The neon lights of the hospital corridor boldly contrast the bland gray of the morning mist creeping through over sized windows. My feet shuffle and then stumble as I absentmindedly propel myself toward the ICU. My eyes shudder, deflecting remnants of last nights sleep.
At this early hour, the hallway feels like a forgotten graveyard. My reverie is interrupted by a flurry of activity. Transport personnel wheel their patients in front of the door well that leads to the operating room. Family members scurry to give one last hug, say one last goodbye, before their loved ones are pushed through the swinging doors and into the unknown.
I can't help but stare at each face as they pass by. I recognize the strange mix of terror, hope, and desperation brought on by powerlessness.
*
If Dagny Taggart existed in real life she would have been a surgeon.
Josie is standing in a circle of men who don't usually take direction from a woman. They belong to an era of medicine that has long past. Like in the days of the giants, they stalk through the hospital indifferent to their surroundings. They are cardiothoracic surgeons.
Josie presents patients like a machine gun. Each diagnosis and vital sign sprays forth in rhythmic staccato. The appearance of her torso is lengthened by her unorthodox posture; one leg is a stilt while the other folds into a triangle. Her hair is slightly disheveled from missing a night of sleep.
I watch from the corner of the room with the other medical students. Josie is pretty but not in the classical sense. Her jaw juts forward and her body is sleek and thin. As she finishes her conversation with the attendings, she strides effortlessly in my direction.
Come with me. We're opening Mr. Simpson's chest.
*
Mr. Simpson is dying. His blood pressure is dropping and his anemia is worsening. His emergent coronary artery bypass, the night before, has kept Josie busy till daybreak.
She leans over her patient in the cardiothoracic ICU. He is too sick to take to the OR, so Josie scrubs and steriley drapes him in his room. She is on the front lines of a battlefield and has created MASH unit.
She expertly removes the sternal wires and opens the chest cavity. Her eyes survey the operative site. I watch from the corner mesmerized. Her hands move with ease and fluidity. She performs a complicated dance with the attending who is functioning as her first assist. They communicate through movement without the exchange of words.
The blood pressure stabilizes. The anesthesiologist transfuses another few units. Josie closes up and takes off her gown. Their are other patients to tend to.
*
I can't help but feel a touch of anxiety as I pass by the operating room doors every morning. Sometimes there is a rush of fear as if I am the one kissing my wife and saying goodbye.
But no patient enters this solemn and sterile world alone. They are accompanied by a surgeon like Josie. Someone who has sworn to protect and cure with the precision of a scalpel.
Surgeons have been called butchers and carpenters. They have been mythologized as goons and thugs.
But, if you ask me, It takes guts to willingly put another person's life in your hands. It takes skill and mastery.
I think we owe them a debt of grattitude.
Wednesday, November 30, 2011
Tuesday, November 29, 2011
Anatomy Of Dying
Two weeks ago I told a man that he was dying. We sat together in the mid afternoon haze. Puffs of snow meandered by the hospital window and wended their way down to the ground. The sun was lost behind winter's never ending clouds.
The tempo of my voice was steady, lacking variation in tenor and pitch. I clung to my lab coat as if I was floating outside the window and being blasted by the inclement conditions.
I waited coldly for a response. At first, he stared at me quizzically. His eyes asked so many questions but his lips remained still. He shook his head and sighed. I glanced above him at the ticking clock.
You're wrong. It's not my time yet!
*
Two days ago I entered the same room. I watched as my patients chest heaved up and down slowly. His laborious breathing like spikes piercing the insides of his family members. They sat somberly around his bed in a circle.
It won't be long now.
As the words slithered out, I realized that I failed to convey the proper warmth. My voice box robotic and stale. The phrase lost in a haze of familiarity.
*
Two minutes ago I pronounced him dead. The room still heavy with doubt and false expectations. The social workers and case managers huddle around the family as funeral plans are made.
And in two days, I will call his wife. I will express my condolences and ask if there is anything I can do.
Then, most likely, I will never speak to her again.
*
Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrance.
He'll stare deeply into my eyes and I'll detect a hint of mirth.
We're all dying my friend.
He will draw in a deep breath and put his hand on my shoulder.
The trick is learning how to live!
The tempo of my voice was steady, lacking variation in tenor and pitch. I clung to my lab coat as if I was floating outside the window and being blasted by the inclement conditions.
I waited coldly for a response. At first, he stared at me quizzically. His eyes asked so many questions but his lips remained still. He shook his head and sighed. I glanced above him at the ticking clock.
You're wrong. It's not my time yet!
