Do Not Resuscitate

He was SO mad at me.  He was sitting in a chair at the foot of the bed facing his wife.  He was wearing his United States veteran baseball hat and his well worn cane was leaning up against his chair.  “Can’t you just wait for our son to get here?!”  He was mad at me and he was pleading with me.

His wife, Helen, would not make eye contact with him and would not take her eyes off of mine.  She was pleading with with me too.  In short, staccato like sentences she said to me, “I’m ready. to go.  He knows. I’m dying.  I don’t want.  my son.  to see me this way.  I’m ready.  to go.”

Helen had come in to the emergency department just about an hour prior.  She was in respiratory distress.  She has end stage COPD (chronic obstructive pulmonary disease). She was recently discharged from the hospital to a nursing facility.  At the time of discharge from the hospital she filled out a MOLST form (Medical Orders for Life Sustaining Treatment).  She very explicitly stated that she is DNR (do not resuscitate), DNI (do not intubate), and does not want positive pressure ventilation (something like BIPAP or CPAP).  This morning at the nursing facility she couldn’t breath.  The facility called 911 and she was sent to me by ambulance.

On arrival her respiratory rate was in the high 40s.  Your respiratory rate right now is probably 12.  She was sitting as straight up as her elderly body would allow, leaning slightly forward on her arms.  She was cachectic, uncomfortable, and struggling for air.  We call this the tripod position- if you know someone with asthma, watch their body position when they are having trouble breathing.  She was using every possible accessory muscle- the muscles in your body that help expand and contract your thoracic cavity when your lungs need extra help.  You could see how hard she was working by simply looking at her sternocleidomastoid, a muscle on the side of your neck.  Her oxygen saturation on room air was 72%.  When we placed her on a nasal cannula at 6L it was 83%.  In a patient with COPD it usually hovers around 90-92%.

As you will hear me say again and again, the mantra of emergency medicine is simple- A, B, C.  Airway, Breathing, Circulation.  Start with the airway.  Anyone who looked the way Helen did on arrival would be emergently intubated.  And if not, she would at the very least be put on BIPAP (bilevel positive airway pressure).  Among other things, BIPAP can increase ventilation, increase oxygenation, decrease airway resistance, and hopefully off put the need for a more invasive procedure, like intubation. Helen was working too hard to breath, she was getting tired.  She was not receiving enough oxygen.  If her sats didn’t raise she’d likely arrest, and without resuscitation, she’d die.

But Helen didn’t want any of this.  She was acutely aware of what was going on.  She had the capacity to make her own medical decisions.  She had explicitly put them in writing.  She ultimately agreed to allow us to place her on BIPAP, temporarily, but now she refused to be admitted to the hospital.

Her gray hair was matted from sweat, but even in this extremis you could tell that it had been cut in a stylish chin length bob.  Her blue eyes were piercing.

And Helen’s husband wasn’t ready to say good-bye.

The BIPAP was a temporizing measure.  If Helen didn’t want to be admitted to the hospital that meant she would go back to her nursing home and die.  They don’t take people with positive pressure ventilation.  And Helen knew that.  She was ready.

Her husband was acutely aware of this as well.  “You can’t just send her out there to die.  You can’t do that. You are a doctor.  You just can’t do that.”  Tears were welling in his eyes.  “I need my son.  I need him for me.  I don’t know what I’m going to do.  We’ve been married for 61 years.”

Tears were welling in my eyes, too.  I don’t want to do that.  I don’t want to send Helen off to a nursing home to die.  But I also have to do what she wants.  He begged and pleaded with me to just keep her in the hospital until her son arrives.  He lives in Arizona.   He won’t be here until late tomorrow.  I wish I could.  I really with I could, I tell him.  But I have to abide by Helen’s wishes.  “I understand your pain, I understand your wishes.  If I were you I would want the same thing.  I would want my family here.  And as much as it hurts me, Helen has made her wishes explicit.”

