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...