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...

an atmospheric discharge of electricity...

i woke up at 4:30 last Sunday morning to a nervous jittering in my chest. At first, i thought i couldn't hit the snooze button on my iphone. Then i realized that i was just nervous. As i shuffled into the shower, i groaned at the thought of today's ridiculous task. 13.1 miles loomed in the dark. Needles to say, our training had been piss poor. i had run about 7 miles the week before (the longest run of my life to date) and Deepti had cleared the 9 mile marker about the same time. The prospect of running nearly twice that distance was disconcerting, to say the least. Left to our own devices, we had gotten a late start in to our training routine. Completion of the race seemed an aggressive goal at best, and a horribly foolish & irresponsible endeavor at worst. Still though, we had paid our dues, gotten our race packets, and committed to finishing even if we found ourselves crawling over the finish line and gasping for breath. In addition, Deepti's unflinching passion for the run fueled me through the morning. Really, she was stronger than I was when it came to these things. We chomped down a few homemade Lara bars, carefully counted out the change we needed for MARTA, and headed down to the station to catch the train to Centennial Park. As we walked down the street, people seemed to emerge from every Midtown street corner and descend upon the station. Inside, we found a swirling mass, studded with Nike swooshes & water bottles, seeming to stretch forever along the MARTA platform. It took me a few minutes to overcome the irony of a crowd of runners waiting on a train, to begin a collective run...

When we got off at downtown, we found ourselves floating in a crowd that poured out of the station. At 6:30am the sky was still dark, angry about the commotion on a sleepy Sunday morning. The air was charged, as a mass of thin, young runners in shorts, polyester shirts, and hydration packs descended on the park. I remember imagining that this was the stratosphere before a storm... a blistering group of positive & negative charges ready to erupt in a miracle of physics.

As the fog of the morning burned away, we made our way to our starting corral. We were in O, the next to last group due to our lackluster projected finish times. We passed through throngs of limber runners stretching, breathing, hopping and jumping to prepare themselves for the race. When the race began, we jogged in staccato fashion for a long time before we finally arrived at the start line. As we ran over the threshold to start the race, a weight lifted from my shoulders. We had made it here. Now all we had to do was run...

The race wound through the city - a rainy-day urban tour of Five Points, Midtown, the 4th Ward, Little Five, the Virginia Highlands, Piedmont Park, the Georgia Tech campus, finally circling back to Centennial Park. People came out from their respective neighborhoods... A deep thanks to all who stood on their street corners and stoops to cheer us on in the rain. In retrospect I'd say the first 9 miles flew by as we ran - A team of 10,000 strong running down the city's rainy streets seemed like more than enough motivation for a race. But then you start to get tired. I tried a flurry of mental gymnastics to distract myself from the mounting fatigue. I imagined running with the bulls in Spain. I imagined the breath of the six angry bulls on my neck. I imagined running from police, framed for a murder I didn't commit. I flashed back to Tom Hanks running with a smiley-faced hand towel tucked in his shorts. At first, these thoughts were enough to push through fleeting moments of fatigue. But, as the race wore on, my poor conditioning bled through. After the adrenaline was all spent, all you had left were the fumes of motivation and the wavering commitment to yourself to finish what you set out to do. Perhaps we could walk a mile or two? I splashed Gatorade across my face at each stop and pushed forward. My knees felt like I had driven rusty nails into the joints. I felt the tetanus spreading through the joint and then into my body. My hand spasmed as I tried to find a better song on my iPod. During the 11th mile, I remember thinking that my shins were shattering with every step. I wondered how long I would have to take off from work if I sustained bilateral tibial plateau fractures. Would my disability kick in? I chuckled. Of course it wouldn't... So I ran harder...

The last mile was an endless stretch of asphalt that seemed to go on forever. The half marathon and full marathon courses had come together at this point, but remain separated by a thin barrier. I still couldn't make out the finish line. As I pressed on, a thin black shadow of a man raced past me along the other side of the barrier. He had run the full marathon and in these final moments, he effortlessly passed me, eyes focused on an imaginary horizon. I pushed harder. When I crossed the line I looked up and saw the green glow of numbers. 2:22:05. Deepti ran into my arms a few second later. For a few brief seconds, there was no pain, no emotion, only a tremendous relief. We had finished this crazy adventure together. As I took my first steps after the race, my joints screamed in agony. I hobbled along as we ran into friends that had already finished. I grabbed a water, a banana, a bagel and a gogurt. I took a deep drag on the crisp, clean air. Thanks to Mr Jynocel Basweti who sped past me to finish the full marathon in 2:20:49. Yeah. Pretty ridiculous. But thanks most of all to my wife... we really are just two crazy souls tumbling together through this thing called life...

