Musings and Misadventures from the ER
“Bilateral is either normal or very very bad.”
“The most severe injury is under the unremoved clothes.”
“What’s it mean when you intubate? It means you care.”
“Despite all our advances in medicine we haven’t changed the death rate. It is still one per person”
Sometimes, the loudest sounds I hear in the emergency department are laughter. It may seem irresponsible. It may seem discordant. It may seem callous. To me, it is the sound of survival. It is the sound of resiliency. It is the sound of making it through the day.
My father was at work when he suddenly became cold, clammy, and collapsed to the ground unresponsive. His staff did the right thing and called 911. He was rushed by ambulance to the emergency department. He had vital signs taken, an EKG done, and blood work drawn. It was an experience that shook my family. My dad, on the other hand, was exasperated. He minimizes his health and upon arriving to the emergency department, was already scheming ways to get himself discharged. He had no such luck, and was ultimately admitted for further monitoring and testing. Today, he is back to his healthy self, and doing well.
I remember speaking with my father while he was in the emergency department. He commented, “All these people. Bunch of jokesters. Everything is a joke!” I could tell he appreciated it. He is not one for dramatics, and their sense of humor helped him get through that visit. It helped me too. It made me feel he was in familiar territory, that culture of humor that pervades all emergency departments across the nation.
It may seem like a strange place to hear laughter. But here is the thing. Working in the emergency department is more emotionally draining than I could ever have fathomed. No matter how high of spirits you are in when you walk in the door, the day will wear you down. You keep up your coat of armor; you navigate the fires, but inside, you feel yourself being broken down. It comes from all directions. It comes from the deepest sadness of sharing bad news with your patients. It comes from the confrontational situations you never wish you were in to begin with. It comes from the stress of hoping that everything is going to turn out okay in a way that will comfort your patients and their loved ones. It comes from the pressure of working fast, the responsibility of not missing any one thing, juggling too many tasks to count at one time. My words could never give that heavy pit in the stomach that follows us through the day true justice.
And so how do we cope? We laugh. We joke. We check in with one another through everyday banter to ensure that we are all still okay. It is the only lighthearted part of our days, and I assure you, we need it to get through. No day for us is a typical day. We are sharing in some of our patients’ lowest moments. We are here to provide support, to provide comfort, we are here to absorb it all, and ultimately, we find our own ways to release what we put on our shoulders. If we allowed ourselves to be consumed by our stress and our sadness from each moment, we just couldn’t come back and do what we do tomorrow.
So. I ask you. Please forgive us if our loud voices and laughter seem callous. Please know it is the opposite of that. It fuels our resiliency; it allows us to take care of the revolving door of patients coming in and out of our emergency department. It allows us to bounce back; it is our way to decompress and destress and face the next challenge of our days with the renewed energy and compassion that we need to get through today in the healthiest way possible.
“it’s everything I thought medicine would be, warts and all. We deal with some of the shittiest situations, and meanest people, and have to tough it out through some of the most heartbreaking situations…but we are the front line- we make the assessment, we come up with the Dx, the plan. We’re the ones who say “clear”, dim the lights & watch someone re-animate. We hold families hands when we tell them they didn’t make it. We -alone, oftentimes it seems- take care of the poor, the destitute, the disenfranchised. And we do it 24 hours a day, 7 days a week. It’s a sacrifice, but it’s also the real deal. We’re the ones with the amazing stories, the ones you want with you on that plane, on that expedition. We fight against the never-ending tide of human illness- illnesses as old as time, ravages of DM and CAD, trauma, flu epidemics, pandemics, just about anything and everything-and we meet it on the shore, ready for a fight. “
We play a contact form of medicine. It’s not for the weak or sensitive, and if you feel you need an “atta boy” or special name like “great sensitive healer”, well you just might be waiting for awhile.
Like they say, ” if you want sympathy, it’s between “shit” and “syphilis” in the dictionary.
“Life is a sexually transmitted terminal illness.”
Courtesy of Joe Lex
Siren in driveway
Two more devastated moms
Section C, page 5
“Two dudes smacked my head…
…What board? What collar? F**k you!!”
“Ten of Haldol, stat.”
“What meds do you take?”
“I takes a purple heart pill.”
“I drive a green car.”
and from others:
Way too much to drink
Ninety to nil, no more fun,
the wall always wins.
I am not quite sure
how I got it in there, Doc.
Just get it out now.
Ouch! Kicked in the head
Longhorns are very good moms
Defensive of calf
Young dude with back pain
Three ER visits today
More ibuprofen
Grandma tripped on cat
Left leg turned out quite badly
Hip replacement
I SAID, I just fell
I think I went unconscious
NO, I was NOT drunk
“Just two beers,” he said.
