My First Blog Post

Here I am.

I’ve been wanting to do this for quite some time.

For those of you who have known me for many years, you may remember when I used to send out email journal entries.  I like to think I was blogging before blogging was a thing, but I didn’t have a platform except for email.

Now, thanks to a few eloquent colleagues and an IT savvy husband, I’ve moved onto the WordPress platform and will begin blogging in earnest (I hope!).

Being an Emergency Physician, mother of two, wife and human can get quite busy.  It’s hard to find time to sit down and write, let the creative juices flow, put words to paper (or screen as the case is these days).

I’ve come to the realization over the last few years as an attending staff, that I need a place to open up and decompress.  I’m tired of coming home and keeping it all bottled up inside.  It’s too much to bear, as so many physicians could attest.  What we do daily is hard stuff – never mind the joys and perils of motherhood on top of that.  Being a doctor can be a lonely profession, when it comes to discussing the emotions that run rampant every day.  I’m lucky in that over the last year or two I’ve become part of a supportive online community of people like me, and have found a space there to at times discuss my day.

But now, I am ready for the next step.  Ready to let the world in.  I have a lot to say, lots of stories to tell.  My patients’ worlds affect me, as much as I affect their lives when they present to my Emergency Department.  I carry them inside my heart, and there is much value in the things they teach me.  I would like to share it with you.

Come along, and I hope the ride will be interesting.

Mortality

“Every time I see you, I feel like I’m lost, wandering around aimlessly” says the young, fresh faced new resident as we bump into each other for the umpteenth time on this night shift.

He is lost in this place, and I am lost as well.

Lost, because this year, for the first time, I feel old.

I turned forty, and suddenly mortality hit me in the gut like a linebacker on a football field. The sucker punch of age left me reeling, unable to catch my breath.

When I teach students these days I realize they could be my children. I am that old.

When I brush my hair, a thread of silver peeks out, laughing, from the most obvious part of my scalp, laying itself firmly in the sunshine for all to glimpse.

My hands, my face, showing weather and sun and the years of my life passing like the river that surrounds my city. The years pull away from me, stretched out behind like the shadow my son likes to make on the wall with my phone light at bedtime.  I play with my children and have to push myself back up to stand, partly due to obesity but also due to my old lady self.

Forty, I feel old, I feel sad, I see time speeding up and away and I don’t know how to slow it. And suddenly, this year, I no longer feel secure in what I always believed – that the end is comforting, present, that when we die our souls look down on family and friends and stay close. Out of nowhere I have started to doubt that anything truly exists when we die. Will the end just really be an end?

I watch his young back and unlined face as he strolls away down the hall, and I wish him many more years of youth and innocence and dark hair. I wish him joy and excitement and the wonder of discovery.
And I wish myself peace, as I kiss my own youth goodbye.

—————

Working a full moon night shift in a large academic tertiary care emergency department is an adventure.  The full moon brings out the worst in people, the crazy, the anxious, the sad. And those people bring all that to the EDs in cities across the continent, where people like me have to help them come to terms with and deal with what the moon brought out. Well, not the moon really, but that’s how it feels.

Doing what I do, I am confronted by mortality – my patients’ – but also my own – every shift.

Tonight, teaching young residents, I felt old. So old. I visited the darkness of age in my mind. Then a few minutes after composing an ode to my own angst while taking a bathroom break, I reassessed an older lady I have met multiple times in the ED. She, a strange cat, but kind, told me that every time she sees me here I grow better looking and get younger. Suddenly, my hair felt full, my face clear of wrinkles, my steps a bit lighter. In her own bizarre but sweet way of self she gave me a gift. Mortality moved further from me and quieted its steps on my soul.

Ruthlessly however the spectre returned later in the long night, when a psychotic, angry, awful man began screaming obscenities at me from his locked room. As he called me unrepeatable names and told me to get on a treadmill, I forced myself to type my notes and keep my cool.

When he yelled “I’ll remember your face”, and threatened to harm me, the knot in my gut twisted. Fear returned, took hold, solidly placed its’ teeth in my belly. This man and many like him walk our streets. We don’t know who they are. Tomorrow, he could be next to me in a cafe, or behind me on the street.  Him, or someone like him. Maybe he will remember my face, maybe he will just see a woman and want to hurt her. This man, and others like him, are the reason I fear. And I see them, every day. They come to me, where I work, and they demand to be acknowledged. Maybe they are sick, maybe they are just mean, maybe they should be in prison. But I, and those like me, must treat them with respect, kindness, like any patient who comes through the door. So I do, and I pay the price by hearing his abuse echo in my ears. I carry a “screamer” on my ID tag, an alarm that emits a high decibel siren if I pull it; it’s sad to think I as a doctor feel at risk enough to carry such a device. But just last week, a health care worker in my department was attacked in a horrific way, out of nowhere. So I take no chances.

