Laughter? That’s the sound of resiliency you hear.

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.

Advertisements

“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. “

Contact Medicine

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.

Trauma Haiku’s

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

Bounce Back

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

Ode to the Frequent Flyer

Ode to the Frequent Flier

Wryly eyes glare sneakingly
crost rooms, and halls, and doorways
Ne’er-do-well, pray do tell
What dark intent doth you bring?

Slither, slip around and under
Stony hearts and minds.
Nay, they soft, naive, aloft
The souls you seek to plunder.

Seek ye roiled poppies spew
A limp, a gimp, a forc’ed tear
Marked and meek, a gilded speak
From whence you’ve come, a rock or pew?

Be gone, be wary, I know thee well
No saint be you, forsaken
Legions o’ visits, archives exquisite
Whilst parlay yourn demented spell

Hippocrates bequeathed to me
One solemn oath non asunder
Yet there ye be, hypocrisy
Obliged we be, and ne’er be free

So we dance; thorny, epithets adorned
Fencing to, aback, and fro
‘Tis time you leave, so frantically?
Aye my flier, there’s the door.

-CSC

Medicine and the Bodhi Tree

Medicine and the Bodhi Tree

By Dr. Tae Kim

Once in a while, somebody will tell me that I have such a nice bedside manner, and for a long time I’d receive that kind of approval with a wince. I was mortified by the praise people gave me, and honestly, more than a little gratified too, because it really felt good to have nice things said about me, but mortified because that night, the one I’m writing about now, that night was a night of abject, miserable failure.

I was on another overnight shift as a senior resident, this time at the university hospital we worked the other part of the year. It was probably a Monday, since the beginning and end of the week tend to be the busiest, although nowadays it seems like every day is busier than the last, and the emergency department was in normal condition, that is to say totally FUBAR’d – ambulance gurneys lined the hallways holding patients in street-clothes, in house-robes, drunks in restraints, the paramedics who had brought them chatting with each other while waiting to be told what bed to take their charge to, the firemen’s yellow jackets smelling faintly of smoke.

Since I was the senior resident on duty, I had the responsibility of the entire department, with nurses pulling at me from all sides, medication needs, test results, consultant problems, new patients. Every time I’d leave the desk to go to a patient’s bed, to the x-ray room, to the bathroom, a crowd of RNs would swarm behind me – picture a deer followed by a pack of wolves, a pack of wolves wearing scrubs and holding clipboards.  One nurse told me that there was a new patient in Bed 1, an 18 year old girl who had chest pain and a high heart rate. Yet another patient.

Every time another nurse popped up with a question or request I’d frantically fire off the first thing that came to mind while I moved on to deal with the next one. I asked the nurse for Bed 1 to get an EKG and told him I’d be there shortly – I was relieved that he seemed satisfied with having something to do, which would hopefully buy me enough time to attend to yet another high priority. But just minutes later he handed me the patient’s EKG, which showed a heart rate of 135 – that really was fast. Not too fast, but faster than it should have been.

I finally made it to the patient’s bedside – the nurse had told me that she’d been complaining of crampy chest pain while out line dancing. What an odd detail to add, that she had been line dancing, apropos of nothing. The girl was sitting up in the gurney, her eyes squeezed shut against the pain. She was pretty? I don’t remember. She seemed young. Dressed to go out. Perhaps I should stick with the details I received in her autopsy, later: “this is the nude body of a well-developed, well-nourished young adult female appearing consistent with the stated age of 18 years. The length is 165 cm, the weight is 62 kg. The hair is black, the eyes are brown, and the complexion is fair. The body is not embalmed. Across the right medial ankle is a small tattoo of a heart. The finger nails are painted red.” I was able to get out, “I’m Dr. Kim, do you have chest pain?” She replied, “my chest hurts,” when she had a seizure.

On t.v., when actors have seizures their eyes kinda roll back and their limbs start sort of flopping around, and that’s how you know that it’s supposed to be a seizure. In real life, though, it’s the most uncanny, unnerving thing, it’s inhuman – her eyes were still open, but they looked like they’d lost the animus behind them, the rational personality who had until then been a girl out with her friends just disappeared, and all that was left was a machine, an automaton in the shape of a human being but without human thought or feeling. Her head twisted to the left, her eyes open, staring at nothing. Her mouth twisted and foamed. Her limbs involuntarily contracted, shook in a way that is impossible to do consciously, a marionette with its strings twisted, and then dropped down when she fell back in to the gurney, unresponsive, gurgling noises coming from her throat. Putting the head of the bed down, I pled for the nurse to get an attending physician, quick – I figured they might want to know that I was intubating someone – that is, putting someone on a ventilator.

Dustin, who was chief resident when I was an intern, and was now an attending, materialized at the bedside.

