with matted bangs from the clotted blood of his forehead injury. His eyes were brown and frightened. He was covered in pale gray blankets, monitors and wires poking out from different angles. He was on a transport board with a hard supportive neck collar wrapped tightly in place to prevent him from moving his head.

Our eyes met. I walked up to the head of the bed as the nurses began obtaining new vital signs and my ER resident and the trauma doctor began their exams. "Hey, buddy," I said, bending down and talking calmly into his ear, "everybody in this room is going to be working hard to help you with your injuries. You are going to be getting poked and prodded and asked a million and one questions, but you have to bear with us. Okay?" He nodded at my words. After a moment's hesitation, he spoke, his voice soft, quiet, disheartened.

"Can somebody call my mom and dad and let them know where I am and what happened?"

"Of course," I assured him, calling in our case manager to his bedside to get a phone number. "We'll talk to them and let them know that you are here in our ER."

I performed my exam, first checking to make sure that his vital signs were stable. They were. I listened to his heart and lungs. All was normal. I palpated his abdomen, impressed by the horizontal line of xxx's that the flight paramedic had drawn across his abdomen to show the loss of sensation below. I did a motor strength test of his arms, which were strong and without deficit, and his legs, which were thick and heavy and without movement. It is quite disconcerting to have a young, healthy, strong patient lay in bed and not be able to move his legs at your command. I held his legs in the air, six inches from the cot, and told the patient to hold them there when I let go. They dropped with a thud. I pinched his great toes, we poked his feet with a clean pin, and still, nothing. He had absent reflexes of both legs.

Finally, my ER resident gained my attention by clearing his throat. He was standing at this patient's right side, lifting the gray sheets from the patient's torso. Sadly, he was showing me the patient's priaprism.

I can assure you that, of all of the telltale signs of sustaining a bad injury, priaprism is one of the worst. You can get priaprism from many various causes (sickle cell disease, medications, etc.), but when it happens hand-in-hand with trauma and some form of paralysis, the results are usually not favorable. Hell, the results are devastating, pure and simple.

I went back to the head of this patient's bed to speak to him. I explained all our clinical results on exam, and told him he would be going to the CT scan immediately. He nodded, wiped a tear from his right eye, and spoke. "My parents are going to kill me."

This patient returned from CT scan with the devastating results that we were expecting. He had sustained a vertebral fracture in his mid-thoracic region that had transected his spinal cord, cutting off all nerve innervation to the rest of the body below that area of injury.

Damn it all.

Neurosurgery was called, the OR was placed on standby, and the patient was emergently transferred to our ICU. Although we could do nothing about the permanence of the complete transection of his spinal cord, this patient would need surgery to stabilize his vertebral fractures. He had a long road ahead of him.

Imagine being this patient's mother and father. Imagine that phone call that came their way at 2 a.m. It is every parent's worst nightmare. Imagine driving an hour to arrive at a hospital you are not familiar with, only to find out that your child has just become a permanent paraplegic. How do you survive such devastation?

You raised a son, giving him your best through his formative years, wishing for all of the world's best offerings to come his way. Unfortunately, due to some poor decision-making, he wrecked his car, becoming an instant paraplegic. That little boy who jumped on his bed after bedtime stories, that young teenager who ran and played ball with the family dog until both passed out from sheer exhaustion, and that brave high-school graduate who walked sheepishly across the graduation stage just a few short years ago--that life would remain in the past, all those dreams and hopes tidied and packaged into the box of life's disappointments.

To be visited time and time again.

Ironically, as I wrote this post last night on my back deck, several medical helicopters flew overhead, I'm sure following their path along the lake's edge towards our hospital. I can only hope all was well...As always, big thanks for reading. See you soon.

Savoring The Moment

I had been running late on another busy summer day. The type of day where you gain one step and lose two. Meetings and paperwork had filled up another summer morning. Baseball games, swimming practices, and soccer scrimmages had filled up another summer afternoon. And for this particular summer evening, I was scheduled to work an odd emergency room shift from eight p.m. to four a.m.

