StorytellERdoc

The Broken Bone

noreply@blogger.com (StorytellERdoc) — Mon, 04 Mar 2013 12:19:00 +0000

Although I rarely get sick with the numerous strains of “bugs” that seem to go around our community this time of year, the week prior to my return to work for my next scheduled string of four shifts was spent mainly in bed, coughing and aching and whining about how miserable I felt. Fully recovered, though, I was excited to return to the emergency department to do my fair share of stamping out disease and healing thy patient from illness and injury.

Walking into Room 21 to see my first patient of the day, however, made me cringe just a bit and suddenly, I wished I could have been back in my bed at home for just one more day.

The patient was young, in his mid-twenties, and appeared to be in significant pain. He was alone. His short-cropped hair was calmly neat, belying his grimaced, pinched face and restless arms and legs that rocked his compact body against the cot’s rails in defiance to his discomfort. His nurse, Sam, one of my favorites, was hurriedly placing an IV into the patient’s right arm.

I gently grabbed the patient’s shoulder to gain his attention, introduced myself, and asked him what brought him to our ER today.

“Doc,” he said, taking a quick gasping breath before continuing, “I was banging the shit out of my girlfriend when my penis snapped in half.” I looked from the patient’s face to Sam’s, who nodded his agreement to this patient’s history.

Ugh, I thought to myself, a fractured penis. A fractured penis!!! It had been, thankfully, several years since the last time I had seen a case like this. For some reason, despite my tolerance and calmness during any other conceived emergency illness or injury, penile or scrotal injuries always made me cringe. And I was cringing. Usually, this type of injury occurs with masturbation, unusual sexual positions, or aggressive sexual intensity, to be politically correct.

“Sir,” I said, “when and how did this happen?”

As it turned out, it had happened immediately before his arrival—about 20-30 minutes before we began treating him. And how? Despite his pain, he spoke with great pride and in great detail about his sexual prowess and escapades that lead him to our department. He painted a picture that, short of sustaining a penile fracture, all of us men have failed our partners in the sexual arena. Call it rough sex if you must. And call me a failure, then, if this was the price of success.

After his explanations, I had no doubt that I would be able to provide the detailed social history necessary on this patient’s medical chart. I imagined the pleasant dictation lady turning beet red from embarrassment as she typed his chart up. “Hey, Sally,” I pictured her saying to her co-worker, “come over here and get a load out of this patient’s story! I wonder how his girlfriend is doing?”

After examining this patient thoroughly, and confirming that he indeed fractured his penis, I ordered him up a healthy dose of pain medicine before calling the on-call urologist urgently. This patient would need emergency surgery to repair his penile injury, which really wasn’t a “broken bone,” per se (since the penis doesn’t contain any bones), but rather an insult (or tear) to the vascular columns that engorge with blood during an erection.

Finishing with a few more patients and while waiting for the urologist to arrive to see this unfortunate patient, I went back into his room to check on him and make sure he was more comfortable. He was definitely more comfortable and no longer alone. A much taller, big-boned woman with a similar shortly-cropped hairstyle sat in a chair beside the room’s sink.

I walked up to her, my hand extended, and introduced myself to her. Understandably, she could barely look me in the eye as we shook hands and she shared with me her name. During our introductions, however, her boyfriend blurted out in his pain-controlled state, “This is my girlfriend who I was banging the shit out of when all of this happened.” Talk about making an embarrassing moment more embarrassing for her. “Don’t worry about it,” I consoled her, “we will be taking good care of him.”

The patient didn’t stop there. “Hey Doc,” he said, his eyes slightly glazed over from the medications, “do you think they will be able to save my penis?” Before I could answer his question though, he continued. “Dude,” he said, now apparently more comfortable with me, “you don’t understand—without my penis, I am nothing.” He paused, took a deep breath, and got a sad look to his face. “I am nothing! Nothing…,” he repeated, remorse and fear now dripping off his words.

I reassured him that the timeline of his injury was in his favor—that presenting to us so quickly after this unfortunate event helped with his percentages of a full recovery. I told him that as soon as the urologist saw him, he would most likely go straight to the operating room.

“But, Doc,” he said, “what if they can’t save my penis. Can I get a new one?”

I assured him that most likely, they would be able to save his prized possession. Deciding to have a little fun with him, though, I continued. “But if on the small chance they can’t save your penis, penile construction/reconstruction surgery is very advanced these days. We have a catalog of new ones you can choose from.” I could only imagine him skipping the petite section and going straight to the plus section.

He looked up at me in surprise to my words. “Really?” he asked, before seeing the hint of a smile on my face. Getting the joke, he continued. “Dude, thanks. I needed that.”

Soon after, the urologist came in, examined the patient, and booked the OR suite to take the patient for immediate repair of his injury. He would need an indwelling foley catheter for 2-4 weeks while he healed from his repair, effectively taking him out of commission for a month or so. I truly wished this patient the best outcome.

Before the patient left our ER, as if things couldn’t be any more embarrassing for this patient or his girlfriend, this patient’s mother and sister came in to be at his bedside. How could you possibly explain such an injury to your mother, the one who is wearing the serious look of dread and concern for her son? Or your sister, the one who cannot contain her incessant giggling? And do you show them the injury or just trust that they would understand the explanation? Some things I just didn’t want to know. Although I am not of the moral fiber to condone lying, I sure as hell would have fabricated some type of story to divert my mother’s and sisters’ attentions if I were in the same situation as he. “Umm, Mom and sissies,” I would say to them, “I got a hernia while chasing a purse-snatcher down the street after he knocked over a 90 year-old lady.” And no, I wouldn’t show them the supposed hernia, either.

This patient, however, didn’t care. He did show his mother and sister his injury. Eeewwww, I know. That makes me cringe almost as much as the injury itself. Just as impressive, though, was that his girlfriend had an anxiety attack. Why? This was the first time she had met her boyfriend’s mother. And sister. Talk about memorable introductions to the family. Can you imagine, once again, that conversation? "Hello, Mrs. Smith, nice to meet you. I'm Ellie--the girl who broke your son's penis in half." I, for one, didn’t hold out much hope that this relationship was going to survive this ordeal. But I didn’t think the patient would show his penis to his mother, either, so I could be wrong.

Is there a moral to this story? I guess, maybe. The moral might just be that we should never ever "bang the shit out of" the ones we love. Sweet lovin’ might just be the best lovin’, right?

Oh, and one more moral to this story? Never ever show your mother your penis, no matter what state you may be in, when you are a grown man. That’s just creepy.

Thanks, as always, for reading. If this post and typical ER humor offends, my apologies. But who can blame all of us in the medical field for having warped senses of humor at certain times in our days. I hope this finds you all well…Jim.

A Hug Is A Hug Is A Hug

noreply@blogger.com (StorytellERdoc) — Wed, 20 Feb 2013 03:06:00 +0000

Sometimes as human beings, despite all the layers we consciously build upon the shell of our souls to shelter us, define us, and project an image to others of what we hope we are, our basic inherent quality of goodness emerges on its own free will. A kind word, a gentle touch, a hint of a smile, an understanding patience--these are all things that escape uncontrollably in moments where our consciousness is left behind, running to catch up to our spontaneous reaction in a moment of crisis for another.

Of all of these unconscious acts of inherent kindness and compassion, though, none ranks higher than a heartfelt hug. Not a light tap on the back, or the fake kiss of a cheek, but rather a hug that emerges from the tightened embrace from one to another that, for the briefest of moments, conveys the wordless caring that we all crave to receive. Like cake batter in waxed pleated cupcake sheaths, these hugs are ready to emerge, when fed warmth, to spill out of us into the want of another.

It was one of these moments, of private hugs and hushed whispers, that I was recently privy to witness in the trauma hallway of our department. Suprisingly, however, it was given from the most unlikely of persons.

Trauma patients are typically the most complex of all our patients, with a wide spectrum of issues ranging from life-threatening physical injuries to the endless abyss of psychological and social tolls from the unexpected event. Like trauma patients before her and trauma patients since, Room 18 held an unfortunate patient (in her early twenties) who presented via helicopter from a car-accident scene. She had been a front-seat passenger who, due to a multi-car collision and the twisted secrets of fate, sustained both severe physical injuries and, more importantly, powerful psychological injuries that would be life-long. Sadly, her mother, the driver of their car, had died at the scene of the accident.

Although I wasn’t the primary ER attending treating this unfortunate patient, I poked my head into the room to see if I could help in any way with her treatment. The mood of the room was somber, an understandable heaviness weighing down any spirit of knowing our quick actions might help this patient recover fully from her physical injuries. The bright lighting that reflected off shiny metal cots and posts and equipment could do nothing to deflect the pain and misery of this patient’s future. Of her impending misery. Of a future life where her mother would not be available to share a secret ingredient to a recipe, to consult over whether to serve ham or turkey on Christmas day, or to call “just because.” Nor did the room’s sterility help clean our own pain for this patient’s tragic loss. Adding to the senselessness, we later learned that the mother’s unselfish reaction in the crash had been to swerve their car in a direction that would protect her daughter from being directly hit, or t-boned. This patient’s mother had given her own life so that her daughter might keep hers.

After this patient was stabilized, it was shared with her that her mother had not survived the crash. Her mournful wails and cries after learning her cruel truth could be heard the hallway through. As tragedy’s effect usually does to each of us in the emergency department, we paused in this moment, recognizing the profoundness of change in one of our patient’s lives.

Eventually, family members trickled in and supported this patient as further emergency treatment was provided to her. Occasionally, I would pass by a pair or group of family standing in the hallway, outside of the patient’s curtained room, hugging and whispering to one another, trying their best to simultaneously provide and receive support. With each pass, I would slow down just a bit and nod my sympathies, wishing I could sponge even just a tad of despair from their shoulders.

It was soon after that Amelia, one of our “regulars,” was placed in the only available room, Room 17, next to the unfolding trauma tragedy. Ms. Amelia was an elderly woman with an extensive mental health history who had signed into our ER, yet again, for a multitude of miniscule complaints. Although she was well-known to much of our staff, I had only met Amelia one prior time a few years earlier.

I walked into Room 17 to introduce myself to Amelia, only to find the room empty. Reentering the hallway, I couldn’t help but notice two younger people fully embraced by the strong, steady arms of their slight, grey-haired grandmother. It was a breathtaking scene—the younger boy and older teen-aged girl leaning their heads into the gathering arms of this strong woman. I walked slowly by, looking for the nurse to ask her where our patient had disappeared. Not finding the nurse, I ran to the lounge for a quick bathroom break.

Returning down the hallway, I happened upon the same scene playing out that I had just passed by, the shorter older woman still embracing the younger two people while turning her head and softly taking turns whispering into each’s ear. It was a touching scene, one that struck me as both comforting and tragic.

Suddenly, though, I heard the hallway nurse yell out, and turned my attention to the young, blonde nurse who was doing the yelling. “Amelia,” the nurse scolded as she approached the same group of three from the opposite direction as me, “leave this family alone.” I was confused. I looked to the group of three. I looked at the nurse. And I looked back to the group of three just as the nurse touched the older woman on the shoulder and spoke again. “Please, Amelia,” she pleaded, “you need to go back into your room and leave this family to themselves.” The nurse’s voice cracked, begging of Amelia to not put up any resistance.