*
Two days ago I entered the same room. I watched as my patients chest heaved up and down slowly. His laborious breathing like spikes piercing the insides of his family members. They sat somberly around his bed in a circle.
It won't be long now.
As the words slithered out, I realized that I failed to convey the proper warmth. My voice box robotic and stale. The phrase lost in a haze of familiarity.
*
Two minutes ago I pronounced him dead. The room still heavy with doubt and false expectations. The social workers and case managers huddle around the family as funeral plans are made.
And in two days, I will call his wife. I will express my condolences and ask if there is anything I can do.
Then, most likely, I will never speak to her again.
*
Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrance.
He'll stare deeply into my eyes and I'll detect a hint of mirth.
We're all dying my friend.
He will draw in a deep breath and put his hand on my shoulder.
The trick is learning how to live!
Monday, November 28, 2011
Is It Just Me?
I use the words "death" and "dying" so often that I sometimes forget that the majority of my life's work is focused on avoiding such things. In a geriatric population like mine, end of life issues are a part of everyday practice. Lately, however, there seems to be a rent in the fabric of my reality.
Where previously these conversations were nurturing and beneficial, recently they've turned quite negative. As hospice and palliative care are moving forward at a breakneck pace nationally, on the ground, there's more resistance than ever.
I'm finding that my relationships with patients and colleagues are souring around such issues. No one wants to acknowledge the elephant in the room.
Or is it just me?
*
I really hated you that day!
I see the anger migrate through her face as Agnes looks at her elderly parent. Her eyes soften when she walks over to the bed and gently combs her fingers through her mother's hair.
She is referring to when I told her that the dementia had progressed and that death was near. The evidence was incontrovertible. Her mother hadn't spoken in weeks. She wasn't eating and her weight had dropped significantly. Now her breaths were prolonged and erratic.
But the neurologist said she could live for years!
Tears drop slowly from Agnes's eyes and cling to her cheeks to avoid the perilous pull of gravity. I can see the question in her posture before her lips part to vocalize. I interrupt her softly.
A feeding tube would provide more harm then good.
Agnes stops mid sentence and her head bobs down toward the floor. Could I tell her that I don't agree with her neurologist? Should I explain that his reputation is to flog his patients well past the point of no return?
Maybe we should call the neurologist again. He says we should put in a feeding tube.
The same neurologist crucified me on the phone the week before for signing the DNR order.
*
Eventually Agnes sent her mother to the hospital for a feeding tube against my objections.
A few days later it fell out.
When her mother's heart eventually stopped, an ambulance was called.
CPR was performed to no avail.
Where previously these conversations were nurturing and beneficial, recently they've turned quite negative. As hospice and palliative care are moving forward at a breakneck pace nationally, on the ground, there's more resistance than ever.
I'm finding that my relationships with patients and colleagues are souring around such issues. No one wants to acknowledge the elephant in the room.
Or is it just me?
*
I really hated you that day!
I see the anger migrate through her face as Agnes looks at her elderly parent. Her eyes soften when she walks over to the bed and gently combs her fingers through her mother's hair.
She is referring to when I told her that the dementia had progressed and that death was near. The evidence was incontrovertible. Her mother hadn't spoken in weeks. She wasn't eating and her weight had dropped significantly. Now her breaths were prolonged and erratic.
But the neurologist said she could live for years!
Tears drop slowly from Agnes's eyes and cling to her cheeks to avoid the perilous pull of gravity. I can see the question in her posture before her lips part to vocalize. I interrupt her softly.
A feeding tube would provide more harm then good.
Agnes stops mid sentence and her head bobs down toward the floor. Could I tell her that I don't agree with her neurologist? Should I explain that his reputation is to flog his patients well past the point of no return?
Maybe we should call the neurologist again. He says we should put in a feeding tube.
The same neurologist crucified me on the phone the week before for signing the DNR order.
*
Eventually Agnes sent her mother to the hospital for a feeding tube against my objections.
A few days later it fell out.
When her mother's heart eventually stopped, an ambulance was called.
CPR was performed to no avail.
Friday, November 25, 2011
Someone's Gettin Scoped! A Farce
Icicles shot down Lisa's back and into her left calf. Standing out in the cold, waiting in line, wasn't the best place for someone with severe sciatica. But this is how Black Friday had become. At least she could stand.
The police had just carted away a belligerent man and his wheel chair bound daughter. There had been a kerfuffle with a young couple standing in front of them. It had been whispered among the crowd that the girl had some sort of brain tumor.
The gold slips for the brain MRI's were going fast. Lisa was lucky. Her spine films were not in such great demand. Although she was easily the hundredth person in line, she would likely limp away with the coveted referral form.