With the help of my social worker, case manager, nurse, and in conjunction with Helen, her husband, and her by phone her son, we all came to an agreement.  Helen would be admitted to the hospital on hospice.  She took off her BIPAP mask.  She was to be admitted to the hospital with comfort measures only.  Her husband knew this meant she may die, and may die very soon.  But he agreed to it.  We took her off all of the beeping monitors.  We were no longer checking her oxygen saturation, we weren’t monitoring her pulse or blood pressure.  I did give her some medication for her anxiety and pain.

Just before she was to be transported to the floor, about seven hours into her emergency department stay, I went back into her room.  I sat down next to her husband and put my hand on his shoulder.  “I’m so sorry for what you’re going through,” was all I could say.  I was again fighting back tears.  I stood up and walked to Helen.  I looked directly into her blue eyes and gave her hand a squeeze.  She squeezed back.  I didn’t have any words.

The following day I came in to work and opened her chart.  Helen passed away peacefully that night.  Her husband had gone home to change his clothes.  She passed after he left.  Her son was to arrive in a few hours and would drive his father back to the hospital to pick up her things. Screen Shot 2017-09-28 at 8.22.06 PM.png

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Happy Doctor’s Day

A few days ago it was National Doctor’s Day.  Yup, that’s actually a day.  In honor of this clearly very important day I have a story to tell.  This story starts about a year ago.

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I had just tied the strings of the surgical mask, I secured one knot above my blonde pony tail and one, tied a little more loosely, at the nape of my neck.  I was standing in my blue scrubs at the head of the bed, I had taken off my white coat in preparation for a mess.  The laryngoscope was poised and ready in my left hand, my right hand was gloved and still empty.  I used it to rip the plastic eye protection part of my mask away from the part that covers my lower face.  Though I’ve been wearing masks like this for at least 9 years now, I still haven’t figured out how to keep it on my face for longer than two minutes without it fogging up and decreasing my visibility.  My glasses are protection enough.  The respiratory therapist was standing to my right, facing me at a ninety degree angle, he was at about the level of the patients right ear, ready to hand me the endotracheal tube when asked.

Just a few minutes prior a young patient with multiple gun shot wounds to the head and neck area happened upon my little, non-level-one-trauma-center ED.  Most of the people in that room had not seen a gun shot wound in years, if ever.  Having done a four year residency at the busiest trauma center in my region- when I was in training this was my bread and butter.  Penetrating trauma to the head and neck region, like a stabbing or gun shot wound, will make even your most seasoned emergency medicine physicians and/or trauma surgeons heart rate increase just a bit. In retrospect I wish I had been wearing my fitbit, my heart rate was up for sure  The head and neck region- think brain, face, trachea, mouth, carotid arteries, etc- it’s a high risk area.  And the A in our ABC mantra stands for airway.  If you can’t secure the airway because of trauma induced anatomical deformities, swelling, or blood- you are in for a really, really bad day.  Particularly if you are at a facility where the closest surgeon is at home and in bed.

Adrenaline and stress are the natural reaction.  And as the attending physician it’s my job to keep this at bay by being in charge.  It’s my job to project confidence, it’s my job to know what I am supposed to be doing, it’s my job to know what everyone else should be doing.  When you are running a trauma things move smoothly if the team knows that someone is in charge.  Every emergency medicine resident learns this- and the most important piece of this (I think) is communication.  I believe in calmly spoken, simple communication- so as I prep to intubate I said to the room (now filled with multiple nurses, respiratory therapists, techs, medical students, paramedic students, and a couple of voyeuristic police men)- “Is everyone ready? I need everyone on board. My first shot will be with the glidescope (video assisted laryngoscopy), I have the mac and bougie ready as back up, and if worse comes to worse” and said with an internal cringe and sphincter tightening, “the cric kit is just to my left.”