T-boned, “f*ck you, EMS”
No more erections
Another beautiful piece by CSC…
Benign presentation. Bounce back. Bad outcome. Dirty, filthy, infectious words we hear as ED docs. Our ears perk. Eyes widen. Was it our patient? What happened? What did I do? What didn’t I do? Common reactions for sure. As a former ED attending at an academic center and now as a medical director of both an ED and EMS department, I’ve reviewed an infinite number of cases. We are humans caring for other humans with man made interventions. Infallible we are not. Counseling the providers involved with outcomes unbecoming can be delicate, contentious, painful, and full of angst. Sometimes it involves a cup of coffee, a long chat following an even longer shift, and a lot of listening. Most often the doc just needs to talk out loud, think into the audible universe, in order to achieve some semblance of understanding. Occasionally it turns into a confession or painful acknowledgment with hopes for medical atonement. Other times we simply realize we can’t change it all, and the final common pathway of all things cellular truly is apoptosis. What does one do, however, when it becomes your case, your bounce back, your bad outcome? The labyrinth of self-assessment becomes convoluted, confusing, and pointless, so its best to offer it up to someone “above” you. A peer. An objective colleague.
She presented as did everyone else this month. Coughing, runny nose, hoarse voice, slight wheeze. No fever, but hx. of COPD and of sleep apnea. The usual and the mundane. Nebs, steroids, IV fluids. Labs including CBC/CMP/Cardiac Enzymes/BNP/VBG all normal. Chest X-ray normal. Symptoms significantly improved. Reassessments proved assuring. Coordinated outpatient care and clinic follow up. Antibiotics and steroids along with the life-saving cough suppressant. On to the next 20 patients in the waiting room. Kind face. Loving husband of nine months. Plans for holiday shopping this weekend.
It’s always subtle at first; the way the unknown comes hurling towards your hospital from the ether. The ED is quiet, and the fluorescent lights are gentle and groggy. Half way through your shift you realize you haven’t eaten anything all day. Where did the time go? You’ll grab one more patient and make your way to the weekend cafeteria choices. The day unfolding as it often does. Yet, when I walked into the hallway yesterday, there it was. A cluster. An amalgam of stunned, muted paramedics, surprised nursing staff, and an apneic patient on a gurney. EMS hadn’t even had time to call in a report because she tanked so fast. No bells or whistles, no code button. Just this vacuous silence of “what the hell just happened?”. It was a 911 call for shortness of breath which unfolded into the arrest before us. We moved the patient I was going to see into another room, and continued our efforts with our newest casualty.
King airway in place with a belligerent IV. Readjust, reassess, continue compressions, bag the tube. Belly swells. The bed rattles from the cardiac massage. It was there before us in her eyes… the raw, unmitigated, ghastly mask of mortality. Exchange the tube with DL and ETT. Place a central line. ACLS medications flowed like water, and saline stretched the venous capacitance. Non-shockable rhythms left us with marginal options. More meds, more thoughts, more discussion, more compressions. Then the recognition. The same, kind face. The same eyes. Registration confirms I saw her 6 days ago. Mind races. What did I miss? Pull the chart, rapid review. Everything normal last time. What happened?
“Yes, please give another Epi.”
“Pulse check….nothing. Continue compressions.”
“Any family around? Please bring them in if possible.”
“Let’s give another bicarb and another Atropine.”
No clues from family discussion. Week was uneventful. More compressions, more tests, more meds, some silent prayers. Cardiac US shows nothing. Outlook is grim. Family at bedside. TOD called. Debrief. Exhale.
I walk into the hallway. It’s quiet again. The department exploded. My partner just picked up six patients. I look at my watch. Ninety minutes of feckless, heart wrenching effort. I visit with the family. Grand baby is due next week. There are Christmas presents with the patient’s name on them under the tree. Tears. Confusion. More prayers. Chaplain. Justice of the Peace.
The ride home was longer than most. I walked myself through what normally happens when I sit down with another physician to discuss their case. I ran through algorithms of risk and etiologies. Parked the jeep in the driveway at home. I marveled at the Christmas lights around the neighborhood. Didn’t want to walk inside. Didn’t want to pretend I had a good day. Didn’t want to break up fighting children or cook dinner. Just wanted to melt into the Christmas backdrop.
We know it happens, and when we consider what our occupation entails the statistics are there. We will have a bad outcome. A death will be felt last by our hands. It somehow feels doubly painful though when you see them within the last week. It’s almost as if you failed twice. Somehow the cosmos granted you a do-over, but the outcome remained the same. The mulligan was wasted. Emergency Medicine is one of the most difficult, emotionally volatile, and spiritually rewarding jobs on the face of the planet. I ask myself if I would have chosen the same path all over again, and honestly, despite my best efforts and current self-awareness, I would have done nothing different. Despite the misery, the loss, the days you wish never existed….I would still put on my stethoscope and drive to a hospital to take care of Society’s unwanted. Some of us can’t leave EM not for any reason other than it’s our most definitive sense of purpose.
Everyone at some point will have to review a case of theirs which usually involves a director, a chairman, or a room full of providers dissecting your practice style and your thinking process. Know this….there is not a single person in your journey of discovery that has escaped the minefield that is medicine. Don’t feel alone or isolated. Don’t think less of yourself. You’re in good company. More often than not, the person discussing your case with you, experienced something eerily similar, and hopefully can provide some insight, some hope, and some emotional salve. The fact is, for those of us who are responsible for medical oversight and quality we often have to look no further than the mirror for reference. -csc
Stethoscope Nunchucks 