*
Everything had changed since the great healthcare reform. No one had dreamed that hospitals would profit so handsomely. But the provision that allowed billing for uncovered services had unintended consequences.
Fettered by poor reimbursements from medicare and private insurance, the market took over. Every other commercial on the TV was hocking some uncovered medical procedure.
Mercy Hospital is going out of business. Everything must go! MRI's half off, CT-thirty percent discount, elective choleys starting at $5000.
Black Friday was the biggest day of all. The people would crawl out of their beds early Thanksgiving morning and push, wheel, or be carried to the nearest medical outlet to stand in line and hope for a bargain. Sure insurance covered many essential procedures, but like Lisa, the panel often denied basic requests. She knew her back surgery would never be payed for unless she obtained the MRI on her own. Once the results came back, it would be a gamble to see if the panel would OK her procedure. If not, the neurosurgeons down the street were having a buy one get one free sale for Christmas. Of course, Lisa would have to hire a lawyer to make the legal arrangements to find and share costs with a complete stranger (anyone no someone trustworthy looking for back surgery?).
Lisa sighed as she crept toward the front entrance. Her chances were good. She wondered if poor John was having as much luck.
*
John couldn't help but salivate as he watched Lisa and the kids slurp down turkey and stuffing for breakfast. Unlike his wife who would receive a referral to have her MRI at a later date, if John was successful he would be whisked off immediately for the procedure. And, of course, you couldn't eat the morning of an endoscopy.
After breakfast, Lisa's parents arrived to watch the kids and it was off to the races. Lisa dropped John at the GI suites, and then rushed to the radiology center. Luckily the parking lot was not yet full when she arrived.
Twelve hours later Lisa left the facility with her hand greedily clutching the thick gold referral form. She sent a quick text to John, but no answer. She hadn't heard from him in hours.
She clicked the Facebook Application on her smart phone. Amidst the pictures of Thanksgiving feasts and newly purchased flat screen TVs was a mobile upload from John.
He was siting on a gurney dressed in a skimpy gown with his black socks covering his dangling feet. He had a large smile on his face and was holding his thumbs up in mock triumph.
Lisa couldn't help but laugh out loud and exclaim to no one in particular.
Someone's gettin scoped!
The police had just carted away a belligerent man and his wheel chair bound daughter. There had been a kerfuffle with a young couple standing in front of them. It had been whispered among the crowd that the girl had some sort of brain tumor.
The gold slips for the brain MRI's were going fast. Lisa was lucky. Her spine films were not in such great demand. Although she was easily the hundredth person in line, she would likely limp away with the coveted referral form.
*
Everything had changed since the great healthcare reform. No one had dreamed that hospitals would profit so handsomely. But the provision that allowed billing for uncovered services had unintended consequences.
Fettered by poor reimbursements from medicare and private insurance, the market took over. Every other commercial on the TV was hocking some uncovered medical procedure.
Mercy Hospital is going out of business. Everything must go! MRI's half off, CT-thirty percent discount, elective choleys starting at $5000.
Black Friday was the biggest day of all. The people would crawl out of their beds early Thanksgiving morning and push, wheel, or be carried to the nearest medical outlet to stand in line and hope for a bargain. Sure insurance covered many essential procedures, but like Lisa, the panel often denied basic requests. She knew her back surgery would never be payed for unless she obtained the MRI on her own. Once the results came back, it would be a gamble to see if the panel would OK her procedure. If not, the neurosurgeons down the street were having a buy one get one free sale for Christmas. Of course, Lisa would have to hire a lawyer to make the legal arrangements to find and share costs with a complete stranger (anyone no someone trustworthy looking for back surgery?).
Lisa sighed as she crept toward the front entrance. Her chances were good. She wondered if poor John was having as much luck.
*
John couldn't help but salivate as he watched Lisa and the kids slurp down turkey and stuffing for breakfast. Unlike his wife who would receive a referral to have her MRI at a later date, if John was successful he would be whisked off immediately for the procedure. And, of course, you couldn't eat the morning of an endoscopy.
After breakfast, Lisa's parents arrived to watch the kids and it was off to the races. Lisa dropped John at the GI suites, and then rushed to the radiology center. Luckily the parking lot was not yet full when she arrived.
Twelve hours later Lisa left the facility with her hand greedily clutching the thick gold referral form. She sent a quick text to John, but no answer. She hadn't heard from him in hours.
She clicked the Facebook Application on her smart phone. Amidst the pictures of Thanksgiving feasts and newly purchased flat screen TVs was a mobile upload from John.
He was siting on a gurney dressed in a skimpy gown with his black socks covering his dangling feet. He had a large smile on his face and was holding his thumbs up in mock triumph.
