holiday heart.

It's Christmas week in a sleepy town wedged between the North and South Carolina border. A 5 o'clock drive to work is marked by the monotone of traffic; a sea of red lights swimming home under a remarkably pink-purple sky. As the last rays of sun disappeared under a dark velvet shroud, I pulled in under a crisp, newly-installed sign in glowing red: EMERGENCY. I was at a new, state-of-the-art facility in a quaint border town that had never known this luxury. After a tumultuous process over the last several years, filled with the finest local politics, the facility had finally opened to great fanfare and was serving the community. The emergency department was a massive, smoothly polished space of gleaming white floors and polished hardwood surfaces. Every patient room was a large, white sanctuary surrounded with walls of clean aluminum and glass. The rooms were replete with the most advanced digital monitors and the brightest multi-colored LED displays I’d ever seen. The overhead lights swiveled smoothly and cast an almost holy glow. The beds were all fitted with smooth, ergonomic adjustments. This was the kind of space that made you believe that ordinary mortals could manufacture miracles; all for a small copay in the span of a two-hour visit to the ER...

As we had recently opened, the volumes were volatile. However, we were fortunate to serve a hard-working, independent community that fought hard to create a place for us. My first week was filled with earaches, over-turned ankles, and allergic reactions. The convenience of having us in the community brought out several who remarked, "Well, I wouldn't have normally gone to a doctor for this, but since you're here..." While holiday weeks promised a predictable lull as people made preparations with their closest family, you never knew what would come in. As I was carefully putting a rambunctious 2 year old's lip back together, I noticed a new patient on the board; a young man checked in with the potpourri triage category "Other Complaint". As I completed the 2 year old's discharge papers, I opened up the young man's chart and browsed the nurse's notes:

"42 year old male presenting with jerking of his right leg earlier today. Symptoms resolved. Probable sinus infection. No active complaints".

As I walked in and pulled the curtain behind me, I found a nondescript man in a navy blue workjacket sitting at the edge of the bed. He was peacefully staring up at the television watching something in Spanish. As we started talking, I noticed his speech had a slow, forced quality; I sat there imagining that I could see him concentrating hard on pressing each word to his lips, carefully explaining what brought him to the ER. He had been walking around that morning when his right leg began to shake uncontrollably. He couldn't control it and for a few minutes had trouble standing. Finally, as he sat down, the symptoms resolved. Here he paused. He also reported feeling sick with a mild headache and a lot of sinus pressure and congestion. He wanted something for a sinus infection…

As I launched into an explanation of how sinus disease couldn't possibly be linked to a tremor in his legs, I asked if he had any other medical issues or medical history. "Nope, that's it doc. Perfectly healthy". It turned out that he was from the Midwest and was only in town for Christmas visiting his brother's family. "I normally wouldn't come in for this doc but you guys have such a nice place...” After hearing this line all week, I asked, "Something must’ve really bothered you to bring you to us while on vacation. What was it?" Again, he seemed to carefully consider his answer, "a few months ago, I was sitting on the toilet and I was reaching for the toilet paper. As I reached across with my right hand, my whole arm just flung itself to the wall and I couldn't control it...it was only for a few seconds...but I had trouble holding the toilet paper. Now it happened to my leg. It may just be a bad sinus infection, but I just thought I should get it knocked out..." I started his neurologic exam and everything appeared to check out. He had no deficits. He had no pain, and he had normal strength with a complete range-of-motion in his arms and legs. As I jerked his Right ankle upwards, I noticed that he had sustained clonus, a steady, rhythmic jerking of the ankle when rapidly flexed. Sometimes this means something, sometimes it doesn’t. As I left the room I heard the nurse come in, look up at the television and ask, “I didn’t know you speak Spanish?” He looked at her and said flatly, “I don’t… Is this Spanish?”

And there it was. The devil was always in the history. A few odd occurrences in an otherwise harmless story that leaves you with a bewildered, sinking feeling. His CT scan revealed an angry golf ball sized mass lodged along the left brain. It had began to press on the surrounding tissue causing swelling of the brain. The tremor in his leg was likely a focal motor seizure. The headache was likely caused by the buildup of pressure in his skull. As I came in and sat down to deliver the news, he just stared at me in silence. He blinked a few times and said nothing. I couldn’t tell if he understood. He asked for his brother. As I called his brother into the room, they looked at each other, and tears began streaming. I explained what we had found, and the brother’s face softened as he wept. It all began to make sense; months of odd behavior, slow speech, the occasional tremor; and the sinus headaches. I got him admitted. I spoke to Neurosurgery. I gave him medicines to make him more comfortable. And silently, I prayed for him.