Mortality. Death. I know it, I walk with it. I recognize it. I fear it.

Delightful

When you tell me your story I often resist making you stop.

I hold myself back from truncating your words.  I stand by you or sit on the bed and I listen, as you say so much and yet so little.

Usually I get only a hint of what I need to know, as your physician, to heal your wounds (the physical ones).  But through your narrative I learn you; what drives you, how you think, where you come from, why you are really here.

If I stay silent long enough you will tell me of your uncle who died last year of brain cancer, and now I have a better idea of why you are here in my emerg at 4 a.m. with a mild headache.

Though I may stay with you longer than perhaps I should, for the sake of efficiency, I don’t sacrifice these moments because I am truly delighted to be someone you can trust, to tell me your story.

I will take your words and write them down, first in your chart and then in my heart, as I learn what it is to have fear.

 

Written at a wellness conference for Canadian women physicians.

Home

Home is the heartbeat of my patient as they roll off the ambulance; rapid, pressured like the speech of the lady in the psych back hallway.

Home is chaos, a tumult of sea-salt smelling air rushing off the ocean as we arrive at the coast.

Home is warmth, a hot chocolate after a long ski day when the kids’ cheeks are apples and my hands are frozen meat.

Home is delicious, spicy, sweet all at once like moroccan salmon cooked by my husband after a long shift, the taste of my son’s cheek in bed in the morning.

Home smells like my daughter’s breath as she sings pop songs off key with such joy and lack of self-consciousness.

Home is pinks, oranges, greens of orchids and lettuce we planted last night, watermelon fresh cut dripping sticky juice on just washed counter.

Home is all of it, and when I stick out my tongue in the backyard to catch snow with my children, home is the hearts we have woven together that I can hear beating in the quiet of night bringing peace to my mind and joy to my heart.

Home is knowing, just knowing, that all is safe and right.

 

Written at a wellness conference for Canadian women physicians.

Sunshine and truth

I want to write.  It’s a sunny day and the world is bright, there are kids cheering at a school across the street, the sidewalks are filled with people dressed like spring and with a spring in their steps.  I have the day off, which doesn’t happen very much lately, and so far I’ve used it to my advantage.  This morning I woke up at 6 as usual, with my cozy, sweet smelling four year old boy snuggling me and his dad still quietly sleeping nearby.  My beautiful, growing, pre-tween nine year old girl joined us a few minutes later, and the peace and joy in my heart almost made my inner balloon burst.  Lots of hugs and kisses and laughter later, with some loss of temper sprinkled in as per usual, the kids were fed, dressed, hair and teeth brushed, shoes on and out the door with their dad to start their days at school and daycare.  After waving goodbye, I closed the door softly on the chaos and fled back upstairs to my still warm, undemanding, restful bed.

 

A nap, then a cleansing, thought filled shower carried me to a lunch date with a best friend.  Lunch with a friend is underrated in the technological hullabaloo of this world; many of us have forgotten the quick ease of conversation and the value of a venting session with someone who knows us well.  I have not neglected the worth of good friends.  Though my life is packed and full, I make time like this in order to make space for calm in my soul.

 

Now here I sit, giving myself the gift of sunshine and a clear mind.  When I write, I open myself.  I reflect, I build rooms in my memory that get filled with words, accessible for a lifetime or more.  I take the stories around me and translate them from biochemical connections in my brain into tangible things that I can share.

 

For instance, today is a good time to digest the story of a young woman I met recently, who is not unlike many women I meet in the Emergency Department.  She came to see a physician because in her 6th week of a very wanted pregnancy, after years of trying, she was bleeding.  The evening before, she had first presented to the hospital, and after an initial evaluation she was asked to return in the morning for a pelvic ultrasound.  Therefore, when I met her it was in the context of giving results.

