"This is a pretty bad one."

“This is a pretty bad one.” “What’s the story.” “Post TPA bleed. They just transferred her from an another hospital.”

 As I walked into one of the resuscitation bays in the emergency department, I took notice of this middle aged woman. She seemed lifeless and intubated; a procedure performed at the outside facility after she lost the ability to protect her airway, a resulting problem from the ongoing bleeding in her brain. As the ventilator forced hyper-oxygenated air into her lungs, the neurosurgeon, already present in the emergency department, was setting up for an attempt at a heroic procedure to help reduce the pressure inside her skull. There was not time for pleasantries or move to the operating room, just a quick look between the neurosurgeon and myself. We both already knew the controversial clot-busting poison, TPA, circulating in her bloodstream gave her a poor prognosis in the face of her brain bleed, especially given the location of the bleed. As he performed the procedure, ventriculostomy, that would allow for relief of the elevated intracranial pressure, I reviewed the documentation from the outside facility. As I read, I became angry, very angry. In spite of hindsight being 20/20, this patient should never have received this controversial drug on at least three different major contraindications. In order to paint a better picture, the indications for use of this drug are so strict that there are clearly delineated guidelines and checklists for its use. Physicians are taught to never use this drug under nonchalant circumstances.

As her intracranial volume decompressed via the emergent procedure of placing an opening in her skull and now the ability to measure her intracranial pressure, we re-examined her and found no real change in her neurologic exam. Just a subtle response to pain, minimal central reflexes, and equal minimal responsive pupils. In the emergency department, she received blood product treatments that futilely attempted to reverse the bleeding process including a blood clotting factor just prior to heroic procedure. All we could do is helplessly watch and hope that her brain did not continue to bleed causing brain herniation and eventual death.

Eventually, the patient’s son arrived. He appeared shocked and bewildered. I honestly didn’t know where to begin, as he knew very little about the events that had transpired. So in the dimly lit room with the ongoing humdrum of the ventilator and occasional beep from the cardiac monitor, I told the family member everything I knew in an objective fashion. As I neared the end of the conversation where I described the prognosis, words became sparse, and my mouth became dry. I resisted the urge to became angry and tear. As the conversation concluded, he had no questions, which I expected. This news for far too deep-seated and shocking to allow for anything beyond breathing and otherwise paralysis. I fought through the piercing, utterly uncomfortable silence allowing the son a chance for any questions. The questions would come later. I left the room and went on to the next fire somewhere else in the intensive care unit.

As the night progressed into the early morning, she lost all reflexes and signs of life. Our fears were realized. Internally, I fumed in complete disgust of the complete incompetence of her prior caregivers. Their indiscretion directly resulted in her death. There was no way around this truth. This was not just a careless mistake or a quick life or death decision. There was time, and there was consultation with a so-called expert. Although I fully admit to not being witness to the initial patient encounter, the history of events and exam upon initial presentation were clearly described. By 8 a.m. with family present in the room, two physicians upon their own individual exam and evaluation, as per state law, declared her brain dead. The family allowed for discontinuation of mechanical ventilation.

Today I wrote the President...

Mr President et al,

I will keep this short. No matter the outcome of the budget debacle. Clearly, we live in a sad state of affairs. Our country has been tarnished by politicians who place their myopic views and greed in front of working together to make sure this country stays afloat, let alone excels. All to often, I feel as if this country is lead from the rear. Leadership on all accounts is by example from the front, not the rear. When I look to the branches of government (Executive, Legislative, Judicial), I feel as if I am sailing the night's sky without any stars.

What say you?

Sincerely,

Will Dishong, M.D.

Misery loves company.

Aside from a miserable overnight shift last night until this morning, I haven’t left the couch in days. Hello, pediatric emergency medicine. I feel as if a nuclear bomb was ignited in my throat, not eating, doing my share of coughing up my lungs. And insult to injury, as I was walking by a mirror during my shift, I noticed one of my eyes seemed a little red. Yes, that’s right, good ole ‘pink eye,’ conjunctivitis, which would explain the slightly blurry vision and watery eye that kept giving me problems during my shift.

