Thursday, August 23, 2012

The Aging Doctor

She was a disheveled, frumpy little thing, with wild eyes and stringy white hair. Slumped on her bed, she was labeled as a psychiatric consult patient, which generally means she was medically low maintenance/priority for our staff unless she causes a disturbance.  However, because her advanced age, the doctors decided to make sure she had no underlying medical problems. And of course, I was asked to draw blood from her with the distinct undertone that she would probably refuse.

She stared at my face as I approached, bloodshot eyes suspicious, lip snarled. "Well what do you want now?"
"Hi, I am S, a technician working in this area. The doctor would like me to draw some blood work...'
"He doesn't know what he's doing.  I'm fine."
I usually like to hear "no" three times before I stop trying, so I tried again.
"Well, he just wants to make sure you're OK since you are in the ER, you know... I see you've brought your veins here with you today and I will be very quick with the needle."
"These young doctors keep ordering all these unnecessary tests. Look at me, I'm fine. I don't even know why I'm here."
"Well, you had said you want to hurt yourself to somebody and they called the ambulance.  How do you know they're unnecessary, ma'am?"
"Where is this place? Am I at ____? (I nodded) I was trained here, you know. I worked here for decades. What do they know?"
I eyed her in a new light; the looks, smart little shoes, haughty dismissals made sense now.
"I guess I ought to call you doctor!"
"Yeah, well, I'm retired many years," she replied, slightly mollified. Then, as if she suspected me, she added defiantly, "and if I wanted to hurt myself, there is nothing you or anyone could do about it."
"I wouldn't say that... that will make you stay even longer. But if you let me draw blood and we have evidence you have nothing going on, then the psychiatrist will see you faster and you could potentially go home sooner."
She considered this. "Fine." She gave me her arm and refused to look at me.

My patient had threatened to put a violent end to her life by taking a metal statue and thrusting a part of it into a light socket.  Alarmed, her facility called an ambulance and she was transported to us.  Looking at her 80+ year old frame in mismatched sweats, one would never guess she was once a pioneer of medicine.  I stayed with her and slowly, I gathered the pieces of her story.  One of the first female physicians, she underwent unbelievable hardships and prejudice what was once the gentleman's exclusive club of medicine.  She told me haughtily that back in the day, there was little distinction between the fields. Your primary care physician could also be your surgeon who could also do your autopsy.  She scoffed at 80 hour residency work weeks, stating that the residents today miss out on so much, which is why they don't know how to put their hands on a patient anymore.  She decried her treatment in her facility, then mused the potential benefits of new technology. Fired up about her passion, she burst temporarily from her depressed cocoon of stained sweatshirts and dementia, and suddenly I caught a vision of the timelessly beautiful and viciously ambitious young physician she was.

Then, she remembered her current state and fell silent. The sharp-eyed girl became again an old woman. I felt the sinking feeling of an elevator descending too fast. What it is like to be at the top of the world, then falling slowly, piece-by-piece, day-by-day, year-by-year into the abyss of dementia, I shudder to think.  Soon, mercifully, the helping hand of dementia and sundown-ing helped her out of her gloom and returned her to the daily distraction of confusion.



"Hi, may I speak to Mr. Rash? This is RN Experienced here at the hospital and I just wanted to talk to him about his trip to the ER here yesterday. I see that he came in for a rash... is he feeling any better?
Oh, I'm sorry he can't come to the phone, wait... WHAT is he doing?
He's bathing in bleach?!... Who told him to do that?
Well it's definitely not a good idea to bathe in bleach.
Yes, well, what kind of cream was he prescribed? Yes, you need to take that prescription and fill it and it will make him feel a lot better.
Please, that would be a great idea. Please tell him to drain the bathtub right now.
Well bleach could burn your skin, it's really not a good idea to bathe in it.
Yes, but I strongly recommend he get out of that bathtub right now. Thanks and please call us if you have any questions. Go drain it right now. You have a good day."

True story.

Friday, August 17, 2012

Bloody Assumptions

A woman dressed in all white rushed in and slapped her hand on the triage counter to get our attention.
"My husband! I need to see my husband!"
S: "Ok, let me look him up in our computer to see where he is."
"Hurry, this is an emergency!" And she burst into worried tears.
S: "It looks like he is not in our system yet. Did he come in by ambulance?"
"Yes. I can't believe you won't let me see him."
S: "Please try to be calm ma'am, you actually arrived before the ambulance did. What is he coming in with?"
She tearfully listed an extensive list of cardiac surgeries and history, his passing out at dinner, and that he had "stopped breathing twice." The triage nurses and I looked at each other- this sounded bad. We looked up to see him coming into our ambulance bay, and Ms. Hypochondriac ran to his gurney.

I followed her, and saw, with horror, a vomit basin filled with bright red foamy stuff. I've seen bloody CHF spit-up before, and this looked just like it. He groaned and seemed weak so the triage team expedited him to critical care before even getting his history.
I brought him into the room and helped the critical care team immediately undress him, take an ekg, and put him on our monitor system, gingerly removing the large red-filled basin to a biohazard bin. Upon looking closer at the bin, I froze. What were those little granules?

I asked Ms. Hypochondriac if it was blood. "Oh, goodness no, he raspberries right before we arrived."
I stared at her blankly as it began to register. "He ate such a big bowl," she added with big eyes, as if eating more would have made a big clinical difference.

Raspberries! Such a big fuss over vomited raspberries!
It was not blood in the basin, which I verified with a gastroccult. I could barely leave the room without letting Ms. Hypochondriac see the grin on my face. I don't think she could have appreciated it.

Working in the ER, we are so hyper-focused on the worst-case scenario that it is sometimes hard to see the most obvious (and comical) possibilities.