While driving to work, I had gotten stuck in a construction zone that had taken much longer than usual to get through. And, like Murphy's Laws would dictate, I had gotten stopped at several intersection lights that took forever to rotate back to giving me the green go-ahead. So, after finally arriving to the hospital and parking my car, I hurried into the emergency department, hopeful that all would be quiet.

Wrong.

The waiting room was jammed. The sounds of chaos hit me immediately, several TVs competing for dominance (Maury Povich vs. Headline News) while multiple conversations in multiple languages lingered heavily in the air. I had to step around several waiting patients while I dodged angry glares. "Excuse me," I said repeatedly, stepping around one patient with a bandaged, bleeding scalp and another sitting in a wheelchair, holding a vomiting bin, before finally making it to the double-doors that connected the triage station and waiting room area to the emergency department's active hallways.

I held my electronic ID badge up to the monitor and deeply exhaled as the double doors opened wide for me, taunting me to step forward into more mayhem. "Come, Jim," they spoke, willing to remain open until I took that first step through, "we've been waiting for you."

I walked into the ER's hallways as the doors clicked shut behind me. Locking me in. A good thing, too, since the hallways were lined with more wheelchairs and multiple cots, all filled with patients waiting to be placed into treatment rooms. The overhead fluorescent lights had been dimmed to create a warmer atmosphere, but failed miserably. Patients were writhing in their cots, holding their aching body parts while the wheel-chaired patients' bodies were slovenly tipping to one side or the other, like wilting flowers in the sunshine, obviously tired from maintaining an upright posture.

For a few brief seconds, I stood there, in the middle of this crazy hallway, taking inventory while rebuffing further angry glares. It seemed that people were quite frustrated and openly showing it. A nurse walked by in this instant. "Hello, Dr. Jim," she said, nodding at the lined hallway, "it's a rough one today." "Hi Kelly," I answered, "how long is the wait?" "Over six hours," she said, hurrying away with one of the wheel-chaired patients. Can you imagine, at eight at night, waiting over six hours to be seen in an emergency department?

And then, among this havoc, where multiple eyes were dancing around looking for the next person to direct their anger towards, I saw it. A sweet and tender moment. Between a mother and daughter. One of those little spaces of time where a typical and mundane, yet incredibly special, happening occurred that was missed by everyone else. Where I was reminded, once again, of our humanity.

They were halfway down the lined hallway, about twenty or so feet from me. The mother was sitting in the wheelchair, attempting to stand. She was fragile, polyester pants and a buttoned-up sweater clinging to her slight frame, with pursed lips and determined eyes. Beside her, standing, trying to help, was her daughter, obviously tired, middle-aged, in capri pants and a short-sleeve shirt, wearing the same pursed lips and determined eyes as her mother.

What made this scene remarkable was the intimacy of their moment despite all of the obnoxious stimuli that bombarded them. While a patient near them dry-heaved into a big pink basin and another grimaced while tightly gripping her head between her hands, this daughter wrapped her thin arms around her mother's waist, gently guiding her to her feet while leaning into her, chest to shoulder, her nose buried into her mother's short hair.

Oddly, as much as I wanted to help, I also wanted to continue watching. "Breathe in," I thought to myself, willing the daughter to inhale the scent of her mother's clothes, of her hair, maybe of the perfume that in years to come the daughter would casually smell and be taken back to this moment of familiarity. "Hug tighter," I willed the daughter's arms, wrapped around her mother's waist, hoping that they appreciated the inherent core strength of this woman who raised her. "Whisper something encouraging in her ear," I willed the daughter's lips, watching closely to see the mother lean even moreso into her daughter before successfully standing. She turned to her daughter and smiled. Soak this all in, I willed the daughter, this little moment of having your mom need you.