I stood still, staring at the scene. I looked at the group of three breaking apart, the older woman lingering to release the younger people from her arms, being urged on by the nurse. I looked at her pained face, watching as she whispered her last words to the young family members, releasing them hesitantly from her grip as the nurse coaxed her towards Room 17. And suddenly, with amazing clarity, the truth of the scenario smacked me in the face. Amelia, my next patient with the psychiatric history, was the “grandmother” who had been embracing two of the family members of the trauma patient.

“Well, I’ll be,” I whispered to myself while approaching Room 17’s doorway. The beauty of Amelia’s gestures were not lost on me, but I readied myself to have a serious discussion with her about privacy issues and respect and all of that stuff. Any family such as this trauma patient’s deserved their privacy in the depths of such crisis. Before entering the room, however, while I was putting a pair of latex gloves on in the hallway, I overheard the two recipients of Amelia’s hugs speak.

“She was a nice lady, wasn’t she?”

“Yes, she was,” the other responded simply. “I wonder what she is here for?”

“I don’t know,” the first answered, “but I hope she is alright.”

I paused to absorb the enormity of the moment, realizing that kindnesses can come from the most unexpected people in the most unexpected places at the most unexpected times. Despite Amelia’s personal struggles, most of which I could only imagine in her daily dealings with mental illness, she gave of herself that which she could, some heartfelt hugs. Hugs that appeared to be received with the intent for which they were given. Those hugs of Amelia’s, well, that was a darn-special privilege of mine to get to witness—one stranger comforting others in their moment of crisis.

Maybe all of this stuff the nurses warned me about Amelia were a thing of the past.

I walked into Room 17, extending my hand in greeting. “Hello, Amelia,” I said with renewed faith in our patient, “I’m Dr. Jim. What can I do to help you today?”

She mumbled something as she paced beside her cot. “Pardon me?” I asked her. The medical student accompanying me gave me a look that he, too, did not make out her words.

She wasted no time in speaking up. “What the hell is wrong with you people I should be out there with those people they need me don’t make me come back in here.” She spoke quickly, hauntingly, in one long exasperated breath.

Even though I knew Amelia wouldn’t like my explanation, I quietly explained to her that, although her hugs were welcomed and appreciated and quite nice, actually, we all had to respect the trauma family’s privacy at such a profound moment of sadness. I reassured her, though, that her actions were a privilege for me to watch and that the family appeared to appreciate her gesture.

“Now,” I continued, “what can I do to help you today?”

“Get me the hell out of here,” she said, glaring at me. “I don’t need to be in no room next to where bad stuff happens.”

I offered to try to find her another room, but she turned the offer down. When I asked her what her complaints were that I could help her with in the emergency room, she ignored me. “I want to leave,” she said with conviction. I made her assure me that she had no pains anywhere. I was reassured by her words that she was having no feelings of despair or urges to hurt herself. Thankfully, she had also assured several of the staff that she was not depressed or having any ideations to harm herself. And judging by her hugs, it appeared that all she wanted to do at this very moment was to help others in need.

“Amelia,” I said calmly and kindly, “are you sure you are going to be alright?” She nodded her head yes. After her hallway hugs, I think she truly forgot what reasons she had that had brought her to our ER that day. I discharged her from our ER without any workup after she passed my screening exam and a consultation with our case managers.

I can’t forget, though, why I think Amelia was there. I think that sometimes, in some mysterious ways, things happen in our daily lives that defy explanation. For unexplained reasons and circumstances, Amelia chose to visit our ER on a day when a few others were in need of a heartfelt hug.

And from Amelia, that got just that.

As always, big thanks for reading. I hope this finds you well. And to those of you who have continued urging me to write, I thank you. Your kindness has been felt…Jim

Have A Little...

noreply@blogger.com (StorytellERdoc) — Wed, 20 Jun 2012 17:35:00 +0000

Faith. A simple word with complicated meaning. It is a seed buried deep within our spiritual cores, ready to be nourished and blossom with the sprinklings of tragedy. It is a belief that things will work out, despite our lack of vision for fate's secretive reasons of the bumpy journey we must endure. It is an inherent hope that has either sustained us or has failed us miserably. Yes, to me, this is faith.

We all have known faith. Embraced it. Bargained with it. Coddled it within our breaking hearts. Placed it on a pedestal of worship. I have, too. With undertones that may be religious, spiritual, or meditative, we lean against its pillars of reassurance. Sometimes, as they say, it is all we have to cling to during desperate times.

Working in an emergency room for 16 years, I have seen faith present its various faces many times. It may be within the circle of a grieving family, their hands clasped in prayer. It may be in the young mother's eyes, watchful of her sick child lying in a hospital cot. It may be in the older gentleman's anguished cries as I share the devastating results of his wife's testing. It may be in the silent strength of the obvious love of a dying man's partner. It may be in the ER staff's comforting whispers. Faith cannot be contained, especially in tragic circumstances. I tend to think it is a part of the coping fabric that threads all of our lives.

Why do I think that? Because, those moments of my life where I had to believe in something more, where I had to dig deep within the rubble of my soul to scrape a little bit of sanity, were during intense, personal moments. My son's illness. My mother's death. My grandmother's death. A life-threatening injury to my father. I swear, when my mother and my son were both simultaneously enduring chemotherapy, I stared faith right in the face and bargained with it. Threatened it, even. "If something happens to my son," I uttered to invisible universal ears while pulling at my hair, "I will never forgive you for it." Yes, I know faith. It has been my best friend and my worst enemy.

After my son's initial diagnosis, I stood in the hospital corridors outside of his pediatric room, disheartened and in disbelief. Cole had just returned from the OR where a mediport had been placed in preparation for an aggressive initial round of chemotherapy. My spiritual guidance, Father Tom, stood beside me, recognizing my slipping faith. "Why Cole?" I asked, over and over, tearful and angry. "Why couldn't it have been me? What kind of world do we live in for a child to endure this?"

Father Tom, in his infinite wisdom, answered my pleas with words that I still carry to this day. His words, to me, exemplify the true nature of faith. "Jim," he said, his voice husky and comforting, his arm wrapped around my trembling shoulders, "I can't answer your questions. I wish I could, but I can't." He paused slightly, choosing his words. "I can only pray that at some point in Cole's life, on his journey, the answers of 'Why?' will become more evident. That the reasons will be more clear to all of us of why he was chosen to endure this illness." In other words, in staring at a big, suffocating fog of nothingness, Father Tom was telling me that I must have faith.

How does one do that?

At my rock bottom, the openness of my mind was staggering. I listened to any words of support and encouragement, my hopes and faith hinging onto any little hint of a better tomorrow. I'd walk away from family and friends, my mind reeling and spitting out their words to suit my recovery, my belief system. Ultimately, I learned to believe that all things in our lives happen for a reason. I had to arrive at the belief that Cole would survive and thrive, that the years we will have together would be many. To not arrive at this point would have meant a certain death in an unattainable part of my core. I was learning to survive by walking the path that my faith created.

Cole survived. And as I type these words, I whisper a silent thank you to those universal ears of faith that fulfilled my every request.

Every day, though, followed by every week, every month, and every year, there is more profound sadness, more tragedy, that requires us to dig deep and rediscover our faith. To recommit ourselves to examine our morals and ideals while we cope with a crisis. A few years back, another setback occurred in my life, plummeting me even farther into my spiritual well. Cole had veered from remission while my mother concurrently fought a losing battle against leukemia. And I was back to the same dark place that I had turned my back on just a few years earlier.

Again, though, my faith sustained me. It wasn't easy. But now, with things going well, especially after my very own first health setback, I sit here and appreciate the moments of goodness in my life. I have learned, from these various experiences, to give my attention to faith during the good times, too. My faith has been tested and tried and, fortunately, has sustained me in my times of need. It is my time to feed some nourishment back, during the good times, to those who have surrounded me with smiles and encouragement and and unwavering friendship and love. A phone call. A card. A lunch date. A smile. Some kind words.

It is a two-way street that I have learned to travel with faith.

Where does your life sit right now, on this very day? Are things going well for you? Are you facing crisis? Are you recovering from or approaching a trying moment? Are you engaged in the environment surrounding your life? How is your support system? And, most importantly, how is your faith? Do you think maybe that little seed patiently waiting to sprout within you, in a moment of need, might appreciate a little attention now? If so, give it some. Sow it. Water it. Feed it. Coddle it. Embrace it. The effort taken now to examine and understand your faith will reap you rewards when you most need them.

All around me, including dear family and friends, including strangers and patients in the ER, I see daily struggles occurring. At times, I feel helpless and out of sorts, my seat on the sidelines but a useless location to witness another's misery. But I know, from continuing to grow as a compassionate and kind person, that good times will prevail if one can just hang in there. So, please, just hang in there.

And have a little...

The Interview

noreply@blogger.com (StorytellERdoc) — Tue, 01 May 2012 15:26:00 +0000

A few years back, my wife and I were sitting on our living room couch watching the local evening news when a segment ran regarding a patient's option, often neglected, to interview a physician prior to agreeing to receive care from that particular caretaker. The interview, the segment continued, could involve questions ranging from professional training to personal attitudes and outlooks on life. Not a bad idea, I reasoned, if the required care was non-emergent. A physician sharing a similar perspective of his patient's well-being could only be beneficial, right? But in an emergency room setting, wouldn't this type of interview only delay necessary treatment? I couldn't imagine a patient with crushing chest pain taking the time to ask me of my residency training (Upstate NY) or how I felt about fitness training (all for it).

Of course, I was wrong. My following shift, I encountered an older, scholarly-looking gentleman who had presented to our department with complaints of acute abdominal pain. After introducing myself to both himself and his wife, I began to ask the patient important history questions when he suddenly interrupted me.

"Doctor," he asked, "before I agree to let you treat me, can you tell me where you went to medical school?" Although surprised, after watching the news segment just two days earlier, I anticipated that an encounter like this would eventually happen. "In Philadelphia," I answered. "And where in your class did you graduate?" "In the top ten percent," I replied. His questions kept coming. "And where did you complete your residency?" "Did you serve as chief resident your final year?" "How long have you been working in this emergency room?" As I patiently answered his questions, I began to wonder if the word "acute" was the right word to describe his abdominal pain.

Finally, though, he appeared satisfied with his interview. "Okay," he said, "I give you permission to treat me."

"Well, sir," I said, deciding to turn the tables on him, "I am not sure I want to treat you." I caught him off-guard. He looked inquisitively at me as I paused for good effect before continuing. "I have one question I want to ask you before I agree to treat you."

"Okay, Doctor," he said, "what is it?"

I took a deep breath and smiled as I spoke. "How will you be paying me for your visit today?" We both laughed. Regardless of his answer, he knew I would be his treating physician.

I hadn't thought about this encounter until just recently, after I had walked into Room 17 to introduce myself and examine a patient my resident was currently treating.

In the dimly-lit room, I found Bertha, alone without company, lying in a cot with hospital blankets pulled up to her chin. She was a 93 year-old woman sent to us from a local rehabilitation unit with complaints of chest pain. She had been placed there recently to recover from a bout of pneumonia. Bertha looked her age, appearing frail in size, her tiny body barely poking it's physicality into her covering sheets. Her face was graced with creviced wrinkles and framed with an unkempt gray bob. Her hazel eyes, however, belied her years. They were fierce and focused, guarded even, glistening with anticipation as I approached to introduce myself.

"Hello, ma'am," I said, reaching for her hand under her covers, "my name is Dr. Jim and I will be following your treatment today with Dr. Brad, one of our resident physicians who I am supervising."

