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...