Maintaining her tight embrace on her mother, the daughter kicked up the foot pedals on the wheelchair before turning her mother toward where I was standing, guiding her several steps in my direction. As they approached me, the daughter and I gained eye contact.

I shifted my work bag over to my other shoulder and approached this patient's left side, opposite the side where the daughter was being supportive. "May I help either of you?" I asked, hoping to help this patient from the middle of this hallway. I could picture a runaway cot or a hurried tech clipping her and, despite her daughter's support, this patient falling to the ground.

"I think we're okay," the daughter answered, "we're just going to the bathroom." They were but ten feet from the bathroom door and looked comfortable enough to make it there. "How long have you been waiting?" I asked, grasping the patient's left elbow to help them the last few steps.

"Too long," the mother blurted out, showing her piss-and-vinegar. I laughed. It seems that an elderly woman's gumption is indirectly proporionate to their physical size. This woman, I had no doubt, had big gumption. "Probably a couple hours," the daughter added. I explained to them that I was one of the doctors and asked them what brought them to our ER. Plain and simple, it was a UTI. The mother had several days of burning and frequency of urination, and her family doctor "couldn't fit her in." Thus, the ER visit. And long wait.

After helping them into the bathroom, where the daughter would stay until her mom finished, I wished them luck and left them to their privacy. I found a tech who was able to wait by the door to help this patient back to her wheelchair from the bathroom, once they were finished.

I plugged myself into my hallway computer, sat down, and found this woman's results, confirming that she had a simple UTI. Thankfully, she was only a few patients down on the waiting list and would be discharged from our ER in the next hour from our express side.

As they left, I got a message sent to me from the daughter through one of our techs, thanking me for my help in the hallway and for "speeding them through." Although I would like to think I yield such power, I don't. It is the result of a cohesive, hard-working staff.

I jumped from my chair and ran to say goodbye to these people, only to find that they were already gone. I was disappointed I had missed them.

That still didn't keep me, though, from willing this daughter to cherish her care-giving role. And remaining time with her mother.

As always, big thanks for reading. A crazy schedule here...thanks for bearing with me. I hope this finds you all well.

The Friendly Head-butter

The ambulance call came in shortly after 2 a.m. "We're bringing you a 27 y.o. unresponsive male with a head injury and alcohol on board." Despite the patient's unresponsive state, the prehospital team's vitals for this patient were stable.

We prepared a trauma room for this patient, unsure if we would need to intubate the patient to protect his airway and get an appropriate work-up. Alcohol ingestion with unresponsiveness can mean something very serious and, until we had a chance to thoroughly examine this patient, we would provide him with every cautionary medical measure available. Of course, flipping the coin, alcohol ingestion with unresponsiveness can also simply mean "passing out." And as anyone who has worked in an ER setting can tell you, the majority of patients who come in with these similar symptoms are usually just of the "passing out" variety.

Soon enough, the prehospital crew wheeled this patient through our ambulance bay doors and rushed him to Room 18, where we were waiting to greet them. The patient was disheveled, laying on his back, his head turned over his right shoulder. The smell of vomitus was overwhelming, a mixture of bile, soured alcohol, and undigested food. On closer inspection, that was not a designer graphic t-shirt he was wearing but rather a run-of-the-mill Hanes t-shirt sprinkled with the remnants of his puking. Corn kernals included. His cargo shorts were hanging halfway down his pelvis.

As we moved this patient from the transport cot to our hospital bed, the paramedics filled me in with a little history. "Einstein, here," the one paramedic started, "was out tonight with a bunch of buddies drinking and having a grand ol' time." He paused for a minute, chuckling to himself, before continuing. "Somewhere around his tenth drink, his buddies said he started head-butting anyone who would let him."

"You mean people actually let this guy come up to them and head-butt a 'hello' to them?" I asked, incredulous at the thought.

"They probably didn't see it coming," the paramedic answered. "Supposedly, he's real quick with the gesture," he continued, "like a head-butting champ or something."