As an ED doc you are always aware of your surroundings and as I finish speaking I see a new figure enter the room, our new case manager.  Before being an ED case manager she worked as an ED nurse.  I am sure I am biased but in my opinion, ED nurses are the best of the best.  I see her make a spot for herself at the foot of the bed, intuitively she was looking to lend an extra hand.  She scanned the room to see how she could help and after she swept the room with her eyes the next words I heard from her were, “uh, aren’t we going to get a doctor in here?”

As these words registered somewhere in my brain I was already on the exhale of the deep breath I take before any intubation, something I learned in residency from my assistant program director.  As soon as that exhale is complete I am in game mode and my focus is on one thing.  I ended my exhale and made direct eye with my nurse, nodded, and she pushed the sedative.  “Etomidate in.”  I gave her a second look and another nod and with that the paralytic had been pushed. “Sux in.”  I watched for a few seconds- which always feels like a million seconds- and saw my patient’s muscles relax.

My right index finger and thumb scissor motioned his jaw open. I placed the laryngoscope in his mouth, I moved it around the tongue and ultimately caught a glimpse of the epiglottis, an epiglottis mostly obscured by blood.  In as measured a tone as I could muster- in a room that was now completely quiet but for the beeping of the medication and blood pumps- I stated, “I need suction”.  In my right hand I felt the plastic of the Yankauer suction tip.  Not moving my eyes from the screen I placed it in the mouth.  My goal was to remove enough blood in order to visualize the structures I’m supposed to.  With my left hand still firmly holding the laryngoscope in place- I managed to suction away enough blood and secretions- I saw vocal cords.  The surrounding structures were edematous and injured, this was not text book anatomy.  But I saw vocal cords!  Calmly I state, “I see cords.” My eyes have not left the screen, I will not lose my place in this mess of pink and red.  And as I held out my right hand the Yankauer was replaced with the endotracheal tube, stylet in place.  I placed the tube in the mouth, I moved it past the tongue, I saw it on the screen.  I slipped it through the cords as my anatomical landmarks again began to disappear and turn red.  My left hand removed and released the laryngoscope blade and I used it to join my right hand in grabbing the endotracheal tube to hold it in place, for dear life, as the respiratory therapist pulled out the metal stylet from the inside of the tube.  He attached the CO2 monitor- good color change- I took my first deep breath. I grabbed my stethoscope to listen to the boy’s chest, I listened on the left and then on the right, bilateral breath sounds. I took my second deep breath. Then I took a third deep breath. I was dripping with sweat but knew that at least for now we were out of the woods.

After this things moved fast.  The patient was appropriately sedated, blood was hanging, proper placement of the endotracheal tube confirmed, no pneumothorax, bedside ultrasound FAST exam was negative- there was no blood in the abdomen, pressure dressings were placed on the wounds, vitals were stable, the med flight critical care team was soon at the bedside, and then the patient was off to a level one trauma center with all appropriate consultants in house.

The police presence ultimately dissipated, the staff returned to their jobs, and I returned to my desk.  I looked at the tracking board and saw that there were many, (sigh) many patients waiting to be seen.  No time to dwell, time to go see that next chest pain.

Once we had all caught up a bit I was pulled aside by the case manager that had been in the room earlier.  I was taken aback because she, normally poised and stoic, seemed uncomfortable.  She was actually mortified and apologetic.  She thought that I was a physician’s assistant and she could not believe how ignorant she had been.  She respects our PAs.  But she couldn’t understand why, when seeing a young blonde woman at the head of the bed, she did not assume she was the attending physician.  Her apology was sincere and gracious.  And, in retrospect, what I realize is maybe worse is that I hadn’t thought twice about what she said in that room.  I am always mistaken for a nurse, a physician’s assistant, or a tech.  I am always mistaken as such even after introducing my self as Doctor.