Before we intubated, the girl had another seizure. We let it pass, and then put her on the vent. Things spiraled. Her blood pressure started dropping precipitously. The patient’s friends and father arrived, and it turned out that her mother had died the year before from a brain aneurysm – the patient was the only family member her father had left. Dustin and I had a rapid-fire discussion about what the patient could be suffering from, while ordering IV fluids and medicines, our arms crossed, faces tight. “What do you think it is?” “Bolus one liter, start a second line and start another bolus in that one.” “All I got was chest pain while line dancing, tachycardia, then this.” “Is her sat dropping? Can someone fix the pulse ox?” “Pneumothorax? Doesn’t seem the type. Chest x-ray’s cooking.” “Can someone please start the fluids? Call blood bank – O neg.” “Tamponade?  No history. MI? Unlikely. Aorta? She doesn’t look Marfanoid. No history.”

We placed large intravenous catheters and resuscitated the patient – she went into cardiac arrest several times, and we kept bringing her heart back, the number of techs and nurses in the room growing, frantically performing CPR, calling out orders, voices strained. It’s always hard when someone’s dying, tougher still when she’s so young, and even more difficult still when she’s the only child of a widowed father standing in the hallway, standing quietly, alone, head down, arms crossed.

During one of the episodes of arrest we discovered that she was, curiously, bleeding inside of her chest. It’s often common procedure in these resuscitations to “needle the chest,” that is, place large catheters in the chest wall to relieve pressure that builds up inside the thorax. I sloshed maroon-colored iodine solution just under her collarbones and slid the needles in place, first on the left side, then on the right – what the fuck? Blood started fountaining out of the right needle, a freshet pulsing out of the catheter with every chest compression. I placed two chest tubes to drain the blood. The presence of that amount of bleeding inside the chest can actually prevent proper circulation, and part of the treatment is to drain the fluid off. The blood drained… and drained… and drained. The girl had already received several transfusions, and we started transfusing back the blood coming out of her chest, and it was clear that she was bleeding to death.

We called the chest surgeons who we learned were in the middle of a thirteen-hour heart transplant and therefore unable to take this patient to the OR – she was too unstable to be taken anywhere anyway, and anything resuscitative would have to be done in the emergency department. The girl kept going into cardiac arrest, had done so five or six times already, and opening her chest in the ER to stop the bleeding was probably futile, but come on – she was 18. Her father alone… You could feel a raw, anxious energy in the room, everyone felt helpless but we had to do something, everything, anything. But without someone to take her to the OR afterwards, there’d be no point to trying to stabilize her in the ER. Dustin called the trauma attending, Dr. O – as a trauma surgeon he’d be the only other doc in the hospital who would routinely know what to do with a cracked chest. An older Irish man, with a thick accent, he was infamous for being so compulsive that he’d often round until midnight, unheard of for a surgeon, but someone totally committed, so committed that he agreed to come in for this patient, appearing at the bedside when I had the knife poised above the girl’s skin.

We cracked opened her chest, first the right side, then extending the incision to the left, opening the chest to access the organs. Scalpel on skin, curvilinear incision, straight through yellow fat, down to muscle. Scissors in thorax, gloved finger guiding, zip through the intercostals. Weighty stainless steel rib retractors, wedged in placed, cranked open. So strange – for a young, otherwise healthy woman, the body would be a secret, the breasts an intimacy hidden from the view of strangers like us, but in the moment, there was nothing particular about her chest, just that we had to open it. It’s funny – I don’t remember much of what her face looked like, but I remember in intimate detail her thoracic cavity, the surfaces glistening with pleura, the individual articulated spinous bodies, her spongy, pink lungs, and everywhere, everywhere, blood, a rising tide of blood that we would suction away only to have it fill right back, ebb and flow. It was like something had exploded in there.

Her heart was flat. Imagine, if you would, the heart roughly like a water balloon, one that actually pumps blood around the body, so it expands, contracts, expands, contracts, but it’s always got something in it, a water balloon made of muscle. Her heart, however, was an empty balloon, nothing in it, all of the blood that was supposed to be filling it seeping in to her chest cavity instead. Her heart was a flat meat balloon. Blood, or at least what was now pinkish tinged fluid having been diluted with all of the fluid we had tried to replace it with, kept welling up from somewhere, more blood than anyone in the room had ever seen come out of a chest, blood from nothing that we could clamp off and prevent her death, and we were at a loss, Dr. O turned to me and stripping off his gloves said, “well, Tae,” in his thick Irish accent, “I tink we’ve dun all we can,” and we called it, my arms were up to the elbows in her thorax, blood was everywhere, and it was done. Later, we’d learn from the autopsy that she’d died from a thoracic aortic dissection, the same thing that later killed John Ritter, rare, unusual, a unicorn of a diagnosis, especially for someone so young.