We came home, showered, slept for an hour, and ate at Chipotle. Then, I put on my scrubs, grabbed a bottle of water, took 800mg of ibuprofen, and drove to the ER for another 10 hours of guts and glory... rain or shine...

the ultimate reality series...

This ranks as one of the best decisions I've ever made. As I've cut myself off from the saccharine life of syndicated television, the mystery and frailty of everyday life comes into view. While we allow ourselves internet access, cutting cable (henceforth referred to as "disconnecting") has taken away the background noise to life... the lifeless soundtrack prepared by Hollywood moguls that dulls the senses and lulls you into a state of perpetual sleep.

I come home. I'm worn out from another grueling twelve hour shift. I take notice of the silence at home. I breathe it in and within a few moments, my head clears. I'm too tired to sleep. Too awake to work on taxes. I collapse on the couch and almost on cue, my mind begins to replay the faces I've encountered over the last week. Like watching television in my head. Emergency medicine, after all, is the ultimate reality series... Each night, I shuffle in and out of rooms, peering into the lives of strangers. A 22 YO girl comes in searching for help in finalizing a divorce. I walk into the room and find her waving a swollen finger in the air. She said that after signing her divorce papers last night, she forgot to take her wedding ring off when she went to sleep. She woke up to find her ring finger swollen. She wasn't sure if it was a sign of her own ambivalence...It looked like an angry, painful silent protest on the part of her finger. We got the ring cutter, however, and made quick work of it...

Another room presents with a young man who arrived by ambulance unable to breathe. I walked in to find a gurgling man drowning in himself. As I reached for the oxygen mask, I called for the respiratory therapist to suction him. His wife reported that he had recently been diagnosed with Amyotrophic Lateral Sclerosis. ALS is a disease of the motor neurons, the circuits of the body that carry electrical impulses to animate the limbs. Over time, the neurons shrivel & wither, fading away and leaving lifeless muscles to atrophy. It's a progressive, fatal disease and one that incapacitates the body in a particularly cruel way. You steadily lose the voluntary control of your arms and legs. He was already unable to walk. He was losing the ability to feed himself. However, in the majority of cases, the disease preserves a patient's mind, personality, and cognitive function. It spares your senses leaving you able to see every trip to the hospital, forcing you to smell the vinyl of the ambulance, to hear the screaming ambulance siren, and to to feel every needle stick. Mr. B's breathing had become precarious over the last week. As we began to treat his respiratory distress, I ran through my familiar battery of questions. In addition to ALS, Mr. B also had Chronic Obstructive Pulmonary Disease (COPD) from smoking for thirty years. "Of course, he's not smoking now" I remarked. "He tries", admitted his wife, "but it's hard you know..." As her words sunk in, I shook my head and walked away. Later, as I looked at his chest xray, I stood still in amazement. A large, bright, spiculated mass in the center of his chest seemed to wrap itself around his left mainstem bronchus, the largest airway that carries oxygen into the left lung. It looked terrible. As I explained to her and her son that he would need to be admitted and that he may have lung cancer, I saw tears welling up in her eyes. I reassured her that we had some of the very best physicians and that they would guide her husband through every step. She asked again about whether the smoking had anything to do with it. I half imagined an open pack of Lucky Strikes in her pocket. Everyone stops smoking eventually...