Fast forward to the present day. As mentioned earlier, a few days ago it was National Doctor’s Day.  I was again pulled aside by this same case manager, she told me she had something to tell me.  Now we are good friends and supportive colleagues and I approached her with a different attitude entirely.  Thinking she wanted to update my on the rehab facility status of my 90 year old with a fall I asked, “What’s up?”  “I just want to be sure to tell you, happy Doctor’s Day, Dr. French Fry.  You continue to rise above the rest- you really do deserve recognition on this day.”

Her apology one year ago had an impact on me.  This was not an old man Vietnam vet who continues to call me “honey” (who’s verbiage I may be able to force myself to rationalize.) This was a fellow woman, a fellow woman working in the medical field, a fellow woman who faces similar discrimination as I do on a daily basis.  She helped me positively reflect on this experience is a few ways- 1) I appreciate how she forced the discussion thus making the issue important, 2) I realize sexism is sometimes so deep we don’t see it in ourselves, and 3) I realize sexism can be so deep and so prevalent that we all become desensitized- even those of us affected.  We don’t notice it.  By acknowledging this and forcing the difficult discussion this brave woman has pushed me to be braver.  It’ll be a slow road, but I am no longer going to let this sh!t slide.

Happy Doctor’s Day :).

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tomorrow will be interesting

I start my life as a attending tomorrow.

I feel pretty much as anxious as I did  that sleepless night before I started my residency. It is a different type of anxiety. It’s different for sure, but it is so obnoxiously there.

I am not as nervous about the doctor part as I was the night before I was an intern. To be clear, I am very nervous about being a doctor (as I am sure, in my chosen specialty, I will always be), but the night before I was an intern, I didn’t even know what it meant to be a doctor.  At least now I’ve been a doctor for more than a minute.

Graduating from residency is emotional, something I will write about at another point.  But one thing is for sure, you make good friends.  One of my closest started his attending gig on July 1.

I asked him how it went, and he told me that for the first 6 hours of his shift he completely forgot how to be a doctor.

I can see that happening to me.

It’s a new place, new people, and for the first time ever, you are on your own. There were many times in residency when we were probably actually on our own, but it didn’t feel that way. At the point where we had been given enough responsibility and trust to be somewhat on our own, we had been there for 2, 3, or even 4 years and, for better or worse, we knew our team. If our attending wasn’t available, we still had seasoned nurses, pharmacists, and even techs who had good clinical judgment, who knew our strengths and weakness in a crisis, who could do good cpr….

So he told me, a 70 F came in after a mechanical fall… no head strike, no LOC, otherwise healthy, currently feeling great.  If she made it past the trauma bay and into the general department, that generally means the mechanism was insignificant and her primary survey was intact. In other words– her airway was patent, breathing/lungs/O2 sats were fine, circulation was functional, her vitals signs were beautiful, GCS pristine. SO, easy peasy, right? Complete a secondary survey.  If she’s over 65, depending on mechanism and other factors more than likely she’ll be getting a head and neck CT, you know this off the bat.  You keep this in mind as you prepare for the secondary survey where you’ll figure out the rest. And as always, you’ll be thorough. Xray an elbow? Arm? Great. Belly tender? CT a/p.

This is our bread and butter.  We trained at the busiest level 1 trauma center in our region.  And on this bread and butter case, my friend could not think. He literally could not decide what xrays to get. If we were back at our home shop, this would have been second nature. This would have been the patient the senior picked up because it would be uncomplicated, allowing him/her to supervise the junior residents as they picked up the more complicated, time-consuming, teachable cases.

But this wasn’t his home.  He didn’t know anyone that worked there.  No one knew him, no one yet trusted him.  This was an entirely new experience.Screen Shot 2015-07-12 at 10.57.10 PM

And with that, I get it.  He is one of our best, and I know without a doubt this woman got the best care possible, but I know better than most– when you are nervous and anxious, and on top of that, OUT OF YOUR ELEMENT, as I have mentioned a million times in the past, your brain just_ stops_ working.