Lisa couldn't help but laugh out loud and exclaim to no one in particular.
Someone's gettin scoped!
Wednesday, November 23, 2011
Thankful
As I pull out of the hospital parking lot, I feel nothing but gratitude. The cold Chicago morning has transformed from blustery to pleasantly sunny. I become acutely aware of the gifts bestowed upon me.
I have a mind to think, a body to work, and a heart to love.
*
I walk into the house to find my four year old daughter singing along to an old Squeeze CD.
Tempted by the fruit of another..
She hops back and forth as her button dress flies through the air. My wife stands over the stove, and the smell of Ghiradelli's brownies wafts through the kitchen. My son's face is stained red from the seeds of a pomegranate that he greedily grasps between his fingers.
I will answer phone calls tonight but how can I complain? I will round at the hospital tomorrow, but it is a small price to bear witness to humanity. To experience such profundity on a regular basis that I am often unable to choke out the words to describe my experiences. Instead I write to clumsily record that which I fail to express by other means.
*
And it is you my dear reader.
You have allowed my words to seep out of your computer or cell phone. You have followed me on facebook, twitter, or read my blog. You, who has given me the greatest honor and pleasure to awkwardly juxtapose my thoughts and phrases into something that pleases.
It is for you reading these words at this moment that I am thankful.
Happy Thanksgiving!
I have a mind to think, a body to work, and a heart to love.
*
I walk into the house to find my four year old daughter singing along to an old Squeeze CD.
Tempted by the fruit of another..
She hops back and forth as her button dress flies through the air. My wife stands over the stove, and the smell of Ghiradelli's brownies wafts through the kitchen. My son's face is stained red from the seeds of a pomegranate that he greedily grasps between his fingers.
I will answer phone calls tonight but how can I complain? I will round at the hospital tomorrow, but it is a small price to bear witness to humanity. To experience such profundity on a regular basis that I am often unable to choke out the words to describe my experiences. Instead I write to clumsily record that which I fail to express by other means.
*
And it is you my dear reader.
You have allowed my words to seep out of your computer or cell phone. You have followed me on facebook, twitter, or read my blog. You, who has given me the greatest honor and pleasure to awkwardly juxtapose my thoughts and phrases into something that pleases.
It is for you reading these words at this moment that I am thankful.
Happy Thanksgiving!
Tuesday, November 22, 2011
Missing The Boat
Arthur's voice rattled as if small bits of gravel were stuck in his throat. His words resonated over the phone and felt more like commandments then questions.
Lillie's coming back home?
By home, he was referring to the assisted living that they both had inhabited for the last few years. But Lillie developed a severe case of shingles and was transferred first to the emergency room and then to the nursing home.
She was like many of the other patients in the dementia unit. Her complaints of pain were both persistent and monotonous. When it was explained that her belly discomfort came form shingles, she would calm down and become quiet. Moments later, however, she would forget the explanation and start to moan all over again.
As the weeks passed, Arthur would call from time to time. The nurses rumored that he was abusive and controlling. Lillie's son mentioned that having them apart was not necessarily a bad idea.
*
So when Arthur made plans to move into the nursing home and sleep in a bed alongside his wife, there was a general uproar. The nurses scurried in and out nervously expecting his arrival. The administrator paced back and forth in her office. Lillie's son sat quietly in the room with his mom.
When Arthur arrived I was surprised that the small thin frame belonged to such a powerful voice. He barraged the staff with a series of demands. They shook their heads but dared not disobey.
The months passed and a routine was established. Every now and then Arthur would spew forth another unreasonable request. The nurses felt less trepidation and grew bold over time. They began to understand that his bark was much worse then his bite.
*
I walked into their room this morning for my monthly visit. Lillie was perched low in her wheel chair and Artur was stooped over her, sitting on his bed. The TV was on and they were holding hands.
I flipped through the chart as I talked to them. Lillie's use of pain medication had dropped seventy five percent since her husbands arrival. I asked Arthur about her tremor.
When her hands start to shake, I reach out and hold them. She then stops within a few seconds.
There was no signs of being overbearing here. There were no accusations of alleged abuse.
*
There is no doubt that as health care practitioners we need to make decisions based on slivers of information. We become like cameras. We store a series of snapshots and use them to tell a story.
Yet clearly we occupy such a small portion of our patients life. We miss 99.99% of their existence. But sometimes it is in those miniscule moments, when doors are shut, that we see a true window into their souls.
If we are lucky, we may get a chance to be a part one of those moments.
If we are not-we might just miss the boat.
Lillie's coming back home?
