Great Balls of Fire

It was once stated to me, "...that will be one of those memories that flashes before me as I die." The words were absolutely perfect and absolutely true. The statement presented in the context of a happy moment in life. I like that idea of my memories flashing before me as I pass away. I imagine that all such memories are not just happy memories. I think it would be wrong to imagine it as such. Life is so much more than happy. Some of my most powerful memories root themselves in loss under such terms of death, leaving home, not having a dad around for a few years, and personal sacrifice in family time. For many of these memories, oddly, I fear forgetting them, thus I keep photographs or physical reminders around me. On my wall is a picture of Columbia's last re-entry as seen on the cover of "Times" with the caption, "The Columbia is lost." The crew's faces, mannerisms, and days on orbit remain burned into my thoughts. In my truck, I keep reminders of my dogs who passed away. For a long time, I kept tokens of injuries that ended my chances of advancing into the world of soccer. And yep, somewhere I have memories of past romantic relationships. Some of these memories feel more like scars than memories. I have noted this to be the case especially with the death of some patients. These patients are the ones who in my mind shouldn't have died yet. When this happens I find myself flashing back to the Columbia's balls of fire. As a kid, I pictured doctors to be these people who could strike down death with fierce unwavering intention to pull people back into the living. Back then, I secretly wanted to be that guy. I wanted to pull people back who shouldn't die yet...along with saving the world from something. I now know that guy really doesn't exist most of the time. However, every now and then if you are in the right place at the right, then you get to be that person. You get to be the person who says, "Not now, not today." When those moments occur then just maybe I will get to see them again right before I die.

Perspective

After a pretty intense month in the ICU, one's perspective on life and priority decisions shifts. Anyone who as spent any amount of time around death knows that something changes in a human being after you have stared down this beast. It morphs from this far off almost imagery place to a very real and very close demon with blood dripping from its claws and its cold, damp breath sending a chill down your spine. Your body wants nothing more than to run from it, but you demand more of yourself. In lieu of performing instinctive behavior, you go toe-to-toe with a monster who takes the very life out of its victims.

For quite some number of years now, I have been in positions where the decisions I made had very real and very ultimate consequences. A month in the ICU only reaffirms the importance of preparedness, of calm in the face of panic, and of team work. There is also this realization of perspective. For some people, as was the case of the gentleman behind me at the coffee shop earlier today, a 'rough day' means they had to spend a whole hour taking care of a cell phone problem that really wasn't a major problem to begin with. To the team in the ICU, a baseline 'rough' day means death and then talking to the family. I learned an important lesson about perspective. Just because I am privileged in what I do for a living, i.e. taking care of sick people and dealing with really deep issues/problems, does not give me the right to stomp on someone else who's problem is of questionable less severity. Quite simply, one must be charitable in character. In other words, something that isn't a big deal to you may be a very big deal to someone else. This is a very hard lesson for me, and at times I must revisit it.

Cheers.

Damn If You Do...

You never know what you will get in the emergency department. Two a.m., as I walked into the room, I found a near eighty year-old nearly climbing out the emergency room bed as if she was a 1 year-old trying to get out of the crib. “Ma’am, I need you to say in the bed.” I repeated iterations of this line three more times. She never responded to me, and further she never really acknowledged my presence in the room. She had a blank stare that looked off into infinity. Her language was broken beyond all recognition. Something was seriously wrong; at that point I had not a clue beyond knowing something was seriously and critically wrong here. “Nurse, let’s get some ativan on board, one now please.” This situation was becoming unsafe for the patient. Soon thereafter she calmed down, but unfortunately she still could not tell me what about what happen. I turned to her desperate sister who could only seem to focus on the wrong details of what happen, as if she was trying to explain why the Moon orbits the Earth by comparing it to Chinese economics. Quite frankly, I spent more time redirected the interview than anything else. Fortunately, I was able to obtain some crucial facts and then had a chance to exam her along with looking over the few labs the emergency department had obtained. Unfortunately, it seemed the emergency physician dismissed the case as soon as the call was made to the ICU; such a move is very dangerous for the patient. Furthermore, the physician couldn’t muster any kind of handover or briefing for me. She quite simply left me to my own devices in lieu of working with me. Fortunately, I was able to get down to the E.D. quickly from the ICU. In summary, I found the patient had a critically low sodium level, level low enough to kill and kill quickly. I also discovered a mass in her lower abdomen, which I diagnosed as an incarcerated hernia causing a blockage of the intestines. At least I could now explain the history of vomiting, dehydration, and to a certain extent the low sodium. I ordered another liter of saline, wide open. Now the delicate balance between ultra low sodium levels causing death and repleting the sodium too fast causing irreversible brain injury began. I had to replete her volume and her sodium, but I had to do so without killing her. In all honesty, the quick rehydration is what saved her life, but in the process nearly caused me to lose a few liters of sweat. Given my examination of her, I ordered a surgery consult. They dismissed the hernia as of being any concern by countering my claim of intestines being trapped in the hernia. I left the unit shortly thereafter…my 24-hour shift turned 36-hour shift had to end sometime.