Sigh.

I won’t sleep well tonight.

And tomorrow will be interesting.

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really?

“Until I get there,” the urology resident instructed me, “you must apply direct manual compression to mechanically disperse the penile and preputial edema.  This will hopefully minimize the swelling and allow for manual retraction by the time I get there.”

So in other words, as my attending so eloquently directed me “grab that thing and hold on tight.”

There are a lot of awkward moments in the emergency department.  Many of them have to do with interactions with nurses (I am really sorry my patient threw up on your leg AGAIN yes he can have some Zofran), paramedics (last time I saw you, I am pretty sure you were making out with one of my co-residents in the middle of a bar), and even correction officers (um, please, just un-handcuff him for the lung exam. Fine, you can keep his feet chained to the bed).

My most awkward moment of late, however, had to do with one particular patient with one particular penis problem.

Paraphimosis is when, in an uncircumcised or partially circumcised male, the foreskin gets retracted behind the glans penis, starts to swell, and gets stuck in that position.  The reason this is an emergency is that this swelling then cuts off blood flow to the head of the penis.  The head will start to turn dark and eventually may become necrotic.  It’s usually iatrogenic in nature, meaning, we cause it.  In this case the patient has a foley catheter in his urethra (secondary to a recent surgery).  He resides at one of the homeless shelters that also provides some medical care, and the nursing staff inadvertently forgot to replace the patient’s foreskin after the most recent foley catheter change. This is actually a great case for me, it’s one of the few urologic emergencies and a case up until now I had only read about.

As great of a case as it may be, the treatment is nothing short of mortifying. Very reluctantly I pulled a chair into the room, and for the next fifteen minutes I sat by my 65 year old patient’s side and “mechanical dispersed the penile and preputial edema,” AKA, I very firmly held his penis in my hand.  For fifteen freakin’ minutes.

Really? I am really doing this right now? Please, just for a moment, put yourself in my shoes.  What are you going to talk about to make this less awkward… football? The weather?

I am a doctor, and this is what I do at work.  Really.

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by the way, it’s sunday

I think was feeling a bit nostalgic tonight. I got out of work early and for the first time in what feels like 9 months, it was still light out for my walk home.  I also may have hallucinated the smell of spring in the air.  Not entirely sure what day it was or what to do with a whole extra one hour of free time, I decided to read through some of my old posts and I– as I have said to myself many times before– realized I need to write more.  I have so many stories from this year.  Some are disturbing, some are sad, most of them are just dumbly entertaining.

As I try to get my act together, allow me to refer you to a post I wrote almost exactly two years ago about what was, in retrospect, maybe one of my favorite days of medical school.

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the wheels on the bus go…

I need a new method of transportation.

Sitting in front of me, alert, oriented, and chatting away on her cell phone was a patient I treated the Friday before.  I saw her last week when I was working triage on the Labor and Delivery floor.  She was high as shit and annoying the piss out of me.  She was complaining of leg pain but wouldn’t answer any of my questions.  It was an imposition that I needed to know about her leg pain, that I needed to know her medical history, and that I not only did I need to know her daily dose of methadone I needed to know what other drugs she took today. I lightly touched her leg and she started wailing uncontrollably and making a scene.  While everyone else on the floor was freaked out about this, I actually felt like I was at home, in my element back in the ED. She is status post c-section, post-op day 8, and is boarding at the hospital because her baby is withdrawing from methadone.  At this point I am tired, annoyed, and have about a million other things that needed to be done 20 minutes ago.  The trouble with this though, as an emergency medicine physician, is that as much as people piss you off, and as much as you think they are full of shit, people can still be sick.  This woman was recently hospitalized, had recent surgery, is an IV drug user, smokes cigarettes (all risk factors for a deep vein thrombosis), and is now having unilateral lower extremity pain and tenderness (which may or may not be real). Those of you who read this blog who are in the medical field (none of the three of you), will understand this: I recommended a lower extremity doppler to my attending.  He, who had the benefit of knowing this patient well (perhaps there’s something to be said for continuity, or maybe just experience), nodded politely at my “emergency medicine” work-up, and discharged her with some Tylenol.  A week later on that bus she was still annoying me but I was relieved to see she was not tachypneic, DVT and pulmonary embolus free.