The drive home that morning was cold. Christmas week in a border town. I called my wife and told her that I loved her; Then I asked her if my speech sounded funny…

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kaos...

some nights just bring it... The ebb and flow of an Emergency Department can be one of the most complex things to predict. Just when you feel that you have things settled, ambulances pour into the ER and line the halls with patients strapped to plastic backboards.
They form a captive group that watches you simultaneously as you rush around and try to move the patients piling up in the waiting room. Abdominal Pain. Chest Pain. Trouble Breathing. And then, interspersed, the Headache that's been constant for over a year. I see a girl who describes a head pressure who was shot with a BB at age 9... she is concerned that the BB is sinking into her skull and causing brain damage.

Just when I feel that I've gotten everyone off of their backboard and I can finally run to the bathroom, a fresh wave of ambulance patients wash into the ER. A young pregnant girl involved in an assault is placed across from the nurses station. I look over to find her screaming and carrying on. Apparently she was pistol whipped. I can not imagine why..."When the hell am i gonna get seen... i'm pregnant. i've been waiting and i'm in pain. awww hell. i knew i shouldn't have come here. i'm in pain. i've got an open wound and ya'll just letting me sit here. i need pain medicine. and i'm pregnant! i need to call an ambulance. ya'll can't handle this shit! these mutha f#%@$ know i'm in pain and they just walkin' around. i need pain medicine. no one's been in to clean my sh%#. i need pain medicine! i've got a head injury and an open wound! i need pain medicine..."

the chant is incessant. but i'm working as hard as I can. I ask a nurse to take her some ice for her head. 4 left to see. She has a 3cm L eyebrow laceration. I move faster. She continues yelling. The belligerence is starting to concern other patients. I call the patient advocate. 3 left to see. Continued yelling. Cursewords hurled through the air. I contemplate calling security. No change.

"Ma'am, we are doing the best we can and I am going to come and see you soon. Please do not yell as we have children and other patients in the ED. I promise I am doing everything I can to get to you but we have a lot of critically ill patients tonight." 2 left to see. She was quiet for a few minutes, but begins to get up and pace in the room. The yelling starts again and then she finds the call button. I think to myself, "now i'm going to stop rushing".

By the time I see her, there is no more bleeding. She waited just over an hour to be seen. The wound is a sharp, linear laceration along her L eyebrow. I explain that I am going to take my time to minimize the scarring and perform a good repair. I explain she'll have a scar but that is she stays out of the sun, the scarring will be minimal. I tell her I've got good hands. And then, almost instantly, she begins to cry. I don't mean a few tears, I mean bawling. In the middle of choked tears and snot running down her face, she apologizes. A garbled "I'm sorry for this..." escapes her. It was as if the thorn had smoothly been plucked from the lion's paw. She cooperated and we finished the repair. She thanked me. And then I discharged her.

These nights teach me that patience is a virtue that I have to cultivate... I am not here to judge. After all, we are all, only human...

its not a tumor...

Before I could sit down last night, the loudspeaker crackled overhead asking for "KEG to Trauma 1". With fresh legs, I jumped. I moved quicker than expected and took the hallway in a few quick strides. Two weeks off from the ER leaves each synapse exploding with double-shots of neurotransmitter. As I walked through the ED, its prep time. Images of tragic trauma victims strobe through my mind. In those precious few seconds, I've learned to feed off the past. I instinctively conjure the worst cases I've seen, for there is nothing scarier than the unknown...

I push open double doors to find a pale, confused, twenty nine year old. His startled eyes were staring into the bright trauma bay lights, pupils as wide as shiny black peacoat buttons. Awake and no one home... and all I could think was 'bad'... severe head injury, intracranial hemorrhage, tumor, anticholinergic toxidrome. When you're holding a hammer, everything looks like a nail.
One of the nurses says something about a history of inoperable brain tumor. As I quickly examined him I called out for a stat head CT. "Let's get him to scan in 3 minutes".

I made my way back into the thick of the ED. A few more had trickled in and I jumped right in. Postcoital headaches, a bevy of unexplained abdominal pain, new onset congestive heart failures, and of course, a host of unexplained chest pains. As I circled back to Trauma 1, I saw that the room was empty. Good. He was in CT.