 

In these moments, I often reflect before and after the visit, on the fact that the power I wield as a physician is astounding.  And not necessarily in a good way.  I can walk into a room, and change someone’s life profoundly.  When I entered this woman’s room, we had never met.  I was a stranger with all the knowledge and the answers; she was an anxious woman waiting for what would prove to be a harsh sentence.  I stepped into her world and ruined her life, shattered her dreams, brought tears and bitterness with my words.  Her pregnancy was an ectopic; the egg and sperm had joined in unity and created the spark of a new life, but that potential new baby had settled outside the uterus and alongside an ovary.  By getting lost in this way, the collection of cells though formed into a gestational sac and beginning to divide into a new world, would not have a chance to continue it’s growth.  An ectopic pregnancy if left to develop, could very possibly result in the death of both fetus and mother.  It is a leading cause of death in women in the first trimester of pregnancy, as it can cause rupture of the pelvic organs and massive bleeding.  Therefore, when I opened the door to her room, I closed the door on her dreams.

 

The responsibility I carry as a physician is not lost on me; every day I feel this acutely.  It is at once a burden on my soul and a blessing; I help, I heal, but I hurt as well.  However, I find myself often having to remind my heart that I am not the cause of a patient’s illness.  I am not the reason this cluster of sperm and egg took a wrong turn.  I did not choose to harm.  I am the messenger, and one whose face she may remember forever for the truth I had to tell.

 

So, writing out her story, I find my way to forgiveness.  I learn about why I feel so tired, so drained, when I finish a day at work.  I remind myself that the power I hold is not to be considered lightly.  I reflect and find insight, and I heal myself.

 

The sunshine outside shines too on my patient; I hope she finds her own way to heal, and to forgive herself and her body for the mistake she had no power to fix, and medicine had no power to change.

Burnout

There’s always so much to write about, and there’s never any time.  I work too much; it’s become evident recently that I need to cut down.  I have started noticing that things affect me much more than they ever did; there are days I hide my tears, and days I show my tears, when before the tears would have waited for the occasional (yes, occasional) shower.  This is a function of my level of exhaustion; if I were to plot it out on a bar graph like the kind my daughter is learning to understand in third grade, the intersection between the extremes of “time at work” on the x axis and “lack of me time” on the y axis would be the way I feel right now.  Burnt out.

 

Burnout: a small word we use a lot recently, to describe a very complex situation.  Physicians (and I can only speak for this category of person as I am one) are suffering.  Many of us won’t mention it, won’t give it breath to solidify itself in our lives.  If we say it, we make it real, when it’s often easier to just push it away and deny it’s existence.  Burnout.  There, I said it again.  To be honest, I’m not always sure this is where I am; but I’d like to learn how to prevent getting there.

 

Physician wellbeing is another catchphrase, like “wellness”, that is getting a lot of air time these days in conversation and at conferences.  This is something I can hang my hat on, that I want to be a part of.  In my little corner of existence I am going to step up and start working on improving my, and my colleagues’, wellbeing.  How?  Well, I have plenty of ideas.  Whether I can bring them to fruition is a good question, but I’m ready to try.

 

How can you help?  Can you help?  Can anyone?  I think so.  Here’s an idea.

Next time you’re in the emergency department, or your family doctor’s office, or visiting a specialist in clinic, try to think about how hard those individuals are working for your benefit.

Put yourselves in our shoes, for a moment, and see through our eyes.  See the way we have to hide our own emotions in order to help you get through yours.  See how we stay late to take care of your children, while our own children miss us at home.  See the glassy look in our eyes when we try not to cry as we tell your mom she will die within the year of a cancer we discovered by accident when we did a CT scan for kidney stones.  Look at my hands clasped tight, white, before me as I break the news that your brother did not make it after I worked for hours to the best of my ability, to save his life.

Look at all of us, stretched far beyond what we ever thought we signed up for, in a system where more and more sick people come to our door but we can’t hire more physicians to help see all of you faster.  When you have waited six hours and it’s 4 AM, and I finally walk into the room with an exhausted look on my face and a droop in my shoulders, but I put on a smile and say “hi, I’m Dr. A., how can I help you today” – please don’t crush me with your anger and your frustration.  Please understand we do our best and work our hardest to navigate fear, exhaustion, panic, sorrow; that we search to balance these with moments of joy at a new pregnancy diagnosis, or a hard fought save in the resuscitation room.  We try so hard to give you good news, or break the bad news with empathy; to see you faster, more efficiently, without skimping on the care we give to each of you.

Please, look at me and see my heart, see my humanity, treat me as you would like me to treat you, with kindness.  Just because I am a doctor, wearing scrubs and a stethoscope and a messy ponytail with pens sticking out from all pockets and phones ringing every few minutes, just because of this garb I put on when I come to work, don’t decide I am any less of a person than you.  I feel what you feel.  I hurt as you hurt.  I bring your stories and your pain home and I feel it over and over with you as you lie in the stretcher where I left you, and feel it yourself.  We feel this together.  You are not alone.  But when I go home, I am alone; no one knows your stories, no one sees the tears you cried when I told you the awful things I had to tell you.  Those moments we had together, that changed your life, don’t think they haven’t changed mine.  They have.  I am changed, by you, and you by me.  And it hurts.