Enough of my violin playing, shall we? The other day I picked up a double chart, which means siblings. Chief complaints: iron burns…from last week. My heart sank. Who waits a week to bring in children who have multiple burns from an iron? I prayed for the truth, but instead I got an unbelievable history, burns that appeared to be different ages and suspicious locations, two very active children, and mother yelling at them the entire time. The two beautiful children, although very active and into everything, were amazing. One came up, gave me a big hug, and wanted to play with my stethoscope. I informed an attending physician of the case, and both attendings in the booth turned to me and gestured a look of professional disgust. Consultation to the social worker in order to involved Child Protective Services (CPS), check. Consultation to the burn service, check. The resident on the trauma / burn service actually disagreed with our standpoint of abuse. He found the implausible story to be plausible. This worried me, given the number of red flags being waived high in the air. As the hours dragged on, anyone walking by the room could hear the mother yelling at her children. Two or three hours later, I received unfortunate news from the social worker: no CPS visit tonight as they will go to the family place of residence in the morning. I would have to discharge these two children home given the circumstances. Now, I do not know a lot about how CPS works. I do know they are spread thin. But, the disposition of these two patients really worried and still worries me to this day.

Umami

Life is so very precious. We take it for grant. We squander our lives in chasing after, for a lack of better terms, materialistic crap. Never mind personal responsibility. Let’s also not bother in bettering the world. We are completely caught up in chasing after some kind of ridiculous status on par with the flavor celebrity of the week. (Did you know there is a fifth ‘flavor’ we taste? Sweet, Sour, Bitter, Salty, and…Umami!) Then, we allow those crooks on the hill to take from us, and in effect we have allowed them to further divide this country. We are running our health care system and our economy into the ground, because we refuse to take responsibility for our actions.

Okay by now perhaps you are wondering why I keep using “We.” The etiology, the cause, lies in all of us, thus it is and will always be “We.” All the same, the answers rest in our appropriate and decisive action. This week I have spent some time reflecting on our Greatest Generation. Look around you, we exist because of their blood, sweat, and toil. Yes, you can dissect this generation and find fault as you can do any point with any one person or people, but as a whole, they were amazing! We have wandered far from them. Ultimately, I fear for the worse. No amount of technology will correct this fundamental problem nor will empty promises without action.

So I have quite the rant going here. What to do? To quote the famous Yoda (little green guy from Star Wars), “Do or do not. There is no try.” He is right! I believe we should not hang our hat on just trying to do right when it comes to noble and just causes. We must do. We must not accept an attempt. We must demand better from ourselves and responsibility for our actions. We must remember that we are all connected to each other and that we must educate, inspire, and nurture our youth.

Umami is a taste that is generally not directly perceived. However, the aforementioned taste revels with a pleasant savory characteristic. In essence, umami could be described as the glue of our fondest flavors. In “All I Need to Learn, I Learned in Kindergarten,” Robert Fulghum reminded us to revisit the Golden Rule, share, respect, take naps, wonder, question, have fun, laugh. I think he is right…well with a touch of umami sprinkled into our lives to help us along.
So, this holiday season I leave you with a final thought. A child name Mischa was battling with a brain tumor in a New York hospital. Unable to walk, from a wheelchair, this child would wheel around the hospital to see other children who had survived brain operations to remove their tumors. From the wheelchair she would offer words of encourage and hand them a tricycle to ride, a goal to achieve. The surgeon of this child wrote in reflection of observing this brave child:

“It’s how you behave in a ****-storm that shows what you’re made of. ‘Commit Random Acts of Kindness.’ There is NOTHING random about acts of kindness. Compassion is an active verb with moral consequences.” – If I Get to Five by Fred Epstein, M.D.

Merry Christmas! Happy Holidays! Peace. Peace be with you.

Acceptable - Draft

"Acceptable," Merriam-Webster, definition #2, section b: barely satisfactory or adequate

Is this our expectation? Should I look no deeper for a fund of knowledge in our youth? Is Plutarch wrong? Forget this mind as a fire to be kindled. Leave it to mindless button pushing, locked into a television set. Let our bodies rot under their own weight. Out, out brief candle without a moment of spark.