How's that title for making your parents proud? "Champion Head-butter, 2010." I don't think I would have a prouder moment than if one of my children came home with that award. Especially if it came with some cash. Throw in a tiara and a sash, too.

"Anyway," the paramedic finished as we began hooking the patient up to our monitors, "he head-butted one too many people. He walked up to another drunk buddy of his, slammed heads with him, and literally dropped. Before he hit the floor, though, somebody standing next to him was able to catch him and ease him down. Witnesses said he was out like a light."

I yelled in this patient's ear and was happy to see him stir. I rubbed his chest and pinched his toes to make sure he was appropriately responsive, and he was, trying to swat away annoying me. I listened to this patient's heart and lungs. All clear. I reviewed his vitals. All stable. I looked closely at his pupils, happy to find them appropriately reactive. I was reassured that he was in no grave danger.

Now I had time to do a closer, more focused exam, starting with his head. Hardly surprising, this patient had a large, erythematous abrasion on his forehead, the skin tense from some localized swelling. I pushed on it to make sure his skull bones were stable underneath, expecting nothing less than a hard-head from this patient. He didn't disappoint. I looked in his ears and nose. No blood. I pushed on his facial bones and found no other abnormalities. The rest of his exam was also unremarkable.

In essence, this patient was a drunk with a big "goomba" on his forehead.

Prior to leaving his room and ordering his CT scans, the patient began stirring. His nurse, fresh out of nursing school, greeted him. "Hello, Mr. Sanders," she said, "I'm Chrissie and this here is Dr. Jim. We'll be taking care of you tonight." I said "hello" to him while I nodded my acknowledgement.

The patient must have liked what he saw in Nurse Chrissie, turning his attention back to her. In an artificially deep voice, slurred slightly, and with a lopsided grin, he said, "How you doin', Chrissie? You can call me Larry." He pulled his hands through his hair, trying to straighten-up a little. Unfortunate for him, though, there is a limit to how appealing you can make yourself when you are drunk, sitting in a hospital cot, covered in a gray, threadbare hospital gown. Oh, with a big "goomba" on your forehead.

"I'm good, Larry," Chrissie answered, enunciating 'Larry', "and how are you doing?" "I got a massive headache," he answered her. Then, turning to look at me, he said, "Hey dude, how about some medicine for this headache. Jesus H. Christ, already." I felt like head-butting him. In a nice, friendly way, of course.

A few minutes later, after this patient returned from the CT scanner and was waiting for his results, a call came back from the waiting room concierge. "Is it okay if Mr. Sanders has a few friends come back and wait with him?" "Are they sober or drunk?" the secretary rightfully asked before giving her permission. "They might have had a few drinks," the concierge said, "but they are really respectful and concerned."

I was walking down the hall, coming back from seeing another patient, when I saw Larry's friends coming from the opposite way. I wasn't aware of the concierge call, but none of that mattered. I knew who these two guys were the minute I saw them. I slowed my walking pace, wishing that the fluorescent hallway lights were just a little more brighter so I could better appreciate their appearances.

Both of the guys were wearing fashionable jeans with flip-flops that clucked with every step, graphic-Ts, and, barring the sprinkles of vomit that covered both of their fronts, looked quite hip. But these weren't the signs of their brotherhood, of best buddies out on a late Friday night having a great time, now bonding in our ER.

No, that sign would be the matching "goombas" they both wore on their foreheads. Bright pink, two inches in diameter, and glaringly obvious under their shaved heads, their warwounds looked almost identical to the injury of our patient, Larry. Their friend.

I stopped them as they walked by. "Hey guys," I said, having a little fun, "what happened to your heads?" The one remained silent, intently watching his pacing feet, while the other spoke. "You don't even want to know," he said, shaking his head in disappointment. "Well," I said, "if you guys want to be seen or get a bad headache, let us know, okay?"

Soon after, Larry's CT reports came back negative for any injury. Outside of a bad headache and a nice-sized contusion/abrasion, he was getting off quite nicely. I went to the room to explain his results to him, and caught my breath as I walked into Room 18. With these three buddies sitting close together with their matching injuries, how could I not think of The Three Muskateers?