 

So please, be kind to your doctor.  We need it.  We need kindness, and compassion.  From you, from each other, from ourselves.  Help us heal, the way we try to heal you.

The monster inside

I met such a brave man the other day, and a brave family.

Fully aware of his disease, my patient told me calmly of the death sentence handed down to him by a higher court than human justice. Nothing just about it, this man had not one but four ways to die all sitting and waiting within him like bombs ticking relentlessly.

He, his wife and daughter had come to the Emerg that day for a new pain, a different pain from his every day suffering. After clearly telling me that he no longer wished any extraordinary measures, including resuscitation or surgery, he allowed that he would like to know the diagnosis for this new agony. I treated his pain with analgesics, and ordered a scan.

The images were astounding. My lovely, sick, profound patient had a monster inside of him. A creature already known to be laying in wait, it had now grown into a true threat putting my patient’s life in imminent danger.

I came back into the room, met by my patient and his wife, who wanted to take him home to die in his own bed. In the most compassionate yet direct way, I explained what I had seen on the scan. I told them the story of his impending demise. I illustrated in colour the beast he was facing, because to do anything less, to hide the truth, would have been cruel and the wrong thing to do for this family.

I can barely express in words the way I, as a doctor and as a person, feel, when having to break bad news to patients and their families. To look good people in the eyes and tell them they are soon going to be separated from each other in the most permanent way, is heartrending. To explicitly tell a patient that he will die very soon, is harder than one can imagine.

And this death. This death would be agony. Of the four bombs set to detonate in this man’s body, the growing goblin on the scan would certainly be the most painful and frightening way to go, for both the patient and his family.

I explained this. In quiet words, simple, straightforward. I asked, do you want to stay here, where we can make you comfortable, take away your pain as you pass? At first, faced with this sudden decision, my patient and even more so his wife said yes, let’s stay in hospital, we aren’t ready at home. I told them I would leave the room and give them time to decide as a family. I involved the palliative care team to assist. By an hour later, the decision was made to allow the family and the patient to go home, armed with sedatives and analgesics to give him when the pain will become too much to bear.

Saying goodbye to my brave, kind, doomed patient with the grizzly bear in his belly tore my heart out. They thanked me for coming back in the room. I almost hadn’t, I had almost let them leave without going to say goodbye. But I couldn’t. This man, his family and his story touched me, and I needed to look once more in their eyes. I knew I would never forgive myself if I didn’t say goodbye before he died. I needed to close the door that I had opened in my heart. But how do you do that? How do you express to a person you just met, that you’re heartbroken that they will very shortly die? How can such a strong connection be formed in such a short timeframe, within one encounter in a busy emergency department? Well, those bonds form and break every day in my world. I am grateful for this, because it teaches me humanity and grounds me on this earth. It makes me appreciate health and my family’s health. My patients’ suffering and deaths make my life somehow so much more worth living, if that makes any sense. Their pain and loss opens my eyes to appreciate the state of comfort and joy I experience in my own life.

So I said goodbye, I put my hand on his arm, I looked him in the eyes, and I wished him the best. And then they left, and I left, and our lives will never be the same.

Rest Day

Today I get to sit in a café and write for an hour.

Yesterday I sat at my desk in the ED and wrote for hours, but in a very different way.

I get asked a lot why I don’t take advantage of the ease of using a scribe when I work.  Scribes in the ED are young men and women who are interested in medicine, who are trained and paid to follow an emerg doc around with a COW (computer on wheels) and type the notes for the physician.  In this way the doctor saves a lot of time that would otherwise be spent dictating or typing notes into the medical record. While many of my colleagues (in fact the majority) at my emerg use scribes and thus leave relatively quickly at the end of their shifts, I often find myself sitting at my desk for two hours after the clinical work ends.

Why?  Because, as you can see, I love to write.

My notes, like this blog, tell stories.  They open a window into the life and ills of each patient I see.  Though I write them in point form, and as concisely as possible, I still manage to convey so much in them that I could never trust a scribe to do for me.  By writing my own notes, I allow myself the space to storytell all day long.  It soothes me, calms my mind, and helps me consider all the possibilities regarding diagnosis and management of each case.  Writing makes my physician vision clear; I can see through my fingertips.  It also helps me process, as you will see now.