Next up was a 28 YO man with severe vomiting. He said he began vomiting after eating a "double chubby decker" from a local restaurant. Seriously. A double chubby decker. It turns out, that after eating this monstrosity, he went on to a cookout and tried to help himself to a heaping plate of barbecue. What are we coming to? He said he immediately became nauseous, and within minutes, began vomiting. He thought he was vomiting up pieces of his stomach. He was panicked and complaining of severe abdominal cramping. I stopped laughing after I looked up at the monitor and saw his heart rate of 126 and his blood pressure in the 90s. I asked him to point to where the pain was with one finger, and he pointed squarely at his epigastric region. I pressed, and he howled in pain. I immediately put on a glove and asked him to roll over. As I pulled my finger out, I saw the characteristic tarry, black coating. Melena, is caused by oxidation of the iron in red blood cells as they are digested through the gastrointestinal tract. He had a bleeding ulcer. I told him that while I wasn't sure if the burger was involved, that he was gonna have to hold off on eating for a while...

The next few rooms brought familiar chief complaints. A circus of midnight marauders with bruises, dancing drunkards with joint injuries and hangovers, and chronic pain patients that always seem to run out of pain medications when their doctors go on vacation. Sometimes, I get tired of looking for needles in haystacks...

Finally, I walked into the room of a 34 YO who came in by ambulance for nausea and vomiting. She was from out of town, and was accompanied by a friend. She was only in town on business and from the Southwest. She had no medical problems, didn't smoke, and didn't take any medications. While she was in Atlanta, she had been eating out nearly every night. She said she woke up and started brushing her teeth and then became intensely nauseous. As I began to talk to her about the many causes of vomiting, I asked if she had eaten anything unusual. A double chubby decker perhaps? She didn't laugh. She explained that she had a left-sided head pressure and she never got headaches. She also felt like she was falling. I wasn't surprised by her normal neurologic exam. Or by the normal CT scan of her head. After all, I see this all the time. Young patients with atypical neurologic complaints and headaches that never seem to quite fit together with a proper neurologic deficit... Roads that lead nowhere fast. But, something did bother me...

When I re-examined her, I had her sit with her eyes closed. And in the silence, she began at first to lean to her left, and then fall to that side. This was a bad sign. She denied feeling dizzy, but just felt "off balance". I put a call out to neurology and explained that I needed to order another test. I never order MRIs in the ER and when I do, it's always bad news. As I ordered the MRI, I wondered if the very act of ordering this test meant that she would suffer some inexplicable malady. Ultimately, I fought away the superstition and moved on. Besides, something was clearly wrong. Maybe it was that she was only in town on business - she wouldn't be in the ER unless something was really wrong. Maybe it was 'the falling with her eyes closed' - a sitting Romberg test, that's a hard, subtle thing to fake. Maybe it was the words "off-balance" that kept echoing in my head. Regardless, with a few quick strokes, I ordered an MRI of her head and an MRA of her neck vessels. When I got the call from radiology a few hours later, I had already moved through a dozen patients. "What's up with this 34 year old getting an MRI?" I told him that maybe it was just a bad hunch, but she had a constellation of signs that were worrisome. It turned out that she had suffered a stroke in the cerebellum, the area of the brain that controlled coordination and balance. In addition, the study of her neck vessels revealed that the cause of this infarction was a dissection of her vertebral artery. 34 years old. No medical history. Nonsmoker.No neck trauma. No judo. No spinal manipulation. No nose blowing. No nothing.
The words cerebellar infarct just didn't belong there...
Please...No more MRIs.

i'm proud to say that I'm running harder than ever before. As the mileage mounts, it's exhilarating to see progress in such tangible levels. Our endurance has lengthened and our drive sharpened. While our first race is only days away, and our training regiment got a late start, we will finish this race. This is only the first race, but we will finish. i only wish we had disconnected sooner. After all, when you finally take notice, life is such a privilege...

its hard to stay healthy...

The health care reform movement appears to be stalling, choking on the unfortunately, partisan politics of Washington. And even as we debate the merits of providing millions of Americans with some basal level of healthcare coverage, another busy night in a crowded urban ER passes. Yesterday, as wait times soared, patients became increasingly restless. We announced that we were working as hard as we could to deal with the heavy volumes but that bought us little sympathy. I went out to the waiting room to try and see a few people that already had studies done. I called on a young man with abdominal pain, rectal bleeding, and hematemesis (vomiting blood), who had already had his bloodwork resulted. He had completely normal labs. I sat him in a triage bay, pulled a curtain, and said, Mr. C, "things look great!" He looked perplexed, but undetermined, I talked through his confusion. I had brought a copy of his labs and explained that his blood counts, kidney function, liver function, and all of his electrolytes were within normal limits. All I needed to do was a rectal exam to ensure that he did not, in fact, have active rectal bleeding. He asked about waiting to be seen in a proper room. I carefully drew the curtain back and pointed to a waiting room spilling over with patients. I didn't have to say another word. He bent over, dropped his shorts, and we proceeded. Sure enough, brown stool that had no occult blood. A few minutes later, with a prescription and a work note, he was on his way... Another life saved.