Larry, thankful for not having any significant injuries, started crying (the gut-wrenching bawling brought on by a stiff drink) and throwing around his apologies to anyone who would accept one. A tech walking by his room even got one. "I'm so sorry, buddy," Larry said. "For what?" the tech asked. "I just am," he replied. The tech kindly went and got Larry a box of tissues.

Finally, a sober friend came to drive them home. A female. Long brown hair, very sophisticated-appearing, wearing a warm smile. Evidently, she also had a great sense of humor. She exhibited a hearty, genuine, gutteral laugh, I'm told, when she walked into Room 18 to gather her friends. And had a hard time stopping.

At least the patient was a gentleman. She wasn't sporting a matching forehead "goomba"...

As always, big thanks for reading. Trying to keep things light this week. See you Friday...

It's Not Working

She was the wife of the patient in Room 24, a gentleman in his early sixties seeking treatment for his abdominal pain. She was of slight stature, barely over five feet tall. Her hair, straight and gray and hanging to her shoulders, was tucked behind her ears. The lenses of her glasses were thick, the type that disproportionately magnify the eyes and give them a non-human appearance. Her thin, gold-wired frames seemed to sag from their weight. Between the constant retucking of her hair behind her ears and the adjusting of her glasses, with her right index finger, on her nasal bridge, this woman came across as quite fidgety.

Although I wasn't treating her husband, I was sitting in my hallway seat just between Room 24 and the nurses' station and had heard the nurse mention the "nervous Nellie" wife of the patient in Room 24.

That was the understatement of the year.

I had first noticed her as she walked out of her husband's treatment room and approached the station. "Excuse me," she said to the unit secretary in a soft, feebly voice, "but can someone help me?" "Sure, maam," the secretary answered, "what can we do for you?"

As she spoke, the wife picked some lint off her craft-store sweater, doctored up with sewn-on pom-poms. "Well," she said, "the monitor keeps beeping in my husband's room."

"Okay, maam," the secretary said, "I'll send someone right in." As the woman turned and walked back into the room, the secretary paged Liz, the nurse for Room 24, who, after examining the monitor, found it to be working just fine.

A few minutes later, as I was hunched over a chart while writing on it, I heard someone clear their throat. I looked up to find the patient's wife, moving in to take ownership of my personal space. "Can I help you, maam?" I asked, amused. "Well, yes," she said, again with a crackling, muted voice, "my husband's phone in his room isn't working."

"Oh," I explained, "you just need to dial "9" first and that will give you an outside line." She nodded as I continued. "Do you need to make a call, maam?" "Well, actually, no," she said, hesitantly, "I just want to make sure it's working in case there is an emergency with my husband. You can never be too prepared."

She didn't strike me as the boy scout type.

I gave her a smile before standing to go meet my next patient. She turned and walked away from me, heading back into Room 24. After finishing with the new patient several minutes later, I returned to sit at my computer, only to find Liz shaking her head in frustration. "What's the matter, Liz?" I asked, quite sure that I would know the answer. "Are you having one of those days?"

"That wife is going to be the death of me," she chuckled, good-naturedly. "She just came out and said our counter drawers are broken because when she opened them to see what was inside, they wouldn't 'close right'." It turns out that a safety-latch had caught that prevented the drawers from closing. "What's she doing going through our drawers, anyway?" Liz added.

Well, unfortunate for us, this woman was just getting warmed up. Soon, and in no particular order, she came out to request an extra pillow for her husband (an impossible task in our ER). "Oh," she added a minute later when she came back out, "and another warm blanket, too." She requested coffee for herself. "And a more comfortable chair if you have one." A few minutes later and she was back. "Do you know that the waste basket is almost full and will probably need emptied? Oh, and that red container on the wall looks like it's filled with needles."