 

Yesterday was my third day in a row in the acute area of our emergency department.  This time of year is full of flu, flu and more flu, punctuated by pneumonia and cardiac disease.  The place is so full and so busy one can hardly sit for a moment, and I think maybe I got to pee once in the ten hours I spent there each shift.  The days blend into each other, and the algorithms of medicine kick in so that each case is managed pretty much by rote.  But sometimes, the day is broken up by the purple resus light over every room, which flashes when an extremely ill patient has arrives in our resuscitation area.  This light beckons the physician, calls to me, tells me to hurry my little feet over to a room where I may truly save a life – or lose one.

 

“Code blue, resus 5”; I hear the call overhead and drop everything and go.  Purple lights galore as I rush into the room, and find a nurse doing CPR on an unresponsive patient.  I stop, breathe, and ask whose patient this is.  Turns out she is admitted to the medicine service, and it’s my colleague’s name on her case as the responsible ED physician.  But neither he nor I know this patient, as she has been under the care of another team for the whole day.  Never mind, we jump in together to try and save her, until we are told that the family and patient had decided on a do not resuscitate order.  We step back, stop compressions, and watch the monitor to see if she will recover.  Her heart tries feebly to pump under the probe of the ultrasound we place on her chest, but no pulse can be felt and the heart gradually slows to a place where it will soon stop.  We take the mask off, fold her hands over her belly, cover her body with a blanket and prepare to let the family know that she will not recover from this.

 

My phone rings, and my husband tells me he and my daughter are outside the emerg with hot soup and lunch for me.

 

I take a last look at the scene before me, the peaceful body of the life we did not save, and I step out into the clamour of triage.  Washing my hands multiple times I leave the chaos for a moment.  Outside the emergency the air is cold, so much colder than when I arrived hours ago, with a chill arctic wind blowing snow in my face.  Suddenly I see the sweet faces of my man and my little girl, and I practically dive into the back seat of the car and shove my face into her warm waiting arms.  Happily surprised, she folds me in and caresses my hair as I kiss her face over and over, bury my not quite there yet tears in her hair and smell her fresh clean healthy little person smell.  Smiling and giggling she hands me my lunch, I kiss her again with such love and thank my husband for coming and giving me this moment, this gift, in my otherwise turbulent day.  I step back, close the door, watch them drive away and remember how cold the air is when I breathe.  I breathe deeper until my lungs ache, cleansing themselves of the death I could not prevent, and walk back into the world where I may face it all over again minutes from now.

 

This life.  It’s not what I signed up for.  The contrasts, the passions, the terrible sorrows, the incredible highs.  I didn’t know.  Would I choose it again if I did?  Probably.  But it still makes me ache and bleed inside every day, as I enter my patients’ worlds and lives and take it all into my own heart.  Thankfully at home I have two beautiful sweet smelling comfy feeling tiny humans who comfort me, and a man who helps me heal.  I didn’t know, I didn’t know why I felt such a need to find a partner and start a family when I started residency.  But now I know, and inside my soul back then I must have realized that without these loves to guide and heal me, I could never ever do what I do.  To help others, I need my family to help me.

Trying my hand at “fiction”

Looking through some of my older writing today, I found a piece that I wrote in 2007.  I am terrible at writing fiction, and when I do try it always feels forced and sounds silly when I read it back to myself.  But this piece that I wrote back then isn’t all that bad, so I figured I would share it here.  The medical details are all true, woven together from different patient experiences I had on the medical ward as a third year student.  Enjoy.

______________________

The sun was shining, she could see it as she entered the room.  Mrs. Johns lay as she always did, a lumpy potato sack on the bed sprouting limbs like toxic green shoots when the rot is near.  Megan could hear the rasping breath she was called to assess; even without the stethoscope the wheezes were audible. For the umpteenth time that month the respiratory therapist would have to be called, and the comatose sack would breathe easy once more.  That is what Megan was thinking as she auscultated the chest.  Only months later would she remember the patch of sun lying gentle as a caress on Mrs. Johns withered cheek.  Then, the quiet beat of her patient’s heart would blend with the birdsong outside the window and the radio next door, into an orchestra of meaning that Megan would recall over a breakfast of runny eggs and soggy toast, made soggier by the surprise of salty tears.