The night wore on without excitement. A nervous, young girl whose arm had fallen out of it's socket (shoulder dislocation). A paraplegic with a finger abscess (paronychia). A few elderly women, whose meager fixed-income diets of bread and canned soup had led to intractable cases of severe constipation (obstipation). Before I knew it, the night was over. On my way home, i listened intently to NPR as a primary care doctor who was being interviewed made a remarkably salient statement. "We don't have a healthcare system... We have a sick care system." How wonderfully succinct and to the point. Modern medicine really has evolved into an organized, parasitic field predominantly feeding off the disease and disability of the human body. After all, there is so little incentive in staying healthy. No colonoscopies or CAT scans. No MRIs. No dialysis or coronary artery bypass grafting. No chemotherapy. No cartloads of pharmaceuticals. No paid time off. No disability benefits. In a capitalistic society, there is no money in staying healthy... Instead, we continue to overeat, exercise less, work more, and drive our bodies to exhaustion. As our bodies crumble under the unfortunate rigors of our lives, we find ourselves weighing the purchase of our monthly pharmaceuticals against the purchase of fresh local, organic produce or renewable energies. And all the while, we become obsessed at a younger and younger age with cycles of disease and treatment. A 24 YO woman with recurrent miscarriages presented with vaginal bleeding. She was in the produce isle of the supermarket and began "gushing" blood. She was emotional and through tears streaming down her face, she mumbled "I saw bloody baby...i saw baby parts. an arm. a leg." Over and over during the course of her evaluation, she remained convinced of another miscarriage. After a thorough evaluation, I found that in fact, she had a health baby and that she had not miscarried. As I went through her medical history I asked, "Do you have any medical problems?" She replied with a list of a dozen including everything from arthritis and attention-deficit disorder to fibromyalgia. She read the incredulous look on my face and offered up, "i know its a lot, but it's hard to know which ones are real..." More confused, I had to ask, "i'm sorry? But what do you mean, which ones are real. Did you see a doctor for these issues?" She beamed like a scout with a new merit badge and stated, "I saw several doctors. Eventually, they told me that my mom had Munchausen's by proxy, so its hard to know..."

the mondays...

It is a universal truth that Monday is the absolute worst day of the week to present to an emergency department. Somehow, the gravitational forces of the universe align to draw the maximal number of people into an already overcrowded waiting room. And yes, everyone in the waiting room happens to be sicker than you are. In fact, I often tell patients that a long wait is a good sign in my line of work. It likely means that your vitals signs are stable and that you have a statistically lower chance of dying. If you have the misfortune of coming in on a Monday night, and you're brought straight back to a room, it's time to start worrying...

Last night was no different. I came in to a department in shambles. The wait times were up to 7 hours with no end in sight. Patients streamed into a crowded waiting room filled with patients too sick to be angry. A few patients at a time kept coming up to the desk, glaring at the triage nurses, and walking away. Welcome to Monday night. I wasted little time. I plucked a blank sheet of paper from the printer, folded it into fourths, whipped out my pen, and went to work...

Everyone comes to the ER wanting something. Pain medicine. Reassurance. Testing. Hand-holding. Some come to make sure they're okay. Others come because they're already sure they aren't okay, and want me to confirm it. Some come for pity. Attention. Others are more pragmatic with their needs. Antibiotics. Medication refills. Work excuses. Disability paperwork. Documentation for frivolous lawsuits. But often, I run into good, honest people that just come to be heard... People that have asked themselves why bad things happen to good people. And as I sit and listen to them, I lose myself in their lives. Life is, after all, a mystery. People, yes even good people, happen upon bad things...