Seriously, she had an endless list of issues that soon became quite comical to us, the staff.

"Shouldn't my husband's IV be dripping faster?"
"Do you have an extra pair of those slippers that I can take home?"
"When's the last time someone washed the room's curtain?"
"Can someone look at the mole on my husband's back as long as he's here?"
"Was that a helicopter I heard outside?"
"Do you think we'll be home before Jeopardy starts at 7:30?"
"Are you sure you set the wheel-brakes on the cot (they were)?"
"I think one of the fluorescent bulbs is burned out in the ceiling (it wasn't)."
"The blood pressure cuff is broken, I can't get it to inflate on my arm."
"Your ER still validates parking vouchers, right?"

I found her initiative and gumption to be refreshing. And funny. It was easy for me to be amused by the ongoing antics since I wasn't the one in this woman's line of fire. That would be Liz, who appeared less and less amused with each new request or complaint.

Although this woman consumed much of our energy, we recognized that she was harmless. At one point, the staff pulled the curtains shut and slid the glass doors to the room closed, trying in vain to contain this woman and her nervousness. But slowly, as we all watched closely, she eased the curtain open about two feet, with the utmost caution and silence, before she slid the glass doors open enough for her to poke her head out, looking up the hallway and looking down the hallway, making sure she wasn't missing anything.

Finally, with about twenty minutes left to my shift, this woman approached the nurses' station yet again. "She's coming, she's coming," I heard the secretary hiss to everyone. Suddenly, everyone gave the appearance they were deeply immersed in charting about the many patients they had single-handedly saved that day in the ER. All but me, that is. I wasn't lucky to be holding a chart at the time.

The woman cleared her throat. "Hmmm, hmmm." "Yes, maam," I asked, "may I help you?"

"Yes, you can. I just used that bathroom right there (she pointed to one of our public restrooms just three doors down from her husband's room) and I don't think the motion-control sensor on the paper towel dispenser is working--it only gave me one piece of paper to dry off with."

"Well," I said, the others glancing at us from their eyes' corners to see if I would address this woman's issues or turf them, "how about we go take a look." She couldn't hurt me now that I only had 15 or so minutes left to my shift.

"And you are sure it didn't work?" I asked her as we walked the short distance to the bathroom. "Nope, I'm sure." "And you just used the bathroom right now? Or earlier today?" I asked her, trying to keep her talking and not complaining. "Oh," she answered, "just right now. I came straight to the station to tell you all about it."

We came to the bathroom door, which was loosely shut. We knocked to make sure it was empty. It was. I went in first, opening the door while I flicked on the lights. I took two steps into the bathroom before it hit me.

The smell, that is. It smacked me right in the face. The bathroom utterly stunk in the most primitive, disgusting, and vile way possible. And trust me, those of us who work in the ER are intimately familiar with stink. It has to be something impressive to rile us up.

While I was trying not to vomit in my mouth, the woman spoke. "See, right there," she said, pointing to the motion-controlled paper-towel dispenser, "I couldn't get more than one piece out of that thing." How, I had wondered to myself, was she even able to take a breath in while this fog of stink gripped my neck, suffocating me?

I moved quickly now, my life goal dramatically reduced to making sure the motion-sensor worked before I dropped to the floor and seized, my body's attempt at violently shaking any trace of this stench from my being. At the paper-towel dispenser, I waved my hand three different times in front of the sensor and, each time, a healthy piece of paper towel came out. "Well," said the woman, "I'll be. It does work!" Like a fireman leading a victim from a burning building, I grabbed this woman's hand and pulled her from the bathroom into the hallway, pulling the door closed behind us.

"Are you okay, sir?" she asked me as I bent over to take a deep breath. "I will be," I said dramatically, which was lost on her. I continued. "You said you just used that room, as in just right now." She nodded yes. Why on earth couldn't she have waited ten minutes before coming to us with this complaint?