She looked me carefully up and down as I continued. "Is your chest pain gone?" She nodded yes to my question. "Do you need anything right now?" She nodded no. "Is it okay, ma'am, if I listen to your heart and lungs?" She nodded yes.

I pulled my stethoscope from around my neck, placing it's diaphragm on her chest wall while inserting the listening buds into my ears. While bent over her and listening, I watched her face closely, appreciating her unique eyes. Suddenly, though, her lips moved. Unable to hear her, I stood up while removing the ear buds. "What is that, ma'am?" I asked.

With a soft, quiet voice, she asked me "Where did you go to medical school?" I told her. "And where did you do residency?" I answered her again. "Do you enjoy being a doctor?" I told her yes, very much so. I wasn't sure if another interview was in my future, so I flipped the coin on her.

"Why do you ask, ma'am?" I questioned her. "Did you once work in the medical field?"

She shook her head. "No, I didn't. But my daughter was going to be a nurse." I waited for her to continue but she seemed absorbed in her memory. "What happened?" I finally asked, my curiosity peaked. "Unfortunately," Bertha answered, sadness sweeping across her face, "she wrecked her car late one night while driving home from a training shift and died. She was nineteen."

I grabbed Bertha's hand again and held it, humbly reminded that every face I encounter holds a story. And quite honestly, I could not even begin to imagine the pain that would come with losing a child. "I'm so sorry," I said, stroking the back of her hand.

"Don't be," she said, "I still had a wonderful life." She went on to explain that she had six children total, four of which were still alive but unfortunately not nearby geographically. This explained why she had been placed into a rehab unit from her assisted-living arrangement while recovering from pneumonia. "They are here, though," she said, lightly tapping her heart with her free hand.

After another pause, I had to ask my next question. "What happened to your other child?" "Oh," she answered thoughtfully, "we had a retarded son that died in adulthood. My husband and I managed to care for him at home until he passed." She went on to proudly explain that it was no small feat to raise a mentally-challenged child in earlier days--that most were institutionalized. "And your husband?" I asked. "Well, he and I were married for 53 years before he passed away. That was quite a few years ago. But, we managed to stay together and keep our love the whole time." We talked a few more minutes, her insightful words leaving a significant imprint upon me.

Finally, I finished my exam. Before leaving her, I thanked Bertha for her time and for sharing her life story with me. Happily, she did very well for us in the ER and was admitted to observation.

Just returning from my recent unplanned medical leave, I felt Bertha's story grab my shoulders and shake me. Not just shake me, but rattle my soul. My encounter with her was a well-timed reminder of just how privileged I was to be an emergency physician.

And suddenly, it dawned on me. I was the one who benefited most from the interview process with a patient. Sure, there is history-taking involved with my job, to find out the specifics of an illness that might help me provide the most focused and complete care to a patient. But this other "stuff," this personal information that a patient shares with me, isn't this more like an interview? I don't necessarily need to know everything a patient shares, but doesn't it all provide a much more complete picture of the person I am trying to help? And, besides, can't some of my patients' shared life experiences help me along my own life's journey?

A resounding yes and yes, if you ask me. I think I'm going to call the local news station and thank them for their meaningful segment...

As always, big thanks for reading. Also, a HUGE thank you to all the personal emails and posted comments from my last posting. Your warm welcomes and kind words are greatly appreciated. I have some of the coolest readers ever...

The Other Side

noreply@blogger.com (StorytellERdoc) — Tue, 24 Apr 2012 15:07:00 +0000

the years teach much which the days never knew

Ralph Waldo Emerson

As I sit at our dining room table to write my first words in five months, I am realizing just how much I've missed writing about both my personal and professional life experiences. Though my family and close friends may know my reasons for this unplanned break, you, my friends and readers from StorytellERdoc, do not. So instead of diving head-first into writing a funny, planned posting, I thought I might simply change course to write and say "hello" and "how the hell are you" to each of you.

Let me briefly explain my absence. Simply, I began to have some vision problems last November, ultimately resulting in urgent surgery. Always the doctor and never the patient, this was my first real health scare. Following successful eye surgery, I was forced to take a few months time to recover. This break included absolutely no gym time and, most odd for me, no work time. Looking back on my career, I had never had so much as a week or two break from working in the ER. This inactivity, at first painfully frustrating, ultimately proved to be one of the greatest learning experiences thus far in my life.

For the first few weeks following surgery, I had to wear an eye patch, a blue, oval-shaped piece of perforated aluminum paper-taped to my face. With this new accessory, I spent much time in front of the mirror, looking to find that invincible, healthy fellow I once was. I couldn't find him. Friends tried to make me feel better, telling me I looked "sexier" with an eye-patch, but I saw through their flimsy compliment--the only way to look sexier, I reasoned while laughing with them, was to have sexy to begin with. My kids, hesitant at first, realized that patch or no patch, I was still the same Dad that I had always been. In fact, soon after surgery, Cole had a basketball game that I wanted to attend. "Cole," I asked, "is it okay if I come to your game with my patch or would you rather I stay home?" Without even a hint of pause, his resounding reply inspired me. "Of course you are coming, Dad, why wouldn't you?"

After several weeks, I was able to lose the eye patch. More importantly, with healing and some serious introspection and reflection, I was able to regain my perspective of what is most important in this journey of life. Family. Friends. Humor. Love. Compassion and kindness. Living a purposeful life.

Part of this time away included reevaluating my job differently. Although I still considered kindness and compassion at the forefront of my ER interactions with patients and their families, even I was not immune to a growing cynicism that occasionally seems to be pervading our medical field. Maybe this had even leaked itself into some previous writings. Luckily, though, I feel more privileged than I ever have, since residency even, in walking the halls of our emergency department and providing care to such a diverse and unique collection of patients. Of course, there will always be patients that are obnoxiously difficult, but my reserve to find something good in each and every patient has definitely been refueled. I've been honestly warned, however, by several of my hard-working partners. "Just give it a few months, Jim," they said, "and then see if you feel the same way about things." I can only hope that I have some great staying-power. I feel I do.

Being a patient, I have also learned and witnessed first-hand just how important a role a doctor can play in one's recovery. Luckily, I am surrounded by four absolutely incredible individuals who have prioritized being a compassionate person first and playing a doctor second, proving that one doesn't need to place himself on a pedestal to be amazing at what he can do. This all-star team of providers, however, did not come without some rearranging on my part. I removed from my team, so to speak, one nationally-recognized specialist who was less than stellar in both his personality and in his style of delivering unwanted news. Although this specialist may have been quite good at what he does, I was less than impressed with his all-around abilities to communicate. To heal well and remain positive throughout my ordeal, I insisted on only being surrounded by similar individuals.

Overall, I have much to be thankful for. An almost complete recovery. A supportive family. Supportive friends. And supportive co-workers. What could have been a terrible outcome was not. For this reason, I will always be humble and grateful. Returning to work, I was greeted with many kindnesses and friendly, encouraging words. Hugs included. I also returned to some sadness as well. One of my favorite nurses, Sue, tragically lost her son during my absence. My ordeal embarrassingly pales in comparison to this tragic event of her life. To hug her and share tears with her as she attempted to give me a warm welcome-back smile speaks volumes of her strength and character.

So there you have it. Officially, I have now returned to my life as I know it. Playing doctor full-time. Playing Dad full-time. Attempting to be a writer again. And, most importantly, continuing to look at my wife with complete wonderment, appreciating more than ever her infinite strength, support and love. Except for the glasses outwardly, my most significant changes from my ordeal have come from within. For this, I am most appreciative. I am stronger than ever, actually. As Ralph wisely stated above, the small day-to-day battles were worth the positive hindsight of it all.

It feels so very good to be back...

As always, I thank you much for reading, my friend. More importantly, I thank you for your patience and returning to read my words.

Changing Faces

noreply@blogger.com (StorytellERdoc) — Mon, 14 Nov 2011 14:47:00 +0000

She walked into the ER's waiting room, her belly protruding from her third pregnancy, only to find an overwhelming number of people standing around, hoping to either be the next called to be taken back into the ER treatment area or, at a minimum, to cop the next available waiting chair.

Tugging a four year-old with one hand while pressing an active two year-old to her chest with the other, the young mother asked a security guard where she should sign-in to be seen. He pointed at the circular desk that sat in the middle of the room, behind which sat two nurses and a technician. Noticing the snaking line of people formed at their counter, she scowled to herself and dragged her gravid belly and two kids to join its end. After standing in the stagnant line for just a few minutes, frustrated, she marched to the left of the line to its front and sat her two year-old on the counter, letting go of her four year-old's hand.

The nurse, startled at the abrupt interruption during her triaging, asked her current client to please wait before focusing on the mother.

"May I help you?" the nurse asked the mother.

"Yeah," the mother answered, "my baby here got a fever two hours ago and I want her looked at. And as long as you all are looking at her, I want my son and me both looked at, too, since we'll probably get what she got." The nurse looked at the baby, sitting on the counter, cooing and slobbering over a lollipop given to her by her mother. The nurse felt the baby's forehead, feeling its coolness, and reassured the mother that they would attend to her and her children as soon as possible. "We'll get your histories and take your vital signs as soon as we take care of these people before you."

The mother obviously didn't want to wait. "You mean I have to go back in line and wait? Can't you see I'm pregnant with two kids hanging off me?" she yelled at the nurse while looking down, noticing her four year-old son missing. "Yes, maam, it does. Everyone before you has been patiently waiting their turn as well. We will be with you as soon as possible, though. If you would like a wheelchair to sit in while you're waiting, we can provide you with one."

"Screw that," the mother said to the offer, before screaming her missing son's name at the top of her lung, adding a few expletives that the entire waiting area heard. Her son came running from the back corner of the room and grabbed his mother's pant leg as she swatted his head. "Who the hell do you think you are," she said, "scaring me like that."

She retook her original position in line, the whole time grumbling and cursing into her iPhone to receptive ears. "Yeah, they making me wait on purpose. She don't like me." She was making a scene, surely, with her crescendos of frustration and anger very evident. Slowly she worked her way to the front of the line where nurse #2 was ready to help her.

"What can I do for you, maam?" the nurse asked her, paper and pen in hand, ready to write. The technician held the thermometer, ready to take one of three temperatures of this family. "You can help me by doing your god-damn job quicker," the mother answered snidely.

The nurse smartly ignored the comment, staring at the mother until the mother continued. "My baby here had a fever start maybe two hours ago and I want her seen. I want me and my son here to be seen, too, since we are gonna get what she's got."

The nurse and technician took the history of all three before doing brief exams and obtaining vital signs. The three were quite stable and none of them had a fever register. "How did you take your daughter's temperature at home?" the nurse asked, curious. "I don't have no thermometer at home," the mother said, "she was just burning up when I felt her."

The nurse reassured the mother that she and her two children appeared okay, and requested the mother have a seat in the waiting room until an available treatment room became available. "What?" the mother yelled, "you mean I have to go back to that waiting room?" "Unfortunately, yes, it does. I'm sorry for your wait today," the nurse answered. "How long is the wait out there?" the mother asked, adding a few more expletives. The nurse explained to the mother that the current wait was about three hours, but could be longer if life-threatening patients presented that needed to be immediately treated. The nurse then had the technician get the mother some formula, some diapers, and some snacks and juice to help with the wait. The mother, pissed at the world, stomped away from the triage area shaking her head.