A full day of rest.

6 a.m., good morning to the ICU. I went immediately to my patient that I admitted over twenty-four hours prior. What an amazing sight! She was completely different. I sat and talked with her for a good 15 minutes, and then I read the reports and notes. Turns out, the surgeon, that night, was wrong, and she very much needed surgery and did get an operation soon after I left. What was neat really neat about the whole thing was the attending general surgeon on service came over to our team in the middle of morning rounds. He apologized to us and was thankful we were so persistent. Apparently, after I left on that prior day, our team lead went ahead and had the patient scanned despite surgery words. Later in the day, I had the pleasure of writing the transfer note to step the patient down to the regular hospital wards and also to meet with the patient and her sister again. I cannot explain the feeling of knowing that I played an important role in saving someone’s life. It is pretty damn neat.

Code Blue

"70 year old male, witnessed cardiac arrest, CPR in progress, peripheral IV line established, intubated, non-shockable rhythm. We'll see you in five." It is an eerie feeling, the waiting that is. You look the room over, equipment in place, personnel ready, white coat off, gloves on, then silence. It is not the normal quiet of the evening as you wind down before bed. This silence pierces your every thought, only interrupted by controlled breathing. The damn thing happens so quick. Someone says, "they're here." You peek down the hall to see paramedics and a gurney wheeling toward the room with one paramedic compressing a chest. With a blink, things fast forward, and now you are walking away from the room. Some of the team perhaps even you is sweating and physically tired from the compressions. You replay the entire course of events, questioning your decisions. Nevertheless, it is over. You don't forget. You try, but you don't forget.

L.O.L. et. al.

It’s not what you think. Keep reading. L.O.L. Little Old Lady. You are guaranteed to walk out of the room with a smile. Hardly the perfect patient, they will make you pull your hair out if you have any left. Patient’s blood pressure reading: 170/82, a whole 40 points above the last reading, not good. I questioned, “What happened with your blood pressure?” I didn’t expect to know the answer; I was just throwing it out there just in case. Through her thick glasses and gentle grin, she retorted, “I started taking them every other day.” Obvious reply from any doctor, “Why?” She looked down at her slow swinging feet with curiosity as they were too short to hit the ground from the chair and spoke with soft authority, “It made me gassy.” Although I’ve never heard of such a side effect from her medications, I wasn’t about to argue with her, and I could barely keep a straight face. This is the same woman who at the age 94 years old presented me with a ten step water-tight plan to squeeze another walker out of Medicare (for good reason mind you), informed me that she has already out lived three husbands, was in the process of writing an autobiography, would not let me exam her feet, and with a lean and whisper informed me that she sneaks half of a chocolate candy bar every day despite her diabetes, not that it would be a point of contention in the presence of a doctor. This lady absolutely made my day. She somehow found the spice of life and kept hold with a grip that would make a cliff climber jealous. Her happiness didn’t come from being a millionaire or wearing the latest fashion; it came from staying in the moment and keeping perspective.

In one breath worth of words, a patient can shock you, make you smile, bring tears, or make you walk away in complete disbelief at the potential variables of stupidity. I remember one recent Friday where I had just had enough and was ready to go home. After seeing my last patient before I left for the day, the patient’s roommate, not my patient, called me as I left the room. With a deep breath before I turned around, I went to his roommate’s bedside. An older gentleman who appeared comfortable but very tired in a sickly kind of way, a poster child of the infirm, but just perhaps on his way back from hell. I softly put my hand on his shoulder and asked him how I may help him. He responded, “Bless you. You do for others. Bless you.”

Over my too quiet Thanksgiving holiday with the world in a state of madness brought on by greed and with people still prioritizing the wrong values (one of many examples: the Wal-Mart worker killed via stampede on Black Friday), I have been thinking…a lot. I have a lot of hope for us, but what will it take? How many will have to die? How many will have to suffer? How many good men and women will it take standing tall against the devil? When will we realize happiness exists not in ideals of power and greed? How long until we realize that we don’t need to be under the very worst to see the very best? Or will we ever? Let us take a take a lesson from the two individuals I just spoke of. Let us be thankful for each other. Let us be thankful for that extra piece of pumpkin pie and that extra glass of wine. Here is to peace and happiness. Cheers.

