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?