Soon, the mother was on the phone again, cursing and bitching at an exaggerated level for the entire waiting room's benefit, leaving her four year-old unsupervised and running around the ER, swatting other young children. "Yeah, they making me wait even though I told them I was in a hurry." A waiting patient graciously gave up his seat to her, for which she said "About time" instead of offering her thanks.

During her wait, several patients signed in and were immediately taken to the back ER treatment area, skipping the wait. The mother complained. It was explained to her that patients in urgent need of treatment, such as those with intractable pain or having a stroke or heart attack, were immediately treated for possible life-saving illnesses. "I don't care about that," she said after her multiple complaints, "me and my kids need some life-saving treatment, too."

After a nearly three-hour predicted wait, this family's turn arrived to be taken to the next available treatment room. While being escorted down the hallway, the mother was very vocal in her her complaints, loud enough for all to hear, despite passing room after filled-room and cot after filled-cot in the hallways. Although she bore witness to the crazy atmosphere, this mother was bitter and defiant about being made to wait.

My physician assistant and I both agreed to attend to this family, dividing up the work between us, trying to make it a quick process. We had been given a "heads-up" by the nursing staff, both in the triage area as well as the treatment room's assigned nurse, as to the mother's disposition and lack of understanding on our busy day. Their stories supported their words. In fact, after this family was placed in their treatment room, we were told by the nurse that the mother made her wait until she finished her phone conversation, holding her index finger up to the nurse and refusing to talk until she was finished. "Why did you wait?" both the PA and I asked.

"That's nothing," the nurse added, "she also wanted two extra pillows after I adjusted the cot for her." Anyone who works in an ER knows how rare an extra pillow is, let alone two. "And," the nurse continued, "she is now demanding turkey sandwiches and pudding and juice for all of them." To placate them further, the nurse also got several blankets for them to cover with if they needed. However, this act of kindness wasn't good enough. "Hey," the mother yelled at the nurse as she was leaving the room, "these blankets aren't warm like they were the last time I was here. Take these back and get me some warm ones."

We treated the family. As suspected, the mother and four year-old son were both healthy with no abnormal findings. The two year-old had some mild nasal congestion and was otherwise as stable as the others.

After the PA and I explained the results of our exam to the mother, she demanded antibiotics for the three of them. We refused, explaining the overuse of antibiotics and their lack of need in their cases. "Then," the mother said, "I at least want a prescription for Tylenol so I don't have to pay for it."

My kids recently had URI symptoms and I knew for a fact that Equate brand acetaminophen was $2.86 a bottle. She, however, assured us that she couldn't afford that. I looked at the mother's gold necklaces, at her and her kids' designer clothes, at her iPhone and cigarettes hanging out of her designer purse, at her perfectly manicured nails, and finally at her eternal scowl while looking back at us. "And," she said, adding good measure, "I need someone to find us a ride home."

They found their own ride home. As for the Tylenol, I told the PA I didn't want to know what decision he made on writing the prescription. That decision alone, whether yes or no, could be examined by countless arguments as to the good and bad of our current medical climate.

Medicine is changing. Emergency departments are changing. In the decade-and-a-half that I have been an active, practicing ER physician, the changes have been astounding. Some good-astounding. Others frustratingly-astounding. Besides the current political and legal climates that exist, I feel firsthand the change in the attitudes of our patients and of our staff. The departments are being overwhelmed with non-emergent cases, and this is frustrating all that seem to be involved.

Is there an answer? Yes? No? Do you have one?

I was a people-person, enjoying the company of my fellow mankind. I am, admittedly, not enjoying their company as much. Instead, I am seeing more negative aspects and disheartening perspectives of humanity that are becoming more accepted by our community. I am seeing, too, the migration of great nurses and doctors away from our chosen field. Is this part of their reasons? Am I the next? I sometimes struggle to remember the great reasons I chose to pursue this career in medicine. Hopefully, with harder, more intense looking into myself, the good will be more in evidence. My father says that, at 81, he has never had a day in the forestry industry that he hasn't driven to work with a smile on his face. Most days I feel this way, too.

I only wish it could be every day.

As always, big thanks for reading... To my readers who have emailed their concerns by my lack of appearances on here, I thank you with much gratitude for your concerns. The family and I are well. To the nurses and technicians who endure triage and similar stories as above, thank you for all you do.

The Reminder--EKG #6

noreply@blogger.com (StorytellERdoc) — Fri, 16 Sep 2011 10:00:00 +0000

Once a week, our residents in our Emergency Medicine program spend a complete morning attending hour-long lectures by various attending physicians from various medical fields, lectures that pertain to our specialty and contribute to their font of knowledge.

As with any lecture series, some can be fantastically entertaining while others can be painfully boring, a timeline made of silly putty stretched much too long. I had no idea that the dry, cynical cardiologist I experience during a typical shift in our ER is the same guy who can deliver a funny, informative, engaging hour of information on cardiac resuscitation. Likewise, there is no amount of abnormal x-rays and CT scans that can save the dry delivery of the well-intentioned orthopedist talking about rare injuries. Sometimes, though, it is the subject material that can make or break the hour. Quite honestly, if I never hear another lecture on abscesses, I will be alright. I promise.

Once a month, my duties include proctoring these morning lectures. Sitting through them, I have learned much. I have seen successful deliveries and I have seen miserable presentations. I have laughed to the point of almost being incontinent, and I have been bored to the point where watching a fallen eyelash on my desk sway from the air conditioner was much more entertaining. One of my favorite things to see in a lecture, though, is when the lecturer tries to engage our residents in a discussion on the hour's topic. Some of the residents are remarkably bold and astute during these types of lectures, participating without fear of being wrong with their answers, while other residents simply stare at their shoes or decide that the flaking cuticle on their left index finger suddenly needs their attention. Avoiding eye contact avoids engagement.

In the past year, though, several of our ambitious residents have asked for a slot of lecture time to review EKGs, to go over interesting cases from our ER, or to review subtle abnormalities in lab work or x-rays. They are willing to put in the extra time to become better doctors. The presenting residents manage the hour how they like and, quite honestly, I am very impressed with their presentations. And those comrades who normally stare at their feet? Even they participate in the spirited conversations that lead from these presentations. It is nice to see their confidence grow in a nurturing setting, a far cry from being lambasted by an asshole surgeon during their surgery rotation.

So, it was with this frame of mind a few months prior that I sat proctoring one of these resident presentations. It was on abnormal EKGs and, as I expected, it was going very well, the residents very interested in interpreting some very bizarre tracings. After a heated discussion on EKG #5, the resident continued with his presentation, clicking the computer button to advance EKG #6 to the big screen. Little did I know that this next EKG would transport me back to wistful memories.

Most of the EKG tops are whited-out, protecting the patient's confidentiality. The official interpretation of the EKG is also whited-out, to make our residents honestly review and interpret the EKG on their own. What isn't whited out, though, is the name of the EKG tech who performed the EKG on the patient. And there, in the left lower border of the EKG's information box, sat the technician's name.

Gigi.

Oh, Gigi. How you are missed! As talk continued in the room, voices dimmed as my mind raced back
several years, to thoughts of a spectacular human being who reminded me of the power of human kindness and compassion. Of the lost art of wanting to learn about your fellow human being. Of just being a good person wearing a big smile as much as one can. She was a hero of mine, and I wrote a piece about her that still makes me choke on my tears (Heroes Among Us--Gigi). Personally, she was a person who cared about me, who cared about my family, and mostly, who cared about my son's battle for his life. She was real. A co-worker like her I will never have again.

The residents finished interpreting the EKG and before clicking to EKG #7, I held up my hand to speak. I hesitated before speaking, all the residents' eyes on me.

"There is something more important about this EKG than it's tracing," I began. "Look at the name of the technician on the left lower border." All of the residents' eyes glanced at the name and then turned back to me. "Do any of you remember this technician?" I asked, knowing that Gigi left right before our most senior residents arrived. They all shook their heads "no" to my question.

"Well, then," I continued, "let me tell you about this magnificent lady." And with that, I proceeded to share Gigi's story with them (I knew she would have let me). I told them how she treated patient's in their room, spending the five minutes it takes to get an EKG learning about the patient, their family, and their illness. Sometimes I heard laughter, sometimes I saw the beginnings of tears, but always I witnessed the boundless kindness and caring compassion that Gigi gifted to every patient she encountered. Then I told them about her concern and hugs through my son's illness and beyond. She saw through my anxiety, my hurt, my pain, and my fake smile as I struggled to maintain my professional life while my personal life was in shambles.

She is one of my heroes and when she passed too soon from this life, I knew the angels were singing in heaven.

The residents continued to watch me as I finished talking. "Just remember," I said, "that it is a privilege to help a patient and their family through a time of need. You can make this 'a job'," I continued, "going through the motions of what is expected of you, or you can embrace the privilege you've been given and do your job with pride and compassion."

The room was quiet. I was still being watched. "That's all I have to say about that EKG, then." Most of the residents slowly turned back around to face the big screen, to review the next EKG, but a few lingered. I think they heard what I had to say, but one can never be sure.

I'm not naive. I know there are people who probably laugh at the thought that one can always be compassionate and kind, especially in a busy ER such as ours. And they would be right. It is impossible to extend oneself to every encountered patient. Heck, even I get cynical and sarcastic, some days worse than others. I am human, after all. But my hope, by continually harping it, is that some of our residents remember why they went to medical school. Not for money. Not to play the number games that we now must play (insurance company numbers, patient survey numbers, patients seen per hour numbers). Not to expose oneself to lawsuits. But rather, to make a difference, a real difference, in some of their patients' lives.

Thanks, Gigi, for the reminder.

Big thanks for reading...in light of this past weekend of the tenth anniversary of 9/11, I wanted a story to remind us that we are all in this world together. Try as we might, we can not unweave the fabric of humanity. To the victims and their families of 9/11, you are not forgotten...your personal pain is our pain...to the heroes, we are eternally grateful for your bravery. Thank you...

He Is Loved

noreply@blogger.com (StorytellERdoc) — Wed, 10 Aug 2011 10:00:00 +0000

He was sitting upright in his treatment cot as I walked into Room 28, his three-year-old eyes turned upwards and focused on the blaring nine-inch corner TV. His young parents, barely in their early twenties, stood to the left of their son's cot, their eyes fluttering between me, the TV, and their son. Within seconds, all three sets of eyes had settled on me, the stranger who had just invaded their privacy. I smiled at them. Before introducing myself, however, I walked up to the TV and turned it off, appreciating the sudden disappearance of Sponge bob and the arrival of a much quieter, calmer room.

I held out my hand first to the little boy. Because of his age, it was only appropriate that he first look to his mother and father for approval before taking it. They approved, after taking in the stethoscope around my neck. "Hey buddy," I said, taking in this little guy's appearance while I grasped his small hand, "I'm Dr. Jim. It sure is nice to meet you!" He smiled shyly as I shook his hand with exaggeration. Next, I focused on the patient's parents, holding out my hand to each and shaking their's warmly.

All the while, I focused on the appearance of this patient and his parents. The patient was healthy- appearing for his age, existing in that stage of healthy-chunky and thinning-out, his cheeks no longer swollen lumps of baby fat. He wore pajamas, littered with small holes and sprinkled with stains of various fruit juices. His face was smudged. His teeth were discouraging, little decaying flecks of brown. His arms and legs needed a good scrubbing. Underneath his nails, I could appreciate the fine-line of brown that would require a bar of soap and a good brushing to make clean again. His hair was slightly matted and blondish-brown, the subtle curls poking several strands in an unexplainable pattern.