"Dr. Patel to CT"

I ran to radiology. There are few times when ER docs run. Getting paged to radiology is always bad. As I walked in, I found him, mouth frothing, with arms and legs rhythmically shaking. I immediately turned his head, laced the oxygen cannula under his nose, and called out for some ativan. In my relatively short career, I've already seen enough bad to know this was going to be bad. He rolled through the scanner and we hustled him back to the main ED. A few moments later, I cautiously opened up the PACS to bring up his images. Family just showed up.

I wondered how I would break the bad news. As I scrolled through the images, I saw the angry mass lodged in his left frontal lobe. As I was reviewing the CT, his friend ambushed the nurses station and started apologizing. "I'm sorry I took so long... I had to park the car. We were driving and he started shaking in the car and foaming at the mouth. I think he had a seizure...He hasn't been taking his medicine for the last 3 days..."

Its okay. You're right. He's had a seizure. But the tumor looks unchanged. No bleeding in the brain. In my line of work, I love being wrong...

In my end is my beginning...

Epilogue. i began writing this on the cusp of my last shift. i thought ahead about the last time i would walk across the glass bridge and through the doors of our bustling ER...the place i've considered 'home' over the last few years. I dwelt on the loss of something that has been both comfortable, and anxiety-provoking at the same time. The last few months had been a hard stretch. But we had continued to serve the community without faltering. Now, as i stand to lose this familiar place, I steel myself to leave behind so many friends. Yet, as I prepare to walk away, I pledge to carry the lessons of our collective experience with me...

I fumbled my way into the ER for the last time taking notice of all the details that you miss in a comfortable life. I gauged the heaviness of the door at the top of parking deck staircase. I counted the paces across the glass bridge. As I wound my way into the back of the ER I noticed with new interest the scuff marks from stretchers that had tattooed bare white walls. I grabbed my stool in the physicians' workspace and spun around one last time.

The night began with weakness, dizziness, nausea & vomiting in pregnancy, and a ground level fall. These first four were easy. After that, I started to think about how these may be the last patients I would see here. I listened to a man tell me that he felt hot. That his insides were on fire and his bones were melting. I listened with great interest to people with chest and abdominal pains. I marveled at the clumsiness of an obviously intoxicated, lethargic woman I had seen a few nights before who had fallen from a ladder. Now she reported she had fallen while hanging some curtains. She was here for more pain meds. But only the Lortab 10s... The night wore on. I saw a mountain of a man with intractable headaches and fevers. I grabbed a bedsheet and my hands instinctively began drawing my spine diagram... to explain the last lumbar puncture I would perform in these cramped rooms. I admitted a girl with pseudoseizures and tried desperately to convince another woman that a bluish tinge in her lips was not the sign of a life threatening illness. Eventually I had to discharge her despite her misgivings... The night ended with a plain woman who had eaten a bad watermelon. That was it. The last shift...

I made rounds through the ER several times trying catch everyone who had been part of our family over the last few years. Clerical partners, environmental services, hospitalists, monitor technicians, secretaries, medical records personnel, nurses, respiratory techs, administrators... the ER is a living, breathing quilt. Hushed goodbyes. A few hugs. A card that made me and my throat catch. I walked passed some of the new physicians and administration that had taken over our operations. It was hard to see the new faces that were part of the ED's restructuring... like meeting the new spouse of an ex... still, as one my partners said, the one thing you can count on in life, is change.

In the days ahead i move to a new madness. A long and windy road to a new hospital, a new group of colleagues, and new patients to serve. As I look forward to busy weeks of memorizing passwords, remembering faces, and learning the terrain of a new department, I will cherish my old colleagues and the life lessons we've shared, the plague & pain we've fought, and the doctorin' we've done...

it's true. the medicine is the easy part.
it's the humanity in medicine, that makes it so incredibly hard,
and yet so incredibly rewarding...

sometimes friends.

Seizures in young men are common. A few nights of hard drinking and little sleep. Poorly treated epilepsy. Traumatic brain injuries. Withdrawal syndromes. Thirty seconds and I could tell that this guy didn't look like an honest citizen. He was probably off his seizure medications. Or drinking. Or drinking and off his seizure meds. Or maybe they weren't really seizures at all. I had to leave the room to take a call and check on Room 3. I came back and tried to catch him in his words. Was this really a seizure? Loss of bowel or bladder function? Were you awake? Do you remember the seizure? You forgot your meds didn't you?