Thursday, August 2, 2012

The Man Who Lived

Poppy Lucky was at a popular upscale restaurant in a nice part of town.  His big Italian family was celebrating his birthday or some equally important event, as one can imagine, with extravagant Italian food, wine, and dancing.  In the middle of  his celebratory dance, Poppy suddenly clutched his chest, fell to the ground, and usually, this is the last memory Poppy would have.

Not this day.  Poppy Lucky opened his eyes to twenty concerned and astonished faces and bright fluorescent lights. "What are you all doing here? Where am I? Why does my chest hurt?"
"Dad!" His son and daughter rushed to his side.
"Why is everybody crying?" Poppy was perplexed.
He would not know until later that the EMTs and Paramedics had performed CPR on his body that had no heartbeat and no breath for half an hour, and even shocked him once with a defibrillator.

"Poppy Lucky, what day is it today?" RN Muscles asked.
"Why, it's Sunday, isn't it?"
"Yes, yes it is," RN Muscles replied, "And do you know my next question, Poppy?"
"No, what is it?"
"Did you go to Church today?"
Poppy thought this was funny and gave us his warm smile.  I could tell that the deep creases in his face were shaped by his frequent use of that big smile throughout his life. He was also pure astonishment. He had many questions, as well as he should have.

As what seemed to be dozens of his offspring, their spouses, their children, cousins, siblings, and family friends took turns to come see him, he began to realize the gravity of his situation.  I could tell that though he was accepting their professions of fear, love, well-wishes, and gratitude with graciousness and well-practiced  humor, he was troubled. It was nearly impossible for him to understand that he had collapsed and almost died.  I don't think he could reconcile nor process the minutes in his life in which he technically ceased to exist.  After all, who really could?

"I'm sorry to interrupt you," I interjected once, "but I'd like to write down your blood pressure and see how you're doing, Poppy." "Well of course, young lady, please come in," he waved me in.
"So, how's his heart-rate?" his red-eyed son asked nervously.
"You know, it is a very stable 70 beats per minute right now," I answered.
"What about his blood pressure?" his son continued perplexedly.
"I think it looks like right where it generally should be at 110/70," I answered.
"What is that blue line? Why is it flat?" his daughter tried, "Why did the machine start beeping?"
"Oh, Poppy, you need to keep this sat probe on your finger, see? It stopped beeping. The blue line is his oxygen level, and it's quite good at 99%" I answered.
"So everything is...okay?" the son asked, a bit incredulously.
"It certainly looks that way," I replied.
"Oh Dad, it looks like the machine still thinks you're alive and that you'll be with us a while longer," he squeezed Poppy's hand and wiped his tears with the other.  This would be an awkward conversation in any other situation, but his words were oddly appropriate for that moment.
"So are you feeling any pain right now, Mr. Lucky?" I asked.
"No, not really, except my ribs, where they apparently worked on me." Poppy shrugged, but I could still strongly sense his uncertainty and sense of wonder at all that had passed.

Perhaps in future days, he will tell his grandchildren and great-grandchildren stories of bright lights, tunnels of darkness, flying angels and the voices of loved ones calling him back into the world of the living, but I saw in those first moments I spent with him an acutely incredulous man.  Those he loved best had convinced him of the biological facts, but it will probably take a long time for Poppy to find peace with how/why he beat the odds of staying asystolic/apneic, of sustaining brain injuries, of being intubated, of not coming back.

Poppy knew he had been given another chance at life the moment he understood what had happened to him.  As he described to me his family, the meal, the dancing, his eyes gained a dream-like state and his voice softened.  I could tell that he was habitually proud and extroverted, but during his stay, he became increasingly contemplative and humble. He will undoubtedly be a changed man after that day. And in some ways, so will I.


Wednesday, August 1, 2012

"So I Was Having Sex Today..."

(in an increasingly serious order from funny to NSFL)

Patient 1: "... when my boyfriend grabbed my boob and now it feels kinda lumpy and sore."
S: "Is that why you came to the ER today?"
Patient 1: "Yes, it's sore and I wanted to get it checked out."
S: *keeps straight face* "Ok, well the doctor will come in to see you in a moment."

Patient 2: "... and my girlfriend was on top ya know, and she was goin' up and down when I look down and it's like a ****in' bloodbath. I was so pissed she didn't tell me she was on her period, and then I started to feel pain, man."
PA: "Well, yes, it sounds and looks like you tore your frenulum." !! ouch!!

Patient 3: "... and I just felt a lot of pain."
PA: "Um, ok, well let's take a look at it. We might have to do a swab for chlamydia..."
PA: "... oh my... I think you fractured it."
What the PA won't tell him is that after surgery, it's common to lose an inch or two.

Patient 4 didn't say much, but it was obvious what happened. He had been using a cockring which he did not try to remove until 4 hours later. By then, his scrotum had swollen to about 3 times its normal size and was quite stuck. Our first attempt at using lubrication to slide the ring off was laughable. Even more funny was how our ring-cutter broke with no noticeable dent to the ring. At this, patient 4 finally admitted that the ring was made of titanium! Now, the fire department had to be called and much to the chagrin of a very private patient 4, he was surrounded by a room full of very fascinated male residents, nurses, firemen, and one female tech who was pouring ice water onto the electric saw to keep the ring from over-heating and burning him. After the ring was cut off, patient 4 left us wordlessly, probably too embarrassed to even say thank you to the team that saved his genitals from falling off. (In animal husbandry practices, this is actually how they castrate sheep and calves)

So next time you feel like gettin' busy, be safe! Otherwise, you should know that there is a small but distinct possibility you could end up awkwardly meeting yours truly,