We covered her up. You may think it’s a cliché, but we really do use a white sheet. I remember Dustin talking to her father in the hallway, the man quietly listening to the news. Dustin found me at the desk, “hey man, here’s the key to my office. There’s some caffeine in the fridge, take some time for yourself.” Okay – wow, that was some traumatizing shit, that’s a good idea. I sat in his office by myself – okay, I’m processing things, that was kind of horrifying, but I’m okay… no, really, I think I’m okay. I’m sitting in Dustin’s comfortably padded office chair, staring at the white door. I can hear housekeeping vacuuming the floor down the hallway. There is a fake potted plant in the corner. There are pictures of Dustin on various trips abroad lining the shelves. My right hand, wrapped around a can of soda, is starting to feel cold and numb. All that comes to mind is the stack of fresh charts piling up in the rack, patients waiting to be seen.

I forced myself to sit there for a full five minutes, checking my internal state to make sure – no, I’m okay. I’m alright. I quickly dictated a note, and then got back out into the ER, spending the rest of the night taking care of the patients who’d waited while we treated the girl.

Things never slowed down that night. Trotting back and forth, I kept spying in on room 1, where the girl’s father was sitting by her bedside, quiet, back turned to the door. He sat there the rest of the night. With all of the hubbub gone, I could finally see him. Brown hair, medium length. Jeans, denim shirt. His face was sad, thoughtful. I moved on to the next patient.

I have difficulty gauging how long to make eye contact when I talk to people. Fact. I’ve realized that I’m either always glancing away, or that I’m suddenly staring straight in to the other person’s eyes, and it’s only when I start noticing their discomfort that I catch on. There’s more: between, I think, 1984 or so and 1992, I could name every single car sold in the U.S. by make and model, name their fuel type, engines available, displacement of said engines, number of valves on the drivetrain, overhead cams or pushrods, interior options available, colors, pricing, and eventually I went on to do the same with motorcycles. It’s not that I’m Rainman or something, and every so often someone really does tell me I have good bedside manner, but people imagine Marcus Welby and what they get instead is me. It’s little wonder that I’m good at the sciences and that I sometimes make people cry when I talk with them because feelings… fuck it, let’s just say it’s because I can list exactly why Betamax was a better standard than VHS.

I couldn’t muster up the courage to talk to him; I couldn’t walk up and, oh, I don’t know, say something, anything. What do you say? Man, sucks that your entire fucking family’s dead, tough times, bro? I kept silent, secretly peeking into the room, the girl’s father still and quiet, that night still and quiet in my memory.

It’s been a few years now and since first writing it down I’ve struggled over how to end this story; maybe I didn’t have the maturity or the ability to articulate what I experienced. I’ve tried a number of different ways to conclude it with some kind of meaning. In one way I guess you can think of it as a cautionary tale. Now, I’m not Buddhist and can’t pretend to know anything about Buddhism, but I’ve heard a story of the Buddha that seems to fit somewhat. In an attempt to teach his disciples to understand the ephemeral nature of life and its boundaries, the Buddha instructed them to meditate on the decaying corpses in the local cemeteries. But in contemplating the inevitability of their own deaths, these students of Gautama slid into despondency and began to take their own lives in their efforts to reach enlightenment, and when the Buddha returned he was aghast to discover that most of his congregants had committed suicide, and then taught them instead to meditate on the cyclicality of their breaths. Like those disciples of Buddha, in learning the truths of medicine and then the limits of that practice, health care professionals can come to despair during their attempt to attain medical enlightenment. And you do dwell on the deaths, the patients you lose, for a long time. But I don’t think that’s what I came to take from this loss.

I told you that night was one of failure, but not because we couldn’t save the girl’s life. We did everything possible. I don’t regret the thoracotomy, I don’t regret the gore. What I regret is that I didn’t – I couldn’t – say anything to the poor man who’d lost his wife and daughter. I didn’t have the courage to walk up to him and let myself feel something while he contemplated the decaying corpse of his daughter.

I can imagine it now, the way it could have been, you know, if I’d been in a movie about how to be a good doctor or something – I’d pull a chair up next to him, put a hand on his shoulder, look him in the eye even if it’s for too short or too long, and then let him talk. Or let me talk. Or just have sat in silence. Instead, I left him to sit there alone, the rest of the night, while I ran around with other patients and stuffed my feelings down, out of sight, out of mind.

Compassion means not only feeling for others, but permitting oneself to feel. The irony is that compassion is easier to have for those who are like you, but of course even though compassion begins with oneself, its ends, compassion’s purposes, are always for the other, the one who is not you. Like I said, for a while you face nothing but death, but later, you start to see the lives around you, the lives of the patients saved, the lives of the survivors of those who don’t make it, the patients whose lives were never in danger but maybe just needed some handholding. And that was my lesson, which I have learned, and learned well, that what I can do, always do, is breathe in co-suffering, to laugh and weep, with compassion, with the ones who are here and the ones who survive those whom we have lost, and although it has only been a few years, I am becoming in medicine a bodhisattva, that is, one who will someday attain enlightenment.