 

But that afternoon, as the Internal Medicine student on-call, all she wanted to do was watch American Idol – it was on in a few hours, and like usual she and the nurses would try to get in a few minutes of what she liked to call “brainfritz”.  Punctuated by snores, coughs, farts, the beeping of monitors and kinked IV lines, the singing would at least drown out the quietest of the hospital’s cacophony of night noises.  As she performed a silent rectal exam on Mr. Crenshaw (who after days of constipation had managed to poop out a whole wad of blackish stool) she mused about what Thai specialty she could order for dinner.  Of course, there was no real question, vegetarian Pad Thai was her favourite with it’s peanuty goodness, but then again tofu in red curry had an edge to it…

 

Abruptly, the shriek of the call pager jolted her out of her Thai reverie; the stool on her gloved finger tested positive for blood as a disembodied voice called “Code Blue, E south” over the intercom.  She hurried out of the room to find the ward a sudden frenzy of nurses, all propelling her down the hall and into Mrs. Jones room.  The nurse taking Mrs. Johns vitals had noticed that suddenly her oxygen saturation was 80% and the wheezing was much worse, and had called a “pre-code”, to perhaps stave off the inevitable.

 

“ICU is on their way!”

“Want to intubate her?”

“Which meds would you like?”

“Should I call the family?”

 

The nurses all peppered Megan with questions as the patient’s respiratory distress worsened.  It should have been simple – try drugs, intubate, stabilize, send to ICU – but Megan’s gut revolted at the thought of putting this months-unresponsive woman through all of that.  She should have had some sort of back-up besides the ICU, but call at Santa Maria Hospital’s Medicine ward as a third year medical student meant she had no resident or attending physician in-house.  Aside from the nurses, RTs, one emerg doc, the ICU attending and a few other medical students on other services, she was the sole person responsible for preventing the deaths of all the patients in the entire freakin’ hospital.  Shrugging the angst aside, she quickly moved for the phone and before the ICU team arrived, she had managed to get the RT back in the room.  After another course of inhalations Mrs. Johns’ saturation perked up to 95%.

 

Crisis averted (at least temporarily), the ward quieted down again and she finally got time for a pee break.  Hospital toilets being what they are, the nurses on E-south had taken pity on Megan and given her the code to their personal throne.  Squatting with her stethoscope hanging on the doorknob and her white coat pulled up out of reach of the wet depths below, the scene replayed itself in crisp detail in her mind.  Had she acted correctly?  Should she have anticipated the emergency before it occurred?  Would Mrs. Johns do this again later, before night’s end?  What would she have done if the meds hadn’t worked and the ICU team was busy with their own patients?  Would she survive the rest of this night, let alone the rest of her career, if patients were always trying to die on her?

 

The night wore on, and she ordered her veggie Pad Thai along with a chicken one for the ortho student upstairs.  Someone sang a terrible song on American Idol, and a demented patient pulled out their catheter, leaving a pool of blood on the floor and calling for his wife to cook the chicken.  Mr. Romano harangued his 99-year old roommate for snoring, Mrs. Cordoza fell out of bed, Mr. Jenkins tried to jump out the window, and Mrs. French found scissors and tried to cut her hair off.  The family of Mrs. Johns showed up at ten p.m. and wanted a family conference, a nurse fell ill with vomiting and had to go home, the fire alarm went off about ten times, and strong winds blew out a window in the conference room.

 

Meanwhile Mrs. Greenspan wandered down the hall in her open gown, 85 year old behind flashing its’ sagging self as she passed the nursing station on her way to the elevators and wished freedom before the nurses reined her in.  Cantankerous and special, her temporal lobe seizures (that Megan had diagnosed!) caused her to become intermittently violent and abusive, which made her the least-loved patient on the ward.  Having admitted her from the emerg and pushed for her initial EEG when the attendings were convinced it was just dementia, Megan felt a bond of sorts with this maligned lady and always kept an eye on her.  After Mrs. Greenspan was man-handled back into bed, Megan went in to make sure she was all right.

 

“Time for bed, Elsie”, the young almost-physician said as she stood by the bed.

 

“Sit down, girl!  I’m not tired yet, and I want you to sit with me.”  Proud and feisty tonight, her patient commanded and was not to be ignored.  Megan sat on the chair by the window, facing the bed, elbows on her knees and hands cupping her chin.  “Did I ever tell you about my husband?”

 

For the next few minutes Mrs. Greenspan relived a trip to Israel with her family, illuminating beaches and markets, archaeological digs in desert sunshine and the walls of the Old City.  Megan sat, fascinated, sleepy, privy to the internal wanderings of this woman’s wise mind in the moments before sleep, when doors thought closed are opened a crack and the subconscious peers out.

 

Silence.  “Would you like me to go so you can sleep now?”

Pleading, vulnerable, – “Stay with me while I fall asleep, won’t you?”