When You Are Neck Deep In It... - DRAFT

I had a bad three weeks. I lost three patients. Death is not pretty; it can be down right ugly if we go the whole nine. In the middle of a working a code, the human aspects of the patient fade way to facts. As doctors (and nurses), we have to set aside any human connection and work the numbers and facts to the best of our abilities. The intensity in the room accelerates to the extent of taking your breath away. "Yes, please" and "No, thank you" abruptly transitions to "get it done" and "we need this yesterday." This is all well and good and should be expected. The part that makes my stomach turn is the family watching the whole process. As a doctor, I can separate myself and move forward through the dramatic process of trying to revive a life quickly fading away. But, what of the husband or wife? Of the son or daughter? What of them? I have seen fear and also looks of horror in their eyes. I dare not imagine the view through their eyes. What horror it must be watching their loved one turn completely unresponsive, and then the intense rush of medical person after medical person into the room as you are slowly squeezed out of the small room as you watch CPR in progress with intubation placement then the central venous access lines and the yells for drugs administration. The process continues to snowball as a hospital representative finally comes up to you and ask you to join them in another room while your loved one's life slowly withers away. I dare not say "I know how you are feeling." They look at you with hopes of a miracle, but all too often the process of dying was already well underway prior to the code, prior to the ER visit. The walk into the room should be one of grace and complete humility. As doctors we are not their to heal in that instant, we are there to carry the truth with soft words and breaths of empathy. The silence is quite uncomfortable; it burns at your lungs. You want to say more; you want to say it will be alright, but again you are there to tell the truth...the truth. In all honesty, the tears upon processing the news compels some sense of odd relief to me, as I know the family understands the news.

Then you have that patient who you have befriended in the hospital. Who has terrorized the poor nurses and staff, only to pick out a few people in the hospital he/she likes and then solely looks to them for assistance. The story underlying such a patient often involves a chronic illness, generally with a very grim prognosis with survival beyond a few months. Watching the suffering can take its toll on the treatment team. Relief to the patient only seems to come with large doses of drugs that dull the patient's spunk and vitality. But moreso, it is hard to listen to such patient ask under grounds of complete sincerity for a lethal dose, and under certain conditions harder to say, "No."

Imagine

Finally, I'm home after a long day at the hospital. Jack Johnson's cover of Lennon's "Imagine" is playing in the background. The song couldn't be more appropriate.

My mother has repeatedly told me over the years of a saying by her mother, my grandmother. In short, my grandmother would say, "We cross back and forth between sanity and insanity every day." It is not that I ever dismissed these words; it is, however, that I never completely understood what they meant. I now do.

Over the last week and half, I have come face to face with horrible illnesses. Most of which there is no cure and the treatment a crude at best in some cases. These patients often struggle to maintain a grip on reality. Before me, the horrors of Schizophrenia / psychosis, Obsessive Compulsive Disorder (OCD), Bipolar Disorder, Major Depression Disorder, and every other mental illness surfaced in the eyes of desperate and almost completely helpless patients.

From the eyes of a schizophrenic, one may find the haunting image of a human being trying to fight off internal voices in a effort to maintain their own sanity and be a functional member of society. Imagine living in a world where one day voices questioned your every thought and slowly through time your thoughts every so slowly twisted with delusions. Imagine knowing you were slowly losing your grip on reality. Imagine trying to fight back...imagine trying to prove to a psychiatrist that you can function by yourself out in this world despite the voices and the deeply seeded beliefs that the president of this country was your friend.

From the eyes of a person with OCD, one may see the confusion and sheer terror of cycling through the same very, very disturbing thoughts without any control over them. Imagine the echoing thought in your every waking moment, and then imagine trying to make sense of why you keeping thinking such horrible thoughts. With such an illness, a person can fall into the trap of depression and slowly give up on life...all because you have these terrifying thoughts that you don't want to be a part of you despite the exhausting struggle to dismiss these thoughts and let alone any compulsions (repeating behaviors that are aimed at calming the obsession).

Imagine knowing that you are now 'crazy' and that at some time in the past you were 'normal' and had a full and wonderful life. The most unfortunate aspect of these illnesses lies in the fact that the patient's prior behavior in life has very little to nothing to do with onset of these severe illnesses. For the majority of cases, people are plucked from reality and left deteriorate before the rest of society. They are trapped in a world they don't deserve and can't escape.