I looked at the board. I groaned. Chest Pain. Chest Pain. Abdominal Pain. The next chief complaint read four letters: "SICK." I walked to the far corner of the ER to room 36 and was surprised to find a pleasant, smiling 61 YO woman sitting calmly with her daughter. She appeared comfortable and in no visible distress. Knowing that she had already been waiting for 3 hours, I walked in, summarily apologized for the wait, washed my hands, and shook hands with her and her daughter. I introduced myself and quickly sat down. She explained that she had a lump in her breast. When I asked when this started, she said "Days." I sat still. Silence often forces reconsideration. After a few seconds, she contemplated, and then nonchalantly filled in, "Well, maybe it's been longer..." It was a more decided tone. "Several months..."

"What changed that made you come in today?" She explained that over the last few days, the underwire of her bra had irritated the breast tissue and that there was an area that was draining. Again she corrected. "Maybe a few areas." As I lifted her gown, I explained that we should probably just take a look to see-

The breast was an angry, red mass of tissue with mutiple areas of ulceration and drainage. I placed my hand to her chest and felt her breast - a sack of smooth stones beneath a thick rind of skin. "Peau d'orange" skin. The ominous French term referring to the dimpled appearance of a breast inflicted with inflammatory breast cancer. This was bad. So bad I didn't need to be an Oncologist. It looked locally invasive. Her daughter, nervous, looked over in a state of horror. Her mouth opened and the words seemed to die in her throat. She was awe struck, and fought back tears as she stood behind her mother. She looked away. I looked up at her as she let out, "She never told us... she never said anything... she never even complains..." The next 2 hours were filled with labs, IV antibiotics for infection of the tissue, and discussions about the possibilities - discussions about cancer. What lay in store for her was a dizzying array of outpatient testing: mammography, core biopsies, CT scans of the chest, abdomen, and pelvis, CT PET imaging, Node sampling. I don't know how much either registered after the word cancer. I promised that I would order some of the necessary CT scans to expedite her workup and get things moving.

Minutes later, I got a call from the radiologist asking why this patient needed multiple CT scans. He academically explained that a malignancy workup should be done as an outpatient, that she didn't need this done in the middle of the night, especially by an overworked radiologist. I offered up that patients in the ER often come in after neglecting issues for a long time and may not follow up as instructed. He pleaded that he was already so far behind with ER studies. He knew too, that I was far behind. "Don't you guys have a long wait already?" Painful, but true. He was right. A long ER wait on a Monday night is not just a possibility, but a certainty. In the end, he swayed me...

I held off on discussions of neo-adjuvant therapy, radiation, chemotherapy, and possible salvage mastectomy. Instead, I gave her a dose of IV antibiotics and a prescription for Bactrim. I gave her the name of several of our top oncologists and surgeons and tried to reinforce that she needed immediate follow up. I discharged her and kept moving through the Monday night traffic. By the end of the shift, I was irate. Perhaps I was angry with not doing what I thought was right. Perhaps I was angry for not doing what I wanted. After all, I hate being told what to do. I mean, if it was my mother in Room 36, would I have let her walk out the door after 6 hours with only a script for antibiotics? As I drove home, I kept asking myself when doctors stopped being doctors...

The next day I woke up and thought to myself, maybe the radiologist was right. I was getting to attached. What sense would it make to keep her in the ER for another 4 hours getting these tests? I mean, after all, you really can't do this job without a certain level of detachment. A certain objectivity. She would get the studies she needed and she would follow up as we discussed. Of course she would. As I got to work the next morning, I sleepily dialed her phone number to follow up with her. I wanted to find out who she was planning on seeing, and what plans she had already made. Mondays can be so painful. I was still recovering from last night's shift and didn't even register when the automated voice clicked in... "We're sorry. You have reached a number that has been disconnected or is no longer in service. If you feel you have reached this number in error, please try again." Please try again...

Post Cable Day #2... death & rebirth

i worked last night after nearly a week off... Even after the span of merely a week, you need to see a few tough patients to shake the dust off. Fortunately for me, a familiar barrage of patients with inexplicably chronic abdominal pain, gastroparesis, and chronic pancreatitis flooded in to help sharpen my clinical acumen and test my resolve. In the midst of wading through them, i heard the secretary's shrill voice, "we need a doc to room 18"... i was called to a narrow exam room with a morbidly obese, elderly woman being wheeled in by EMS after a sudden cardaic arrest. She had just completed an outpatient CT scan of her chest and abdomen. In fact, she had been transported to the hospital, completed the scan, and was being loaded back into the ambulance when she suddenly stopped breathing. I rushed to the room, yelled for the story, and called upon the ACLS algorithm - monitor, pads, IV, IV fluids, Epinephrine, and most importantly, more help...