 

A shaft of moonlight cuts the blanket, landing on a gnarled hand, the band of gold and a diamond glittering brilliantly in the night.  Soon, the soft slowness of breath a lullabye, arms braced on the bed railing and head cradled above, Megan’s eyes close and for a few minutes she finds peace in the darkness of her patient’s room.

Old Men of the ED

I see you, sitting in your bed, the gown askew on your shoulders.  Too frail to tie it yourself, or perhaps with aching shoulders that don’t allow you to reach behind to grasp the other end of the tie, you lie back instead and just leave it open so it slides around when you move.  Your thin white hair, what’s left of it, sticks up off your aged scalp underneath a worn kippah, and the thin skin on your arms shows abrasions and bruising from any little bump.

 

I come in, to greet you, and your eyes light up.  As we talk about why you’re in the Emergency Department today, the wrinkles in your face become animated and show me your personality.  Somehow, even ninety years later you still have a dimple when you smile, and are able to flirt like a man many years younger.  In your illness, you remain as dignified as you can be, and do your best to cooperate with my barrage of quick medical questions and physical exam maneuvers.  I spend only a few minutes in your room, but yet we form a relationship.  You imprint your kindness upon me when you graciously tell me how young I look, how smart I am for being so young, how pretty my smile is.  (I don’t believe half of it myself, but you do, and that is what makes me leave your room with a spring in my step).

 

Later, testing complete, I come back to your room to share the news.  I stand by your side and tell you how your tests are all normal, and you are free to go back to your residence in reasonable health.  You take my hand in thanks, and I look down to see that faded tattoo on your arm; a number, etched in so many years ago, still blue and painful to both of us.  I swallow tears as I rub my thumb across the horror you still bear witness to, and give your hand a squeeze as I wish you the best and say goodbye.

 

Across the way, another day, there is another room, and it contains another man.  He is the same age as you, and has seen the same horrors.  He has the same white whispy hair under the same style kippah, the same crooked gown, same wrinkled skin.  He has the same tattoo, albeit a different number.  But he suffers from dementia, and to him those horrors are happening today, every day, in these rooms.  He doesn’t know that the Holocaust ended in 1945, and that we are in 2018.  He believes, truly believes, that it is 1941 and the hospital room he lies in is a dormitory in Auschwitz.  Every examination by a nurse or a physician, he knows is being done by a Nazi doctor intent on experimenting upon and hurting him.  Every needle poke, every medication he is forced to take, are torture.  All night long I can hear him crying, screaming, moaning in agony.  Even after we stop investigating, and are just trying to keep him comfortable, he continues to fight and spit, hit and kick at everyone who comes into his room.  Though we wish dearly that we could send him home, to a place he somewhat knows, we can’t do so because his nursing home shipped him here for unmanageable behaviour.  All I can do is tell him it’s ok, every time I go near his room.  I try to calm him, like I would a small child, with soothing voice and calming demeanour.  But when he looks at me all he sees is a torturer, a murderer of his family and his people, and so he shouts and waves his fists still strong enough to wield a painful blow should I come too close.  When he is finally admitted to hospital and is taken upstairs to a room hopefully quieter and less frightening to him, I sadly breathe a sigh of relief because his shrill shrieks will no longer tear into my soul.

 

Every day, in the halls of medicine, we meet patients that touch our hearts.  These stories are only some of those I could tell about old men in my Emergency Department.  When I meet men like these, they stir deep emotion.  Before motherhood, I used to think of my father when faced with older men needing my help.  Now, all I can think when I care for these men, is, “I hope one day, when my son is an old man, a young doctor will treat him with as much kindness and compassion as I do with this patient”.

 

I close my eyes in the brightly lit hallway in the middle of a night shift and pray with all my heart that the good deeds I do today come back to me as a safeguard for my children.  Let all the light I bring to others brighten the future of my son and daughter, in a time when I will be gone and unable to care for them myself.

 

When the heart wants to stop

Recently I had a case that stirred emotion: joy, frustration, concern, pride.

It’s not every day that my heart feels such a range of flutters while at work; generally, while I love what I do, I don’t always want to jump up and down on the couch screaming “Woohoo!”.  With this case, I had a woohoo moment.

 

A reasonably healthy older patient presented to our emergency department after fainting.  Actually, he didn’t just faint.  Most people faint after feeling unwell, or having the classic sensation of light headedness, a black haze clouding their vision, ringing in the ears, maybe nausea…what we call a prodrome.  Rarely, a person will lose consciousness suddenly, without warning, and go down hard.  When a physician hears that kind of story, we call it syncope with no prodrome – and it always raises the red flag.  With these cases, we must always consider a cardiac cause, i.e. an abnormal rhythm, that makes the individual pass out without warning, like a shark in the water pulling them down.