Yet, he smiled. Big and beautiful, innocent and endearing. Bad teeth and all. He smiled at me. He smiled at his parents. He smiled at the nurse who came in to check on him while I was in the room.

The parents, she taller than he, paced beside the cot. She was the talker, he the backer-upper. With every question I asked, she would answer it first with a concise answer, sometimes being quite insightful. He would listen to her answer and then, like a well-oiled machine, add "Yeah." Nothing more and nothing less. They both, like their son, wore clothes that were scrappy and stained, well past the normal point of a necessary washing. Their hair, his short and brown and her's long and blond, was oily. Upon smiling at me during introductions, I noticed the same teeth as what their son had. Plaque build-up was very evident from my close stance. I imagined them to be chocolate Chiclets, if there was such a flavor of Chiclets, fragmented from being dropped to the ground. Their exposed skin, that not covered by their t-shirts and shorts, had a sheen of grime.

Yet, they smiled. Just like their son.

I sat on the foot of the cot, facing the parents. "What," I asked them, "may I do to help you out with Joshua today?"

The mother moved from her standing spot along the counter to the head of the bed, where she held the back of her hand to Joshua's forehead. She turned her hand and held her palm to Joshua's cheek, letting it linger there for a while, the way a mother's hand should linger when touching her child.

"We were so worried, Doctor," she said, her smile dissipating and her face gaining an anxious quality, "about Joshua's fever. It wouldn't come down for us."

"Yeah," added her husband.

She continued, her voice quivering slightly. "It's been about three days of sweating and chills and high fevers for Joshua. We just don't know what to do anymore."

"Yeah," added Joshua's father, his eyes darting from Joshua to his wife to me.

After a little more talking, I discovered that she had been under-dosing Joshua's acetaminophen and had not been aware she could use concurrent ibuprofen intermittently. The nurse had educated both mom and dad, in triage, to Joshua's proper dose after she had recorded a temperature of 103.4 F. As a result, I was now examining a child who was smiling and had broken his fever. And despite his slovenly appearance, this was one cute kid who appeared to be very happy and very loved.

Sometimes, a three-year-old boy can make for a very difficult exam but, in Joshua's case, he could not have been a better patient. Whether it was the fever breaking, his starting to eat and drink again, or just his baseline personality of unadulterated happiness, he was a pleasure to treat. Thankfully, he appeared quite stable despite having bilateral ear infections (acute otitis media). What could have been a very serious illness turned out to be something less that could be treated with high-dose amoxicillin. In addition to good fluid intake and proper use of acetaminophen and ibuprofen, I expected Joshua to be back to his normal self in a few short days.

Typically, after treating a child with ear infections and having a thorough conversation with the parent(s), I would race to fill out the appropriate chart paperwork, including prescriptions and discharge instructions. With Joshua and his family, though, things were different. This was a patient who made me reevaluate my first impressions. Because although Joshua and his family were indigent and struggling with proper hygiene and material things, never once did I doubt his parents' love for him. They sat with him on his cot. They played with him. They helped me coax Joshua to open his mouth so I could visualize his throat. They held him over their shoulder so I could listen to his lungs more clearly.

They did everything, with ease, that I look for to make sure a child is safe and loved.

I guess love comes in many forms. Part of my love for my children includes that they be clean, dressed appropriately, be respectful, and learn from an early age to appreciate good hygiene. Although, truth be told, my wife and I shower our kids with the more important stuff--lots and lots of unconditional love. That kind of love outweighs all. Whether for financial reasons or lack of knowledge, or maybe for reasons I simply didn't uncover, Joshua's parents seemed to struggle with certain learned parental roles. What they did endorse, however, was to show their son patience, concern, worry, and happiness. And love. Lots of unconditional love.

I talked to them a bit. They had an apartment, although they struggled to make financial ends meet. They both came from broken homes. "I don't know what a good mother should be like," the mother said with honest introspection. "Yeah," added her husband. I assured them that they already seemed to have mastered the most important part of parenting, by giving their child unlimited love and attention, but there were other ways they could improve Joshua's life. Because they wanted the world to be Joshua's, they were willing to do whatever that might take. Thus, I called social services to have them follow Joshua's family. Maybe find some parenting classes. Give suggestions for whatever they may need. Basically, just bring their attention to more of the learned parenting skills.

Later on in my shift, I was fortunate to take care of another child, this one dressed well in designer clothes, clean, with perfect four-year-old baby teeth. Uppity parents. Unfortunately, this child and his family had nothing on Joshua and his family. Not...a...thing.

Sometimes, I gotta love my job and the cool people I get to meet.

As always, big thanks for reading. I hope this finds you well and your summer going smoothly. We are vacationing in the New England states and enjoying every minute of our family time. Soon, the posts will become much more regular (as soon as the writing rust wears off)...

Godspeed (Sweet Dreams)

noreply@blogger.com (StorytellERdoc) — Fri, 08 Jul 2011 11:00:00 +0000

Ah, summertime. Sunshine. Warm weather. No school. Mounds of sports. Shrieking, playful kids. Sleeping in. Swimming at the club. Yes, this is the stuff that we who live along the shores of a Great Lake anticipate and dream of, especially in the midst of a three-foot snow dumping. Life is good when those dreams come true.

Ah, but, summertime. Time to eat picnic foods and have an extra drink and snack on another opened bag of chips. French onion dip included, thank you. Big burgers with Greek sauce. All beef wieners loaded with pickles and ketchup and mustard. Milkshakes topped with real whipped cream to slurp while watching the distant sun's setting over the discrete line of two worlds merging, our world with its blue-green waves gently swishing the emerging shadows toward our shores and that invisible red-glowing world that the sun slowly dips into, hiding from our searching eyes, to gather it's next-day strength of warmth and light.

I've enjoyed my summer so far, no doubt about it. I was ahead in my work hours for my July to June contract and, as a result, had a few weeks off that were unplanned as some of my partners got extended hours to meet their contract obligations. Lucky me. More kid-time. Bike-rides. Tennis and swimming. Lacrosse and soccer. More shooting hoops in the backyard. Especially, though, for me--no cell phone calling, no texting, and no computer time. I revolted, in a benign way, to the thrusts of technology into my private life. Thus, no recent posts.

Thanks for hanging along with me. Am I alone, though, in embracing a few weeks without modern conveniences? How many of you miss the days of your childhood where fun seemed more easy to come by, where friends knocked on each others' doors just to see if someone could come out to play. I miss the days of my childhood where a typical day was an unplanned day, spent playing kick-the-can, kickball, hide-and-seek, fishing, and taking long country-road bike rides and hikes through the woods. The day was finished off, of course, with one of Mom's delicious four course meals. Then a bowl of vanilla ice cream drizzled with Mom's famous homemade peanut butter chocolate fudge. Finally, it was off to bed, completely exhausted, wondering what excitement the next day would hold.

We don't do enough of that these days, what with all the organized sports and practices and such. Swimming practices at 7 am and 8:30 am, meets at 6 pm. Baseball batting and fielding practices and all-star league play. Lacrosse warm-ups. Tennis tournaments. Soccer practices and games. Basketball camps. A half-hour minimum of book reading per day. Not only our kids, but most of the kids of our friends do the same thing. It is not forced, though, and the kids love the various get-togethers with their diverse yet close-friends to do something they enjoy. As a parent, you gotta endorse that, especially since my sharp parental eye is not spotting any creepy "badness" happening that seems to be permeating our teenage society. No drugs. No alcohol. Just plain ol' fun. But my favorite and most important times of day, the meal times, have become a struggle to maintain among all this organized frenzy.

Besides ignoring technology, I have also been trying to boost up my own physical activity. It's summer time--translation, more short-sleeves and swimsuits. This equates to me as more gym time and weight-lifting, more yoga, calming walks, and lots of daily stretching. Oh yeah, and my morning sit-up ritual.

Recently, I've struggled with my sit-up routine. It is my least favorite of all of my workouts. But thankfully, I found a way around it. Since I am usually on our bedroom floor at 9 am, in front of the TV, ready to go at it for 20 minutes, and not wanting to watch Steve Wilcko or Jerry Springer, The Doctors or extended hours of The Today Show, I have begun watching concerts of some of our favorite artists on DVD. Sarah McLachlan, of course. Celine Dion from Vegas. Mary Chapin Carpenter from years ago. And The Dixie Chicks.

The other day, while grunting and sweating out my sit-up routine to An Evening With The Dixie Chicks, I had to stop. Catch my breath. Wipe my eyes. Not from being tired or sweaty, though, but because one of their amazing songs took me back almost ten years, to a time when our summer wasn't what I described above. It was a much different summer. A summer with no sports. A summer with little joy. A summer of no typical activities of fun-in-the-sun.

It was the first summer we guided Cole through his year-long chemotherapy regiment. A summer filled with angst and worry. As I sat up to get a better look at the DVD while crossing my legs Indian-style, I turned up the volume and let the song's lyrics and the genius musical interpretation by The Dixie Chicks transport me to that time, washing me over in emotions to powerful to control. The power of an amazing song always seems to stun me to a different level of consciousness.

When the song ended, though, I couldn't help but smile. And marvel at how far my family and how far my son Cole had come. How a summer a decade ago represented nothing to me of familiarity. And how far, how amazingly far, we had come. Suddenly, I realized that I missed my childhood summers very much, but I didn't miss that summer of Cole's illness where the true spirit of summertime passed us by. I understood a deeper appreciation for the summers we have now, both with the similarities and differences of summertimes past.

The power of a song, the power of a memory, and the power of our responses to both is a thing of beauty. From this power, my new appreciation for these more recent summers that don't imitate my own childhood ones.

Oh, I forgot to tell you the name of the song that sucker-punched my emotions--Godspeed (Sweet Dreams) on YouTube.com. You may need to type it in as a search as "An Evening With The Dixie Chicks--Godspeed." A worthy search. In this clip, it is even explained how the song got its origin, another amazing story in and of itself. I hope you can appreciate the connection this song made with me during that haunting summer.

I hope you are having a good, bustling summer so far, my friend, and thanks for reading...

As always, big thanks for reading. I hope this finds you well and enjoying an amazing summer. Thanks for bearing with me through my technology rebellion...

With A Little Help

noreply@blogger.com (StorytellERdoc) — Fri, 17 Jun 2011 11:30:00 +0000

Friends. The family that we can choose, some say. You can't live with them and you can't live without them, others say. I've heard, "I don't know why I am still friends with them!" and I've heard "I don't know what I would do without my friends." The comments and feelings stirred among people when talking about their friends run the whole gambit of emotional investments.

I was thinking the other day about my various groups of friends, searching for the commonality that they all hold. I have friends from my childhood and high school, friends from college, friends from medical school, friends from residency years, and friendships built from our life in this same town we have lived in for the past 15 years. Because my wife and I settled into a city where our closest relatives live two hours away, our friends hold even more weight in our lives for the part they have played, sometimes even physically and mentally substituting for our family on special occasions.

Yes, we all need friends. Better yet, we all better damn-well appreciate our friends. A good friend, tested and true, will be there through the pretty and ugly, through the happy and sad, and through the fun and miserable life moments.

I came up with a lot of reasons for the friends I have chosen or have chosen me over the years. First and foremost, I like people that don't take themselves to serious. After all, life is not such a stellar example of structure and order, and through the many moments of a typical day where something can go unexpectedly wrong, I like the person who can adapt with the situation and laugh off the change in plans. So you thought you were going to be going to NYC for the weekend but your car broke down in the Poconos? If you check in a motel and enjoy the Poconos, I like you. If you bitch and whine and obsess over your ruined plans, I really hope to not spend more time with you in the future.