"I don't know. I don't remember... I just passed out and woke up on the floor with a headache. I had to crawl to the phone and call my neighbors. I live alone." I went to auscultate his chest. I opened his gown, I saw a massive, deep scar on his back. I smiled weakly at his neighbors. It was as if the very hand of god had reached down from the heavens to claim a pound of flesh from his back. It was a deep, eye-shaped crater characteristic of wide-margin excisions performed typically for skin cancers. "Melanoma he said" They found it two years ago and cut it out of my back... As I stood there awe-struck, Room 15, next door began a sort-of howling that could only come from gastroparesis...

When I came back into the room, the neighbors had stepped out. I remember he talked with a nervous joviality around them. That too, was now gone. He already knew what the return of his seizures meant. In fact, I think he had known for some time...

35 year old... History of melanoma excision 2 years prior with negative margins and negative sentinel nodes. 2 months ago he had some R hand twitching. A CT scan had revealed three small masses in his brain. 15 cycles of outpatient radiation to shrink the tumors. An outpatient MRI had been done 2 days ago and he was sent home to wait on the results. He lives alone. And today, he is carried in by neighbors, after having focal motor seizure. Joking. I opened up the MRI which reveals a brain riddled with disease. He has cerebral edema. I discussed with his oncologist. They advise a referral to hospice. 35 years old...

He told me he already knew. He also suspected that little could be done. He tried to remain composed. Imagine trying to spread cheer as your own life is being extinguished. Lying in an ER stretcher surrounded by people that you can't genuinely call friends... neighbors. He smiled indifferently..."what are you gonna do, right?"... I could see him trying to lighten the atmosphere..for their sakes. Maybe lighten is not the right word but numb... suffusing it with a novocaine to make this easier for us all to accept. After all, the realization of mortality had visited him long ago. The rotting teeth from focused radiation treatments, the patches of alopecia that dotted his scalp, the sallow cast that can only come from the ravages of cancer... He had known for weeks that things were rapidly deteriorating...that he was dying. Struggling to deal with his own plodding death while trying not to become a mire of pity. After all, no one wants to be around someone as they're dying...

Pity, sorrow, and a general melancholy seems to flow from people unconsciously around those marked for death. It stifles the human spirit when you're no longer a person with hopes and dreams. I wanted to call him several days later...What would I say? Maybe share a game of cards or a few minutes of idle chatter. Maybe have lunch. Over the years, doctors have become wary of crossing lines. Of HIPPA. Of impropriety. Of presuming and asking too much. Of human decency and emotion. Too often, we are the "sometimes friends"... willing to share a smile but never call on a rainy day.

certifying death.

i picked up the phone and sleepily punched in the numbers from the "Contact Info" tab on her electronic medical record. I paused for a moment and gulped. Heartburn. I felt the acid burn as it slid down my throat. Finally, the phone rang with an eery crackling in the background. A crackling that you can't help but notice at 3:30 in the morning. No matter how many times i do this, it never gets easier. "Hello..." A sleep-infused voice answered the line on the other end. It's always best to be direct and straight to the point. "Is this Mr. Peterson?" No matter how you broach it, an unfamiliar voice in the darkness that appears to know you, is always unsettling. "Yes... Who is this? What time is it?!?".

At this point I always, always, always apologize. It's the start of an apology that stretches beyond this chance telephone call and into the night. It stretches into the days following this tragedy, and sometimes longer than that. "I'm sorry to disturb you... this is Dr. Patel from the Hope Valley Emergency Department. Again, I'm sorry to wake you, but I'm calling about your mother, Mrs. Peterson". I usually offer a long pause and wait for a response. I hear "Oh my God! Is she okay? What happened?" Here the is always an instinctive pause. I steady myself and launch into a set narrative. "She was brought into the ER by paramedics. She had called 911 after complaining of indigestion that wouldn't go away. By the time they arrived with her, we were already set up to try and stabilize her. She had already lost consciousness." A cry or a wail usually interrupts me, but I typically press on. "When she arrived, we immediately began CPR and tried to get her heart to beat again. A breathing tube was placed to take the stress of breathing off her body and to get 100% oxygen to her. We used every medication we could to stimulate her heart. But..."

"Is she okay? How is she??!@?"

"She's passed..."