The paramedics explained that she had come from a nursing home for this study, and that she had "looked great" just a few minutes ago. I was irritated. Everyone looks great in the moments before they arrest. Ultimately, they said they were only transporting her and knew nothing about her. She lay there with eyes already glossy and a large, thick mass of tongue half-protruding from her mouth. Her chin was swimming in the girth of her neck. Fortunately for me, she already had a tracheostomy, a hole carved neatly through the midline of the neck into the trachea, allowing patients to be ventilated using a machine. As we initiated the code, we flooded her body with medications: Epinephrine, Vasopressin, Calcium Chloride, Sodium Bicarbonate... I thought about the irony of instilling her with preservatives to stave off death. As my mind raced through the potential reversible causes, I took her in... I remembered her from months earlier, a jovial woman presenting with a chronic cough and breathlessness. She had come into the ER one night after getting her hair done, tight bands of white corn rows laced to her scalp. I remembered a deep, smoldering smile. Tonight, her corn rows were lines of unravelling, wild fibers, her chest exposed, being thumped with compressions, her generous abdomen spilling over the stretcher. She lay motionless and still. Her face came to look like so many of the faces I had already seen, vacant, where the flicker of life was already extinguished.

Her body habitus made it hard to find a reliable pulse. At first, she responded to our heroics. I used a doppler to confirm a distal pulse. At about 20 minutes, we regained a reliable pulse with a very low blood pressure and initiated vasopressors, medications to force the heart to beat harder and push more blood around the body's vital organs... As in many aspects of life, pushing things uphill only gets you so far... Simultaneously, i asked one of the nurses to pull up her CAT scan. The scan showed a body riddled with cancer and effusions, collections of fluid in every possible body cavity - her very organs weeping from her cancer. As I turned back to face her, we lost her pulse, and again resumed CPR. We continued on for nearly 40 minutes to no avail. Finally, I stepped out of the room and told her daughter what she already knew. Her mother had said goodbye... i couldn't help but think that she wanted to show us all, family and physicians, how far her cancer had spread... so there would be no lingering doubt, when she finally said farewell...

i called her primary care provider who was stuck with disbelief. i hung up with his voice echoing in my head, "she was doing so well...".

i came home spent and went straight to sleep. This morning, i fished out the bottle of generic vitamins I bought a few weeks ago and never opened. I popped one in my mouth and chased it with a glass of water. I took our dog to the dog park. I've been listening to music again. And to NPR. And finally, after a long hiatus, last night I started reading again...

its hard to fight a fundamental principle of classical physics...

I woke up this morning still tired, sleepy, and unable to shrug off the weight of the upcoming day. As I muddled my way through another day, I hit the familiar morning milestones and readied myself. I walked into the kitchen and rummaged through the fridge only to come across some leftover pancakes from the Social House. Light, airy, blueberry cakes that went straight into the microwave. Instinctively, my hand began to fidget and twitch, searching for the television remote. I hadn't watched television in several hours and I could feel the familiar symptoms of withdrawal, the outcome of the physical and psychological dependance. It was here, at this pivotal juncture in my life, on a Wednesday morning, with a half-eaten pancake in my mouth, that I realized the inertia of this morning routine. As the television flickered into existence, my eyes began to gloss over. I felt my hand relax...the drug worked. How many more mornings would be devoured in this fashion - lost to a mindless circus of images and poor dialogue. How much more of this mindless banter could I endure. I called DirecTV, the pushers of this profane programming, and requested a cancellation. They knew that my contract had expired and they threw incentive after incentive. How about a DVR? How about additional channels? How about paying a little less for the programming that is already ruining your life? After 45 minutes on the phone, and being passed around among several service representatives strewn somewhere across Southeast Asia, I achieved victory. The cable has been canceled... And with that, this first blog post is born. D, i love you terribly, and I know you'll see the wisdom in this. After all, i woke up this morning. For an ER doc, that's a start isn't it?