Diversity. A key commonality among my friends. My best friend growing up was Himer, an awesome buddy throughout our school years, classes and school sports and first dates and all. His parents were much more liberal than my conservative parents, and somewhere between our different upbringings, we found a common bond of friendship. My roommate all four years in college? Christopher, straight from the rat-race we call Long Island. Me--country boy, small-town, Adidas shorts and Hanes t-shirts, sneakers. Chris--city-bred, big-town, Ralph Lauren pressed khaki shorts and purple shirts, penny-loafers. I took him four-wheeling and he took me to Manhattan. Oh, I can't forget about Gailie, my fellow Biology buddy who was a Catholic princess, through-and-through. Together, we were inseparable (along with Tony and Barnes and Dave) for much of our college days. Best friend in medical school? Easily KT, a Jersey girl with a heart of gold and an eye on public service. We shared a bond of tennis and creative writing among many other things (including who to trust and distrust in our competitive class). My best friend in residency? Tomer, my Jewish, sharp-witted, cowboy-boot-wearing buddy for always, who watched my back during our 30 hour call-days. Thankfully, sprinkled among all of these friends were more and more friends who impacted my life.

Even in my city life now, I surround myself with diverse friends. Some of my best friends from the creative world? A very cool, committed couple named Christine and Marcy. Not only did they foster my love of the writing world, they also fostered my love of pets, of wine in quantity, in music, and in myself, helping me seek out ways to make myself better through some trying times. My other friends all hold some diverse characteristics within their personalities that keep me coming back. I love the fact that I do not seek "like" individuals, but rather people that can teach me and open my eyes to the many beautiful differences of their lives from mine.

Finally, without a doubt, the biggest commonality among my friends is humor. Straight-up. If you laugh at my silliness and I laugh at yours, we will be friends. Prank phone calls, crazy texts, recognizing life's many absurdities, morning "sore-face" after a night of frenzied laughing and joking over a bottle of wine--those are the friends I gravitate to. Inappropriate and risque perspectives will get you bonus points, even.

Just last night, we were at an amazing dinner with six friends, eating great food (thanks, Michele!), drinking great martinis (thanks, Eric!) and wine, and just laughing and howling for four straight hours. No subject was off-limits and by the time we were hugging our goodbyes, we had solved most of the world's problems. Driving home, my wife and I both noted just how much fun we have with our friends. We are blessed to be surrounded by such cool people.

A better example? Here is a reference letter our good friend Mike wrote for my wife when she was applying for a full-time position in a local school district. It is just a rough draft, but one that he thought "might just get her the job." Thankfully, he got serious and started at square one again, producing the perfect reference letter needed. However, I tend to agree with him that this original letter may have gotten her the job in a much quicker fashion:

Dear Mr. K.,

I am a writin this letter to let you know that Karin is an awsim persin who would be a great choic for your new secretary girl. She haz a nice houz and drives a really cool bug! Her kidz are nice too and are clean most of the time. She haz good toes and a strong back. Lord knowz shez been carryin that husband Jim of herz for years. She must be an angel from heven to be able to put up with his bull-shit, so she certainly can handle workin for you.

Karin is a great cleaner and bakes good tastin stuff. At a party once she made these reelly good brownies that made us feel reel mello. She must have a majik touch! Jim would never know that because he is always suckin down his fancy vodka drinkz. I think if he were smart enuf he would have hiz own moonshine still. I’ve only seen Karin reely drunk a few times so you don’t have to worry about her.

Karin is a reel cool mom too. She lets her kidz eat all the candy that Jim buyz at Sam’s Club and they still have most of there teeth. I bet those kidz will even gradute high scool one day despite the upbrigin of there pa. He has good intentionz but is a bit misgided when it comes to raisin youngins. I think he waz born in the woods or somthin.

Karin is good at managin stuff too. She can go to work all day then come home and cook and clean and get those kidz where they need to be…all the while Jim is “gettin his nap on”. It is amazin that she keeps that guy around. Allthou he is sorta pretty and has a nice set of gunz on him. I did see him without hiz shirt once and wuz amazd by what wuz there….. but this iznt the time to go into that!

Karin is reel easy on the eyes too. She would add some class to that school buildin. She haz nize hair, skinny ankelz and amazin elbows. She smellz nize too. I bet she showerz almost every day and usez fancy lotionz. She certinly would not smell up the place.

Well, I hope you hir Karin for the job despit any shortcomins of her husband. Maybe he won’t come to the chrismas party so you wont have to meet him.

This made me laugh for days. And days. Only a good friend would waste an hour of his time to pull something like this off, right? By the way, my payback to him? Threatening to put his innovative letter on my blog and actually going through with it! Didn't think I would do it, did you Mike?

Appreciate your friends. Appreciate your acquaintances. Appreciate the people around you who bring good humor, diversity, and a light-perspective to balance the seriousness that life sometimes holds. And appreciate the reflection of you that is mirrored back by all of your various friendships--this insight may prove to be invaluable and priceless.

As for me, I'll just keep laughing and smiling my way through this journey we call life. With a little help from my friends, of course.

As always, big thanks for reading... do you recognize the common thread that runs through your various friendships? Please share... and Happy Father's Day to all you fathers out there, especially those who treat the title of "Dad" or "Daddy" with the utmost respect...you are a heroes, each and every one of you.

To Like Or Dislike

noreply@blogger.com (StorytellERdoc) — Fri, 03 Jun 2011 15:18:00 +0000

I was shocked by her appearance. Although she was in her early 50s, she looked closer to 80. Matted peroxide hair. Dull, lifeless eyes. Sagging skin and deep wrinkles. Protruding cheek bones. Cracked, dry lips with a hint of yesterday's lipstick caked in their corners. Gray and yellow-stained teeth, some chipped. In her prime and before alcohol and cigarettes became her every thought, I could imagine an attractive, lovely woman. Now, sadly, what sat in front of me on the hospital cot in Room 12 was nothing short of a shell of a human being. This was a woman who lived a hard life.

She had presented to our ER in respiratory distress. Although she already had an established diagnosis of emphysema, she continued to smoke two packs of cigarettes a day. On top of this, she had just finished a ten-day drinking binge, the last five of which she spent either passed out or drinking. She claimed to have not eaten in that time. I was called to her room because she was in such dire respiratory distress.

"Maam," I said after introducing myself, "how long have you been having trouble breathing?" She was gasping for air, her nasal folds flaring with each struggle to breath deeply in. Through her thin hospital gown, I could see her ribcage and diaphragm heaving, compensating for her non-compliant lungs, trying to pull that extra oomph of air into her body.

"I...don't...know," she managed to answer, each word a struggle for her. Her hands, I noticed, were pale, their spidery veins popping through her thin transparent skin. They gripped the top rail of the cot for dear life.

Immediately, I ordered breathing treatments. Steroids. BiPAP (a machine with an attached mask that would force supplemented oxygenated air into the patient's lungs every time she initiated a breath). Blood work. A stat chest x-ray. The rapid intubation kit and ventilator for stand-by. I asked more questions, questions she could answer simply by nodding her head. "If you get worse, maam," I spoke, asking the most important question of all, "we may need to insert a breathing tube into your lungs, hook you up to a ventilator, and do your breathing for you. Do you want that if it comes to that?"

A "yes" nod. She tried to speak. "I've...had...that...before," she gasped. "You've been intubated before, maam?" I repeated. She held up two fingers of her left hand in a peace-sign. "Twice," she said.

Within the half-hour, surprisingly, she began to turn around for us. I spent considerable time in her room during this period, making sure she would not decompensate before our eyes. With the additional attention of two stellar nurses and a respiratory therapist at bedside, she thrived and slowly improved. Finally, as her lungs began to fill with more air, her nasal flaring and ribcage retractions subsided.

After stabilizing her breathing, we began to treat her other problems. For malnutrition and dehydration, we gave her several liters of normal saline and a "banana bag," a liter of fluid supplemented with thiamine, folic acid, and multi-vitamins, giving it a yellowish-color. For her withdrawal tremors, we gave her Ativan, a longer acting valium-derivative. We fed her ice-chips. We gave her anti-nausea medicine and several low doses of pain medication for her evolving alcohol-induced pancreatitis. Her chest x-ray revealed pneumonia in both lungs, and we began antibiotics to cover her for the common community-acquired organisms as well as for aspiration organisms (only God knew if she swallowed some puke into her lungs).

Finally, after a lot of attention and energy given to her, she was at the point where I could sit down a few extra minutes with her, making sure I understood all of her history and didn't miss anything.

"Maam," I started, "have you ever tried to quit smoking?" "Yeah," she said, her voice now a little stronger, more gruff, "but I don't really want to. I like it." She looked at me with challenging eyes as she said it.

"And maam," I continued, "do you consider yourself to be an alcoholic? Have you ever had treatment for it before?" She answered immediately. "No, I'm not an alcoholic. I like my booze, but I don't drink nearly as much as my husband. Now he's an alcoholic. But I'm not." She enunciated "he," spitting out the word like it was poison. Her denial was remarkable. And expected. "Do you want help while your hospitalized for your drinking, then?" "Why," she asked me, "if I don't have a problem?"

I asked her about abuse. She denied physical abuse but claimed "that he yells at me a lot." Again, she refused to accept any counseling.

Finally, as I was finishing, she said "Can I ask you a question, Doctor?"

"Of course you can, maam," I said. "What can I do for you?"

"Well," she said, "I don't understand why doctors can't take care of my problems. I don't like coming here all the time for belly pain and breathing problems. Why can't they just get it right the first time I come in?"

I was shocked. Completely and utterly thrown off my game. Hackles up. The nurse, standing at the room counter with her back to us, writing on her chart, turned her head around to face the patient, her mouth gaping and shoulders tightening. I'm sure mine were, too. Although we don't expect appreciation, we certainly don't expect to be blamed for a patient's medical problems, either.

"Maam," I said in my calmest , most respectful voice, "you have emphysema and, yet, continue to smoke two packs a day. You have pancreatitis and, yet, continue to drink. You completely ignore your body's needs, not drinking water or eating food for five days. You are hacking up phlegm and don't use your inhaler or pursue treatment of these symptoms, resulting in pneumonia. You've been intubated twice and have come to the ER multiple times. And you can't understand why your doctors 'can't take care of your problems'? Have you considered that your problems might be from your own poor decisions?"

I stopped and stared at her. She stared back. I waited for her to speak. I was going to stand there all day if I had to. Finally, with the nurse now standing along her other side, the patient spoke. "I guess you are right. Some of these problems are my own fault."

"Not some of them, maam," I said, "all of them. By accepting personal responsibility for them, though, maybe you can move on and start treating yourself and your body a little better." Although I'm sure my words fell on deaf ears, I still needed to have my say. Especially when we all worked so hard to turn this unappreciative patient around from her multiple medical problems, some life-threatening.

I grabbed the patient's hand. "Listen, maam," I said, "I wish you well. I want nothing but the best for you. But if you don't change your habits, I am sure I will see you in our ER again. And again. And, one of these times, I fear, we won't be able to undo your problems."

I let go of her hand and turned to walk out the door. She was admitted to the ICU and was going to be transported up shortly. Before leaving, though, she called out. "Doctor!" I paused and turned around. "Yes, maam?" She hesitated before speaking. "Thank you for your help today. I'll think about the counseling, okay?"