"Okay, maam," I said, escorting her back to Room 24, "I know you have come out to the nurses' station several times for help, but go ahead and relax in the room a bit with your husband. I'm sure he will be going home shortly."

This was the last I saw of that woman before I left my ER shift (running out the door), eager to get home to change my clothes. I had told Liz exactly what had gone on in that bathroom. "I swear, that woman must have dropped a deuce to shame all deuces," I said. "That little, frail woman?" Liz asked in disbelief. "And she didn't smell it?" "Not once," I said, incredulous, "did she act like she smelled it or was embarrassed by the stench." "Amazing," Liz muttered, stifling her laughter, "she complained this entire visit and then led you to a bathroom she was responsible for smelling up. She had to have known..."

I drove home in my car thinking about this wife. I had, at one point wanted to meet the husband, to see what kind of guy this woman was married to. But, in my haste to leave the ER, I had abandoned that venture.

Since this wife had been very critical of our ER, though, I think it's only fair that I give a little critique of my own.

1. This wife's olfactory senses, well, they ain't workin'.
2. This wife's bowels, well, they are working just fine. Trust me.
3. And finally, if you ever need a bathroom's motion-sensor checked, do not, and I repeat, do not come looking for me. I'm retired.

As always, big thanks for reading. I hope everyone had a great weekend. To the commenters on Bald Is Beautiful, thank you for sharing your stories. I'll see you Wednesday, July 28th. Emma update--she is home and safe and slept 16 straight hours, a house record! Our circle is complete again. Thank you all for your prayers and well-wishes!

Bald Is Beautiful

She was sitting up and resting comfortably in her hospital cot, her home-made mauve and black afghan tucked comfortably under her arms. A pale yellow handkerchief was lumped on the bedside table beside the phone. She looked up at me as I walked into the room, greeting me with her big smile and sparkling hazel eyes. Except for a few patches of sparse, fuzzy auburn hair, she was bald.

"Hi, Mom," I said, walking up to her and pulling my mask down to gently kiss her cheek, "how are you today?" Despite the heart-breaking circumstances which lead to her being a patient lying in a hospital bed, I had never seen Mom look so beautifully breath-taking. And under normal, healthy circumstances, she was already quite a beautiful person, inside and out.

Mom ran her hands over her scalp, weakly smiling. "Well, honey," she said, "I guess we can cancel the rest of my hair-dressing appointments for the year." Over the past few days, the ravaging effects of Mom's chemotherapy regiment had taken ahold, which included her hair falling out in clumps.

"Mom," I said, reassuringly, "I don't think I have ever seen you look more beautiful." I walked over to the yellow handkerchief and picked it up, examining it. Strands of her thick, wavy hair clung to it. "What do you say we just throw this out?"

"Oh, Jimmy," she said, exhaling a deep breath, "I just don't think I am ready for that yet."

I understood completely. Mom had been raised in an era where curlers and perms and colorings played an important part of a woman's presentation. And although Mom was far from vain (how could she be when she was busy raising seven kids), she thoroughly enjoyed indulging in her hair. Hair that was now gone.

Despite a custom-made wig and multiple handkerchiefs, I don't think Mom's beauty was ever more evident than when she went bald during her chemotherapy days. Her baldness only seemed to enhance her indomitable spirit. Her eyes danced more openly. Her raw facial expressions confirmed her appreciation of life. Her prominent cheekbones exuded her infinite strength And the curve of her smiling lips were only that much more welcoming, appropriately framing the beauty of her words.

Accompanying her baldness, the truth of Mom's bravery in fighting her illness could not have been any more evident.

As I go along in my typical days of being an ER physician and the father of a child who has survived his own life-threatening illness, I can only tell you, without hesitation, that this baldness that accompanies one's fight for their life is as pure and as defining of one's character as any physical attribute can be. Without any words spoken, a patient's baldness from chemotherapy reveals a fighting spirit and a commitment to continue living. It reveals a strength drawn from reservoirs most people don't recognize they have until faced with crisis.

It commands my respect. And I rightfully give it.