No more is there pride. Long since been replaced by acceptable. We have lost sight of our past. Much of this country has forgotten, never learned, or never fully grasped the blood, sweat, and tears of our 'Greatest Generation' and those who came before. We have become soft, weak, full of blame, and completely lacking responsibility.

In essence, without a clear understanding of our past, without true leadership, without a protected family nucleus, without respect, without sympathy, without empathy, without responsibility, the future is lost. America is at risk. We are at risk of the ultimate of all risks, extinction.

The Rant

(This is the short version without any stories…more to come later.)

Enough. I have had it with people not taking responsibility for their actions. There is no place in the Emergency Department (E.D.) for the drunken patient who was brought in by Emergency Medical Services (EMS, aka ambulance) and needs to “sleep it off.” I am tired of his / her (most often a male) belligerent behavior, physical and/or verbal harassment of nurses and staff. I am beyond pissed off at the potential needle stick that comes with a staff member trying to place an intravenous line on these belligerent patients. As it goes, chances are this is a person who doesn’t make good decisions from the get go, and thus he/she is at a higher risk of having a virus that could cause problems for the person stuck by the needle. Furthermore, these individuals clog the E.D., as the “sleeping it off period” takes hours. And finally, the overall healthcare cost of these patients presenting to the E.D. is astronomical. And guess who takes on the bill…you and I. It is completely and utterly ridiculous. Quite frankly, I am disgusted at not only these patients but also at our leadership for not taking on what has been an obvious problem for a very long time. We need a strong voice. We need legislature that will take a stern, no exception approach to dealing with people who present to the Emergency Department secondary to alcohol and/or other drug abuse. My solution is as follows:

1) Any patient who presents to the E.D. for medical care directly related to alcohol / illicit drug use MUST pay back society no matter the ability of the patient to pay for the ambulance ride and E.D. visit. It should be considered a misdemeanor under the strict sense of public intoxication. Repayment to society, i.e. punishment, should be in the form of public service, perhaps cleaning the ambulance used to bring the person to the E.D among many, many other options.
2) With regard to the same person in #1, any level of physical or verbal abuse to a staff member in the E.D. should result in an automatic charge of assault, battery, and/or equivalent against the person.

This is the short and sweet version. This is a serious issue, and ‘We’ should not allow this to happen any more. By establishing consequences, we are placing the responsibility back to the individual and away from our current lackluster approach of societal responsibility, which was put in place by our ever so wonderful ‘leaders’ on the Hill.

Teachers...

The life of a young doctor is riddled to the brim with ups and downs. I spend most of my time thinking, worrying, fighting with an internal dialogue over my next question, my next exam, my next order, my next anything. It is not so much that I am frozen by fear although I hold my fears close and allow them to help guide me through the valley of death. This internal dialogue rests in the realm of polar opposites. In life there are fundamentally two kinds of people: those who do and those who do not. Inherently, we slide back and forth between these two kinds of people throughout each day, a continuum of doing and not doing. Each decision between these two end points carries consequence and responsibility. So what does this all have to do with teachers? In the emergency room, there is a lot of doing especially from the young doctors who are still treading through that soupy matrix of residency. Young doctors mainly learn from three people: the patient, the nurse, and finally senior doctors. We learn the most from the patient, who trusts us to do no harm and find a way to the right decision, albeit stumbling at times. Above all, however, it is the nurse who carries my utmost respect and admiration. A nurse carries the weight of the patient care and advocacy, of teaching, and of keeping the physician out of trouble. To the resident who is about to make a mistake in ordering a drug or laboratory study, one might hear from an experience emergency department nurse to the new intern, “Doctor are you sure you want to order that lab?” There is a method in their ways. They come at you with the respect of a colleague but also with deep down seeded confidence in knowing the right answer and still offering the student, the young doctor, a chance to learn. The nurse could easily pass on the opportunity to teach and continue to go about his/her duties, but he or she doesn’t. The nurse cares not only about the patient of which he or she is responsible for but also for the young doctor. Tonight, with my glass of gentle red wine, I toast the nurse from which I will learn more than I may ever realize.