I nodded to her. "Good luck," I said before continuing out the door.

One of the most frustrating parts of my jobs is dealing with patients' frustrations of their medical problems, simply because of their lack of personal responsibility. It's rampant, too. I cannot cure patient's who do not put their own effort into their health. None of us in the medical field can. We are here to help you along your journey, to walk sided-by-side with you in your, hopefully, healthy path. Of course, some people do everything right, by the book, and still have medical issues. That's different. But if you want to eat profuse and bad meals, please don't expect us to cure it with a simple "sugar" pill. If you want to eat fatty and greasy foods, please don't get pissed at us when your cholesterol pill isn't helping.

I love my ER patients. Seriously. I have met some very cool people over the years, from both different and similar walks of life, simply from what I chose to do for a living. I appreciate and enjoy learning the diverse stories that rest behind their faces. Sometimes, though, I get frustrated. We all do in the medical field. At the end of the day, we are all human, whether we perch ourselves on a pedestal or not. And, regardless, we want the best for you, the patient.

To my patients that have made my job rewarding, a simple thank you...it has been my pleasure learning about you and helping you on your healthy path.

As always, big thanks for reading...I hope this finds you all well. Enjoy the weekend...

The Appreciative Cashier

noreply@blogger.com (StorytellERdoc) — Tue, 31 May 2011 10:00:00 +0000

With every breath, may we remember you, the brave and proud soldier, who has given more of yourself than any of us have the right to ask. God Bless each and every one of you. Originally posted on March 5, 2010, this essay is my thank you.

Sometimes, in the midst of a crazy shift and six-hour patient waiting times, I can easily forget that I signed up for this job. This forgetfulness can lead to extreme frustration, which only leads to a vicious cycle of being more and more short-fused and less appreciative of our jobs. I don't like these types of days, and I am grateful when I'm reminded that our jobs are not isolated in these frustrations.

A few years back, I was at a local store waiting in a very long cash-out line. It seemed that several cashiers had called in sick and the store was trying to cope as best as they could. I picked the shortest of the waiting lines and still was about eight customers back.

I clearly remember the grumbling. It seemed that everyone had an opinion of either how to make things go quicker or shared their thoughts that they would never return to this particular store again. How dare they make us wait like this? What were we, cattle or something? I smiled, correlating this to how our ER waiting room mood must be on those hectic days.

Slowly, but steadily, my line advanced to where I was next, following a gentleman who wore an armed-service ball cap. He had grumbled along with everyone else and, by the look on his face, was tired of the waiting. He placed his merchandise on the counter as the cashier greeted him.

"Hello, sir," she said, with a warm smile, "I'm sorry about your long wait. Did you find everything you were looking for?" Her pleasantness, apparently, remained unscathed.

The gentleman ignored her as he pulled out his wallet and a few bills. The cashier, her hair mussed and her make-up long past the point of retouch, was not to be deterred. She continued scanning his merchandise while she spoke. "Oh my, is that your hat, sir?" she asked, pointing to his cap. "I see it states that you are a veteran of the Army."

He touched the brim of his hat as he sized her up, finally returning her smile. "Well, yes, I was in the Army during the Korean War."

"Well, then," she said, now pausing and giving him her undivided attention, "I would like to thank you for your service to our country."

Hey, wait a second here! I had just witnessed something pretty special and neat. I was so caught-off guard and pleased by this cashier's actions that I could only imagine how this gentleman now felt. In fact, he was a completely different fellow after that--talking and joking around until she finished cashing him out.

I was next. "I have to tell you," I said to her after her kind greeting, "that how you handled that gentleman was great. You made his day with your kind words."

"Thank you, but I really do mean it. My grandfather and my father were both in the Army, and my brother is in Iraq right now. I can't even imagine what it would be like to go to war, you know?" She went on to tell me that every customer who goes through her line wearing some form of armed-service clothing gets a "thank you" from her.

She was an inspiration. Despite everything falling apart around her, she never once thought to be huffy or rude and, more so, was handing out compliments and immersing her customers in kindness. She demonstrated that grace-under-fire is not a lost art. If I could, I would have offered her a job in our ER. And lots and lots of money.

Several weeks after this, my wife, my kids and I drove a few hours to a nearby city's zoo, much larger than our local one. We were having a perfect zoo-kind-of-day, sunny and warm, with all the animals out and about within their exhibits. As we were walking down a paved, gently-sloping pathway, away from the exhibits of pacing polar and grizzly bears, we approached a gentleman in a wheelchair, coming from the opposite direction. He had bilateral below-the-knee amputations and was being pushed by what looked to be an adult grandchild. The man was wearing a matching t-shirt and baseball cap.

They read "United States Army."

As we were about to pass him, I stopped and looked at the both of them. "Excuse me," I asked, "but do you need any help pushing your wheelchair up the hill?"

"Why, no," the man in the wheelchair answered, his grandson nodding his agreement, "but thank you for asking. He looked at my children, who had halted by my side, and gave them a crooked, toothy, friendly smile.

I have to admit, I was nervous about what I said next. "Sir," I said, focusing on his clear brown eyes, "I can't help but notice your shirt and cap. Did you serve in the Army?" Was it any of my business?

He didn't seem to mind my question, although he did seem surprised that I had noticed. "Yes," he answered, "that's where I lost both of these." He nodded his attention to his partial legs before clasping his hands to his denim-covered knees. "Lost 'em in Vietnam when I was 24."

"Well, sir," I said, taking a note from the department store cashier, "I thank you for your service to our country. Because of you, my family knows what freedom is." I held out my hand and he took it, shaking it vigorously. I shook his grandson's hand next, and then we parted.

Walking away, I turned back for one last look at an everyday hero, a war veteran. Lucky for me, he was doing the same. Our eyes met. I'm not sure what he read in mine (hopefully profound appreciation), but I saw the gratefulness emanating from his. I smiled before turning back to my family.

My kids, ages nine, seven, and five at the time, were completely mesmerized. "Daddy," they asked, "did you know that man? And what happened to his legs?" No, I didn't know him, I answered them, before trying my best to explain how he had lost his legs, fighting for our country and defending our freedom.

After my wife and I answered our kids' questions the best we could, we continued on with our day, enveloped in our freedom, each of us walking on two good legs. My family on the paved path, me on a cloud. Man, did that interaction feel good!

As a result of the appreciative cashier, I try to greet every ER patient who has served in the armed forces with a heartfelt thanks. Try it sometime...it will make their day. And yours, too.

To think, this happened only because some cashier, during a busy, hurried moment, was able to remember the more important things in life. She made a difference. And I was there to witness it.

As always, big thanks for reading. And, big thanks to the families of our current soldiers and veterans for our freedom. Thank you, thank you...

Make Yourself At Home

noreply@blogger.com (StorytellERdoc) — Mon, 16 May 2011 14:08:00 +0000

Every ER has its regulars--those patients who return multiple times for a multitude of complaints. Sometimes their complaints are easy and minor, yet other times their complaints can be quite concerning, demanding our full attention. Regardless, that familiar face and voice can become quite a mainstay to a typical ER day. Depending on the patient, these repeat visits, over and over and over, can be the stuff that can sink an already hectic day. Or, remarkably, elevate it.

With multiple visits to an ER, then, a patient can learn the ropes of how our system works, using it to their advantage. For example, what are our busiest times? Most of our regulars know not to come in the evening, especially on a weekend or Monday night. Which doctors are working? They learn quite quickly which ones are more generous with the pain medications. Which nurses will be available to lend them an ear and a sympathetic nod of the head? Which case managers can get them free rides home and complimentary prescription refills? The list of "inside information" can be exposed and manipulated quite easily in the right hands.

We even get frequent "anonymous" phone calls, answered quite brilliantly by our secretaries, asking for the name of the currently working physician. "Umm," the phone caller starts, "my family doctor told me to come to the ER right now. But I'll only come in if Dr. Smith is working."  "Well, sir," the secretary will say, "if you are sick enough to visit the ER, I don't think it would really matter to you who is working." "But can you just tell me who is on?" To which our secretary shakes her head as she answers. "I'm sorry, sir, but I can't give that information out." The first click of the phone never seems to come from our end.

So walking into Room 12, I was quite prepared to see one of our more frequent patients, a pleasant, middle-aged woman with chronic abdominal pain of five years. Unfortunately, she is very susceptible to alcohol-induced pancreatitis and hasn't yet mastered her drinking problem. As a result, her abdominal pain and drinking issues keep her in a perpetual state of requiring our ER services. The more she drinks, the worse her abdominal pain becomes. The worse her pain becomes, the more she drinks (to dull the pain). A vicious cycle of dependency, for sure.

I smiled at my patient as I walked into the room. "Hello, Ms. Tinnell," I said, extending my hand, "how are you today?" I paused, before adding, "I haven't seen you in a few weeks!"

The patient's face lit up. Obviously, I thought to myself, I must be one of the docs generous with the pain medications. Ms. Tinnell looked worn-out, very sallow, and just overall miserable. She was holding her belly, despite her happiness to see me.

"Hi, Doctor," she said, "I'm glad you are on today. I'm hurting real bad here, sir."

"Was it your drinking again?" I asked, cutting to Ms. Tinnell's chase. She nodded her head in the affirmative. "Ms. Tinnell," I said, "how do you expect to get better if you don't want help with your drinking problem?" We had been over this time and again, but she didn't want any offered services for her abuse issues. That said, I sure couldn't leave a patient like Ms. Tinnell suffering, either. Despite bringing all of these problems on herself, I still needed to address her pain issue.

After finishing the interview, I performed an exam.  Leaning in to listen to her heart, I smelled her staleness, her sleep--that scent of just rolling out of bed in two-day old clothes. It was a smell I abhorred. "Ms. Tinnell," I said, "are you taking care of yourself? It smells like you haven't showered in a few days. Have you been binging again?"

"Oh, no, Doctor," she assured me, "I just had a couple last night to help with the pain. That's all." I looked closely at her disheveled self as she tried to sell me her line, shaking my head "no" as she spoke. "Okay, okay," she said, after watching my reaction, "you are right. I've been drinking for three days straight."

"Well," I asked, "what are we going to do about this? I want to help you but I'm not sure how I can. Are you willing to be admitted for your pain?" She nodded "yes." I continued. "Are you willing to talk to someone this visit about your drinking?" Again, she nodded "yes." "Good, Ms. Tinnell," I said. "I will order up a work-up, give you some IV fluids with nausea and pain medication, and start working on admitting you to the hospital, okay?" I had no doubt her chronic pancreatitis had been exacerbated by her drinking.

Once again, she nodded "yes" to me.

And then, Ms. Tinnell reminded me of how frequently she comes to our ER. "Um, Doctor," she said, before I could step out of her room, "can you get me an extra pillow?" "Ms. Tinnell," I said, "you know how hard it is to find an extra pillow around here! I'll look, but I doubt I will find one." She continued. "Then how about some extra blankets. And not those regular ones, either. I want the warm ones from the toaster oven." Those warm blankets were usually saved for trauma patients, to keep them warm as we undressed them to closely examine their injuries. "Okay," I told her, "I'll have one of our aides run a few down to you." She continued. "And Doctor, do you know if the pudding you have today is lemon or chocolate?  Your chocolate pudding doesn't sit well with my stomach." Oh, the cafeteria pudding is now my fault? I chuckled to myself. "Ms. Tinnell," I said, "you and I both know you won't be eating anything for a day or two, not until we get your pancreatitis under control."