 

This patient had a syncope with no prodrome.  When he was initially assessed by my resident, he felt reasonably well with no headache, neck pain, chest pain, palpitations or other symptoms.  He did admit to feeling generally weak for the last few days or so.  The exam was completely normal, and the first electrocardiogram (cardiac rhythm evaluation) was normal.  Completely normal.

 

We sent the patient for imaging studies to make sure he had nothing serious as a sequelae of his fall.  Trauma is a pretty straightforward field to an experienced emergency physician: it involves evaluation and stabilization of a patient’s airway, breathing and circulation, monitoring of vital signs, and head to toe evaluation for injuries.  Diagnosis is clear as well: CT, xray and bedside ultrasound, along with routine labs.  There are protocols and algorithms that guide us.  For example, this patient needed a cervical collar because as an older person he fell outside the range of our evidence based decision rules (which allow us to say that a patient does not need xrays of their neck to rule out fracture).  We asked for a CT scan of his head and neck.  When I saw the images of a brain full of blood and a fractured skull, I knew this patient needed urgent transfer to a trauma center, and urgent platelet transfusions to combat the anti-platelet medication he was on.

 

I called the trauma team leader urgently and discussed the case, but stressed the point that aside from the traumatic injuries, this patient still needed a workup for the cause of syncope.  I told the surgeon that I was concerned that the etiology was cardiac in nature, and that the patient would be at risk of further deterioration if it was not addressed.  His answer?  “I am more worried about the blood in his brain”.  Needless to say, I documented that interaction very clearly.

 

Shortly thereafter, the ambulance crew arrived to take our patient to the trauma center.  Suddenly, as I stood a few steps away from the room, and just prior to loading him on the ambulance stretcher, a code blue was called for our patient.  My resident and I ran to the room, and found the patient not breathing and staring into space.  He rapidly recovered but we rushed him to the resuscitation room with the immediate decision to intubate him for airway protection during transport.  While in the resus room and preparing for the procedure, I glanced up at the rhythm on the monitor and my heart skipped beats just as the patient’s heart was skipping beats.  Many beats.  Dropped beats.  Non conducted beats.  Meaning, this was, finally, a cardiac syncope.  The patient fainted not once, but twice – and the second time just happened to be here, in my ED, with his chest hooked up to a monitor that captured the rhythm as it happened.  And there it was: the heart was beating in a totally dissociated rhythm, meaning that the 4 chambers of the heart were not coordinating, not sending appropriate signals to each other.  A rhythm like this means that blood isn’t adequately pumped to vital organs, including the brain, so a person will faint.

 

Or the heart will stop.

 

His heart essentially did stop.  For a few seconds.  At least the major chambers of the heart stopped.  The atria, the smaller chambers at the top of the heart, were sending signals that the ventricles lower down were not receiving.  So the ventricles were not beating, for a good 15 to 30 seconds.  Lucky for him and for us, he came back without intervention and we were able to get on top of it by applying pacer pads to his chest in case it happened again.

 

I called the surgeon back.  Hello, his heart is the problem; the bleeding brain is the consequence.  GET CARDIO INVOLVED ASAP.  He agreed.

 

I shipped the patient off with a nurse, a respiratory therapist and my resident with a pocket full of lifesaving medication and a monitor that could start pacing the patient if needed – keep the patient’s heart beating in an organized fashion.

 

When my resident got back from the transfer, and I heard that he made it there without incident, only then could my own heart go back to beating smoothly.  Not that my heart rate ever increased – it doesn’t, when I deal with stressful cases at work.  But the feeling of my heart in my throat fluttering like a bird caught in a nest finally resolved.  My heart was free, and rivers of pride and relief flooded me like a hurricane.

 

This case was so great not only because we saved a life – because we did – but also because it tied together everything I learned in medical school, residency and attending staff life.  It reminded me, again, of the sheer scope of knowledge I have been blessed to possess after so many years of striving to learn it.  I feel so in awe of the physicians who came before me, who learned all of this through trial and error and hard hard work. They created protocols, wrote textbooks, trained learners and now I hold all that history, and power, of medicine, in myself.  And I am passing it on to residents, students, and the entire team I work with, every day.  This is the joy of what we do – constant learning, constant growth, sometimes fulfillment.

 

And saving lives, even when the heart wants to stop.