I let the words sink into the space between us. I again offer my apologies and assure the family that she felt no pain. I ask them to carefully drive to the ED so that we can talk in person and they can spend time with their loved one. I offer to call her primary care provider. I again ask them to drive carefully. When they arrive, it begins anew. More family arrives. I tell my story to a series of faces that have already stopped listening. I begin the tale again. I offer condolences. I try to explain... But the reality is that we almost never know. In the morning I will scrawl my signature into a death certificate. Proclaiming the time that another life was extinguished...

Death is always unexpected. And never welcome. And in its wake, families are left with a gaping wound in their lives. The grief, the shock, the despair. A hopelessness sets in as all of the words left unsaid come to mind. It's exhaustive to witness. I seize the moment and ask families to be strong. To use each other. To cry as a family and to support each other. I've always considered it a deep privilege to be with families as they begin this grieving process. To be the one to deliver this news, to inflict this pain, and then to try and desperately begin to heal these wounds...

Sometimes, the way we dignify the passing of a life seems more human than all that we do to try and save it...

The Striker.

Looking back now, I had just come on shift and I think I was looking for...well, for someone sicker. I came to work psyching myself up on Eminem's Eight Mile soundtrack. I began scanning the electronic patient tracking screen looking for the sickest patients. When the ER is busy, you look at the board, make a plan, sign up for patients, map out the rooms in your head, and calculate the most efficient route. There are no pit stops. No water coolers. No chit chat. No deviations from course. You go all in, right from the beginning...

You acclimate to walking through chaos - through patients wailing, moaning, and retching. I must've walked past his room several times. At the start of my shifts, I am always looking for an adrenaline rush. A 31 YO male with "multiple complaints" was not only uninteresting, but would likely sap the little motivation I tried so hard to build at the start of my shift. It wasn't until the third time I passed the room that I noticed that he was a pallid, young Hispanic male. It was 11 o'clock at night. His brow was heavily creased and more than worried, he looked nervous. In retrospect, the whole scene looked wrong. Furthermore, there are some age and ethnic patient permutations that we almost never see in the ER... and when you do, they're always bad.

I opened up his triage notes. These summary notes often help encapsulate a patient's major concerns - "Pt complains of leg swelling. Pt pale. Interpreter assisted nurse with triage. Alert and Oriented x 4. Pt ambulated to ED with c/o sore throat and was told he had infection in mouth. Pt also c/o dizziness, vomiting when eats, R knee swelling x1 month. Pt states went to clinic approximately 2 weeks ago while in Florida. Pt was given prescriptions for Benzonatate, Loratadine, Amoxicillin, and Ibuprofen." Sometimes these notes are really helpful and help cater the workup. Unfortunately, not his...

As I walked into his room, I sat down and introduced myself. I had barely sat down, and he spit out two words: "spanish interpreter". It was already a busy tonight. I already had four patients to see. I looked at him with a kind of exasperation, and said, "Okay but you'll have to wait..." and marched out. My Spanish is good. I ran past the nurse and told her to get the interpreter so we could begin. An hour later, I was back in the room and learned that he had progressive leg swelling for 3 weeks. He had a large, smooth fleshy mass along his distal thigh. We also ran through his dental pain and his prior visit to a clinic in Florida where he was prescribed antibiotics for a throat infection. The dental pain. Leg pain. Dizziness. Vomiting. None of this made any sense... The more I asked, the more symptoms he reported. Finally, I shut up and asked to examine him. When in doubt, look at the patient right? When he opened his mouth, I had a 'Kobayashi moment' (Note: Usual Suspects reference). His gums were an angry, raw red and immensely swollen. They seemed to swell around his teeth. The crevices between his teeth were caked with dried blood. He lifted his chin and I could feel the chains of lymph nodes like marbles under the skin of his neck. The hollow of his right collarbone felt like the striker, the largest marble, was neatly tucked into it for safe-keeping.

There are times when you want to say so much. Often however, it's when nothing you say matters. When you want to explain how you're sorry for circumstance. When you want someone to forgive you your indiscretions...a long wait, a callous demeanor, a skeptical glance. Unfortunately, these empathetic epiphanies only come on the heels of great tragedy. This wasn't gingivitis. He had cancer. Likely Acute Myeloid Leukemia. He was severely anemic. His platelet count was dangerously suppressed, which was why his gums were gushing with blood. The swelling on his leg was a large hematoma.

As I opened my mouth to explain in my broken Spanish, I stopped, and went off to find the interpreter. This was gonna be a long night...