Finally, the big question that I knew was coming. "Doctor," she asked, "what are you going to give me for pain? You remember that the one that starts with a "D" works best for me, right?" "Yes, Ms. Tinnell," I answered, "I know the dilaudid (a morphine derivative) helps you the most with your pain." She was only going to get half of her typical dose, though, to start with, since her renewed energy in making all her requests was quite impressive to me.

I stepped out of the room, but not before I heard Ms. Tinnell giving her nurse explicit instructions on where and where not to place the IV. "Honey," she was saying, holding up her left arm, "they always get one here.  Are you new here? I don't think I've seen you before."

I stepped out, shaking my head. This patient obviously felt right at home with us.

Twenty or so minutes later, I walked back into Ms. Tinnell's room to check on her as well as explain that her pancreas enzyme levels (amylase and lipase) had returned from lab and were quite elevated, signifying, for her, a flare-up of her pancreatitis. She was not alone in the room.

"I feel much better already, Doctor," Ms. Tinnell said, before I could even approach her bedside. "That "D" medicine works great!" I smiled at Ms. Tinnell as I walked up to her guest, and older gentleman, who was sitting in the room's corner. "Hello, sir," I said, "may I ask who you are?"  I was not going to share any of her private information without knowing his identity. "Oh," Ms. Tinnell answered, "this here is Johnnie. He's my new boyfriend." I held out my hand to Johnnie, shaking his. "Nice to meet you, Johnnie." Johnnie smiled, revealing his sparse, yellow-stained teeth. He appeared quite comfortable, sprawled out in the room's only chair, covered with one of the hospital blankets that Ms. Tinnell must have chosen to share.

I walked back to the cot and stood . "Ms. Tinnell," I said, "your pancreatitis is flared-up again. I called the medical doctors and case management. They are both going to be in to see you quite shortly, okay?" She nodded "yes," again. "We'll admit you like we planned." A part of me thought maybe, just maybe, she was going to back out of her admission, since we made her more comfortable and eased her pain. But she didn't.

As I stepped away from her cot, preparing to leave her room, Johnnie grunted. It was a signal to Ms. Tinnell. "Oh, yeah," she said, "I hope you don't mind that Johnnie is using the oh-two." I looked from Johnnie's nose, where two nasal prongs hovered in their silent swishing, and followed the clear plastic tubing that led to the oxygen hook-up on the hospital wall. It was set on two liters. Until this point, I hadn't even noticed that his tubing wasn't hooked up to the green tank that sat behind his chair.

They both must have followed my eyes as I took in the scene. "Yeah," Johnnie said in a low, rumbling voice, "I need to save my oh-two since I'm running low."

This was a new one for me--a patient's visitor hooking himself up to the hospital's oxygen. Not the patient, but one of their visitors! It gave a whole new lever to the phrase "make yourself at home." I shrugged at the both of them. "I guess it would be okay," I answered, "since you are only going to be here a few more minutes. When you go upstairs, though, you'll have to check with your nurse before you hook up to any more hospital oxygen."

Again, I started to walk out of the room. Before I could, though, Johnnie had cleared his throat yet again. I turned around, now growing a little impatient. "Yes?" I asked him. He looked to Ms. Tinnell. "I ain't gonna ask him," she said to him, "you have to." "What is it, Johnnie?" I asked.

"Well, do you have an extra chair that I can put my legs up on while I'm waiting here?" Um, no. Sorry, Johnnie, I thought to myself as I shook my head. He continued. "Then do you have an extra pillow and more warm blankets?" "Johnnie," I spoke, "we don't have any more pillows. I looked. And those warm blankets are for trauma patients. We gave you three between the two of you--you don't want to take any more in case someone really injured needs them, right? We'll get you some regular blankets if you want them." He looked at Ms. Tinnell before speaking a final time. "Well, then, how about some pudding or a turkey sandwich? Nobody's even asked me if I want coffee or something to eat yet." The words were spoken with entitlement dripping off every syllable, not as a question.

It was obvious Ms. Tinnell had shared the secrets of our system with her new boyfriend. Ughhhhh! And to top it off, right before walking out of the room, Ms. Tinnell did her own little throat rumble. "Doctor," she said, looking quite comfortable lying in her cot, "the pain is coming back. Can I have more of that "D" medicine to help me?"

According to Ms. Tinnell's nurse, the requests from their room continued throughout the entire ER visit. "Do you have any extra tooth brushes?" "Why won't channel 68 come in on the TV?" "Can someone get me some reading magazines from the waiting room?" Imagine a typical hectic ER day--the noise, the crowded hallways, the prehospital sirens going off, the commotion, the incessant phone ringings, the scurrying staff, the enormous traffic of patients coming and going, the arrival and departure of ambulance after ambulance. Now, imagine getting called into the same room repeatedly for such above issues.

I am quite fine with helping someone, anyone, in need. It's what I signed up to do, what any of us in medicine do, really. But, between Johnnie and Ms. Tinnell, I was feeling, once again, that our kindnesses and our system were being taken advantage of. It appears to be a growing problem with emergency departments across the nation as we struggle to redefine our roles in our changing medical world. Despite the pressure from administration and patient satisfaction surveys, there will always be patients and families that we simply cannot make happy. I felt we had gone above and beyond providing for our patient and, especially, for her visitor. But where is the endpoint?

Right before Ms. Tinnell was transferred to her medical admission room, the nurse approached me. It seemed Johnnie was upset that our case managers couldn't provide him a free taxi ride home. I shrugged my shoulders at her, exasperated.

"It looks like Johnnie is just going to have to find his own way home, I guess," I said. The nurse smiled, adding, "Or make himself at home...in our waiting room."

I could only hope they had some extra pillows out there.

As always, big thanks for reading. I hope this finds you all well...

Scratching Below

noreply@blogger.com (StorytellERdoc) — Fri, 06 May 2011 15:30:00 +0000

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

noreply@blogger.com (StorytellERdoc) — Tue, 19 Apr 2011 11:00:00 +0000

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

noreply@blogger.com (StorytellERdoc) — Tue, 12 Apr 2011 11:00:00 +0000

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

noreply@blogger.com (StorytellERdoc) — Mon, 04 Apr 2011 17:06:00 +0000

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

noreply@blogger.com (StorytellERdoc) — Tue, 29 Mar 2011 12:00:00 +0000

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

noreply@blogger.com (StorytellERdoc) — Tue, 22 Mar 2011 15:00:00 +0000

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

noreply@blogger.com (StorytellERdoc) — Fri, 18 Mar 2011 11:00:00 +0000

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

noreply@blogger.com (StorytellERdoc) — Mon, 07 Mar 2011 12:00:00 +0000

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.

Thank You...

noreply@blogger.com (StorytellERdoc) — Fri, 18 Feb 2011 15:00:00 +0000

Hey All!

Thank you, thank you, thank you...to Medgadget, to Epocrates, and to Lenovo, for uniting our community by offering a glimpse of the numerous, amazing medical blogs "out there" through your annual contest. Like last year, my eyes are a little brighter to such infinite talent in the medical writing world. Thank you for your energy brought to this endeavor. To my fellow nominees and winners, my heartiest congratulations on your recognition. Well-deserved and well-placed, each and every one of you. To my fellow nominees and finalists in the Best Literary category, it is truly my honor and pleasure to be listed beside each of you. A reward in and of itself. Thank you for your passionate words and eloquent insights.

Finally, to my readers--my amazing, faithful, insightful, intelligent, and devoted readers--I thank you always for your support, for embracing my words, and for making this such a thrilling personal experience. Your friendships and kindnesses outweigh any awards or votes I may ever receive. Thank you...

There are times when I simply cannot believe that I have been blogging for over a year. November, 2009, in fact, was the official start of this endeavor and now, with the blink of an eye, we sit in the year 2011 with anticipation for another spring and summer to roll around.

When I had first started out, I was diligent and adamant about posting three stories a week, aiming for Monday, Wednesday, and Friday. Although it was extremely hard work and, at times, exhausting, the rewards were worth it. I remember being in Hilton Head, last March, and staying up until 3 am to finish a post for that Wednesday. Of course, the next day I was a mess on the tennis courts, but I reasoned it was a small price to pay.

As some of you may have noticed, then, I've slacked off a bit since those days of three posts a week. It was late fall/early winter when I finally was able to breath out and not carry around too much guilt if I didn't get several postings done in one week. Sure, I think about writing a story here and a story there, but it was also nice to focus a little more on work, on family, and, especially, on my kids. Something had to give and, unfortunately, it was my blogging.

That said, I am going to try harder to pick up the pace again. Some weeks may entail only one posting, some weeks two. I think the days of three postings a week, though, may be behind us. I thank you, though, for sticking this out with me. The only reason I am still going, of course, is because you, the reader, have been so committed. For that, I thank you.

Finally, I have been asked repeatedly over the past year if there are any posts that are my absolute favorites. It's a question that I can't answer. I view my posts, my stories, as works of literature (in a feeble sort of way), and I don't know if I can pick out a batch of favorites. I do know that the majority of my stories focus on compassion and kindness and those little, obscure moments of humanity that many might miss. When I finish another posting, if I am smiling, then I know I have done some good.

Intrigued by the question, though, I did review my library of postings and was able to pull out several that really hit home with me. And my readers. If you are a new reader to my blog, this might be a great way to catch up on some of my perspective. If you are a tried and true steady reader, these old stories might be a fun read (again). I thank you for visiting some of my older works. So, onward...

If you want to learn a bit more about me;
Against The Norm
The Quivering Finger
Blogging & Me

More about my family;
My Buddy, For Always
Dear Australia
The Fringe Benefits
The Beaten Path

Sad;
A Mother's Cry
Grandpa's Grandkids
Heroes Among Us--Gigi
A Love Story
The Emaciated Shoulder
No Second Chances
This Father's Daughter

Talk-worthy;
The Damaged Eyes of Alcoholism
The Appreciative Cashier
No Love For A Father
The Pit Stop
The Witness
Please Make Her Comfortable

Funny;
Ssshhh
The Half-Load Predicament
All Bound Up
My John Deere Cap
Double Crack
It Wasn't Me!

How's that for a start? Looking at the list myself, I keep wanting to add to it...it's hard for me to pick one "baby" over another. Some of the funnies, even, have gotten me into trouble. Can you do me a favor, though? I would love to hear from you--to know what previous postings or stories may have hit home with you, hit that raw nerve or made you smile or burst out laughing. Even from ones I haven't mentioned.

Again, big thanks and kudos for all of your support over the past year. I am a lucky and fortunate guy. Happy (and sad) reading...and have a great weekend. See you next week...

Jim

Future Hopes

noreply@blogger.com (StorytellERdoc) — Tue, 08 Feb 2011 13:30:00 +0000

Vote for StorytellERdoc for Best Literary Blog at the Medgadget Medical Blog Awards! Thanks for your support...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A hero.

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

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

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

Sister, Sister

noreply@blogger.com (StorytellERdoc) — Fri, 04 Feb 2011 14:00:00 +0000

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sick-kid Season

noreply@blogger.com (StorytellERdoc) — Mon, 31 Jan 2011 16:00:00 +0000

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

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

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

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

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

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

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

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

That's where we came in.

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

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

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

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

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

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

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

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

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

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

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

I've been there...have you?

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

It was another good day in the ER...

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