Recently, at my gym, I couldn't help but notice one of the trainers, Barb, working-out with a woman who wore a handkerchief over her scalp. It was obvious that this client was intimately familiar with chemotherapy. It was very inspiring, to say the least, to watch this woman physically push herself through a workout despite her recent setback.

A few weeks later, surprisingly, I saw this same woman working-out without her handkerchief. Evidently, she chose not to cover up her baldness. And she looked stunning. As Barb and she worked out beside me in the cable room, I decided I had to speak up.

"Excuse me," I said to the woman. keeping it simple, as Barb looked on, "but I just have to tell you how stunning you look. I have no idea what you are going through, but I've seen you working out and pushing yourself these past few weeks and am thoroughly impressed. I wish you the best."

Well, Barb's client blushed a little as she thanked me. And later on, Barb came up to me and said that my words were exactly what her client had needed to hear since she was having a bad day. I hadn't been sure I should have said something, but Barb reassured me that my words were quite welcomed by this brave woman.

Especially in our ER, because of our regional cancer institute, we are privileged to treat many people who are wearing their baldness proudly as they undergo chemotherapy treatments. Both male and female. From the very young to the very old. And every time I have a patient who is bald for this reason, I make sure they know that they have my utmost respect. And if it is a child, that respect is also accompanied by a pile of stickers, a coloring book, and a Popsicle, if allowed.

A few weeks back, a brave little seven year-old girl greeted me as I walked into her ER room. She had been battling acute lymphocytic leukemia and, despite some mouth sores, still managed to greet me with her fading smile. On her head, nothing but baldness. At most, just a few patches of fine blond hair clinging desperately to their homeland. I smiled back at her as I approached, hoping my eyes conveyed my happiness to meet her. I must have looked like a big giant Smurf--I had donned a blue paper gown, a blue mask, blue foot covers, and cream-colored gloves. Until we figured out her immune status, we had to protect her from us.

"Hello, May," I said, extending my hand. "It sure is nice to meet you." We talked a few minutes about school, her best friend, and who her favorite doctors at the regional Children's Hospital were. Her mother sat at May's bedside, contributing to May's memories. "May," I continued, when there was a pause in conversation, "when did you lose your hair?"

She got quiet, hesitant almost. Her mom spoke up. "About three weeks ago, doctor." "Well, May" I said, my eyes hopefully conveying my sincerity, "I've seen many patients who have lost their hair because of their medicines, but I must say that you are by far the most beautiful." May looked up at me, serious now, and locked her eyes onto mine. I didn't flinch nor did I look away.

"Seriously?" she asked. "Seriously," I replied. In her child's voice, she softly said "But I don't like it. Everybody stares at me."

"You know why, May?" I asked, grabbing her hand with my gloved one. "They aren't staring because you lost your hair. They are staring because they are amazed to see such a brave and courageous seven year-old. And that's you. Showing all these people that you can be beautiful and brave no matter what medicines you are on or no matter what disease you are fighting." She nodded at my words. "The next time someone stares at you, May, just give them your biggest smile ever!"

"Like this?" she asked before donning one of the most perfect smiles I have ever seen.

"Just like that." I told her, admiring her gaps from losing her baby teeth.

I'm not saying that if you are undergoing chemotherapy and have lost your hair, that you need to express your baldness. Hardly. Wear a wig or a bandana if you feel more comfortable. During your fight, you do what you need to do and don't worry about what the rest of us think. But if you are in my ER or if you pass a middle-aged guy who happens to take a second glance at you, don't be alarmed.

It's just me, sending you good energy and well-wishes. And recognizing your courage.

Yes, indeed. Bald is beautiful.

As always, big thanks for reading. I appreciate your time. Emma update--day 15 of 17. Swimming at the Great Barrier Reef today before beginning the long trip home tomorrow. If she comes home, that is! Australia, you have a new, wildly-excited admirer in my daughter. Thank you. See you in a few days...