On that same bus ride, sitting directly next to me was another lovely gentleman I ran into two weekends earlier.  Two weeks prior he was asking for money on the subway.  “I just need $6.75 for the commuter rail. I already have a dollar.  I can’t get into the shelter tonight and have nowhere to stay and really need money for the commuter rail.”  There was no response from the passengers and next thing I know he’s making a scene, screaming, swearing, punching the walls, and scaring the crap out of those from whom he was just begging for money. Before my experiences working as an intern at the hospital where I work I think I probably would have been frightened, or maybe felt bad for not giving him money. I think it’s also important to note, however, that I know this guy.  During my first month as a doctor I saw him come into our trauma bay two times over the course of one twelve hour shift.  The first time he left angry and AMA (against medical advice) as soon as he was able, the second time he was admitted for a heroin withdrawal. During his outburst on the subway I was neither frightened nor felt compassion for his plight. Mostly because he turned into a jerk and started scaring people. Needless to say, yesterday the same dude, in the same red sweatshirt, hopped onto my bus.  “I just need $6.75 for the commuter rail. I already have a dollar.  I can’t get into the shelter tonight and have nowhere to stay and really need money for the commuter rail.” And as luck will have it, there was a seat open right next to me.  I was about to get a bit nervous, I didn’t want to be between him and the window when no one offered him money.  Luckily, there was a nice gentleman with one of those classic heroin toothless smiles (who also looked vaguely familiar) in the front of the bus who gave him five bucks.  My buddy in the red sweatshirt got off at the next stop.

And then, no joke, toward the front of the bus on the right there was another familiar face.  It was an overweight 28 yo male who I have treated on numerous overnight shifts.  He lives in a shelter and has a multitude of mental problems and likely a very low IQ.  He abuses the system, but has no idea what that even means.  He likes coming to the ED.  We give him sandwiches and we’re nice to him.  Last time I saw him it was at 3am because he had a cut on his foot.  It wasn’t infected, though with his lifestyle and medical history, it easily could have been.  It was just a little cut.  I cleaned it and gave him a band-aid and wrote him a doctor’s note so the shelter would let him back in at such a late hour. Twenty minutes after he left I called the shelter to make sure he arrived, it was a slow night.  I walked by him on my way off the bus and we made eye contact, there was no recognition on his part.  And I’ll probably see him again next week.

Oh how I love taking the bus.

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kickin’ it

Just about four months in, and I still get a kick out of being called Doctor.

Thus far I’ve spent 2 months in the ED, a month in the MICU, and am now finishing up my month on OB.  All four months have been utterly exhausting. But I can’t believe how much I’ve changed in such a short amount of time.  You really only realize it when you compare yourself to the med-students.  Once every few days, for survival purposes, it’s necessary to listen to them present on rounds and realize that you are not the total asshole that everyone else makes you feel like. You’ve actually come a long way. God I love med students, especially the third years.

Intern year sucks and there is no way around it.  Sometimes I wonder how anyone makes it through, and then I realize that everyone makes it through.  It’s a year of being perpetually tired, shit-on, abused, uncomfortable, and anxious.  That being said, I’m at an amazing program, working with awesome people, and I see  fascinating/hilarious/upsetting stuff on a daily basis.  As much as it sucks, and as much as I complain, I really do love what I do. I love what I’m learning, I love my crazy-ass patient population, I appreciate the strange group of people that are drawn to emergency medicine in one form or another, and I most of the time love the raw emotion that I get to be a part of every single day.

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