By home, he was referring to the assisted living that they both had inhabited for the last few years. But Lillie developed a severe case of shingles and was transferred first to the emergency room and then to the nursing home.
She was like many of the other patients in the dementia unit. Her complaints of pain were both persistent and monotonous. When it was explained that her belly discomfort came form shingles, she would calm down and become quiet. Moments later, however, she would forget the explanation and start to moan all over again.
As the weeks passed, Arthur would call from time to time. The nurses rumored that he was abusive and controlling. Lillie's son mentioned that having them apart was not necessarily a bad idea.
*
So when Arthur made plans to move into the nursing home and sleep in a bed alongside his wife, there was a general uproar. The nurses scurried in and out nervously expecting his arrival. The administrator paced back and forth in her office. Lillie's son sat quietly in the room with his mom.
When Arthur arrived I was surprised that the small thin frame belonged to such a powerful voice. He barraged the staff with a series of demands. They shook their heads but dared not disobey.
The months passed and a routine was established. Every now and then Arthur would spew forth another unreasonable request. The nurses felt less trepidation and grew bold over time. They began to understand that his bark was much worse then his bite.
*
I walked into their room this morning for my monthly visit. Lillie was perched low in her wheel chair and Artur was stooped over her, sitting on his bed. The TV was on and they were holding hands.
I flipped through the chart as I talked to them. Lillie's use of pain medication had dropped seventy five percent since her husbands arrival. I asked Arthur about her tremor.
When her hands start to shake, I reach out and hold them. She then stops within a few seconds.
There was no signs of being overbearing here. There were no accusations of alleged abuse.
*
There is no doubt that as health care practitioners we need to make decisions based on slivers of information. We become like cameras. We store a series of snapshots and use them to tell a story.
Yet clearly we occupy such a small portion of our patients life. We miss 99.99% of their existence. But sometimes it is in those miniscule moments, when doors are shut, that we see a true window into their souls.
If we are lucky, we may get a chance to be a part one of those moments.
If we are not-we might just miss the boat.
Monday, November 21, 2011
Concussion
The thud vibrated through my body as the pipe refused to budge against the sudden upward force. Damn crawl space! My eyes closed and bright shards of light shot through my visual field. I struggled out into the open and put my hand on my scalp. I could feel the lump beginning to form.
The vague pain in my head and neck lingered. I payed little attention as I continued to inspect the house. My thoughts limped forward as if caught in a deep haze. When I was finished, I slid into the passenger seat of the car and my wife began the long drive home.
My eyes felt heavy and my head woozy. A spasm of nausea started in my abdomen and worked its way up my throat. The saliva spilled into my mouth as I gulped to keep from vomiting.
*
It's just a concussion. It's just a concussion.
I kept repeating as I crawled into bed. The nausea abating only in complete stillness. My head was pulsating. My eyes felt heavy as they rotated to survey my surroundings.
I fell asleep hoping that I would feel well enough to make the long drive to work the next morning. Every few hours I awoke and choked back the uncomfortable feeling in my belly.
As morning came, I arose and walked down the stairs to get a Tylenol. I stumbled over the ledge. I felt like each step was another turn on a roller coaster. I walked past the bathroom but thought better and turned back quickly.
As I lay on the ground in front of the toilet my body heaved and convulsed rhythmically. Each wretch sent spasms of pain up my spine and down my forehead. After a few minutes I was able to get up and flush the toilet. I wandered up the stairs and woke up my wife. It was time to go to the emergency room.
*
The ER is such a different place seen through the eyes of a patient. I slumped in the chair at the front desk as the intake person took my insurance information. As she asked me questions, I tried my best to control the war that was raging in my abdomen.
I was walked quickly back to a bed. The gown was cold and the bed had neither sheets nor pillow. I laid flat and moved as little as possible. A nurse came in and placed an IV. The blood trickled down my arm as she applied pressure.
Sorry we hit a bleeder!
Zofran and ativan were pushed through my IV. The nurse dutifully scanned my wrist band after each new medication as If I was a box of cereal being checked out of the grocery.
The attending came in and checked me over. I fidgeted at the thought of the radiation of the suggested cat scan, but I felt too sick to argue. This is what I would have suggested for my patient.
*
The cat scan was negative and I was sent home with an anti emetic. After sleeping most of the day I finally feel well enough to sit up and write this blog.
Tomorrow I will return to work and forget this day as if nothing happened.
But maybe I'll be just a little bit more understanding of what it's like to be sent to the emergency room.
Maybe, from now on I'll avoid crawl spaces.
The vague pain in my head and neck lingered. I payed little attention as I continued to inspect the house. My thoughts limped forward as if caught in a deep haze. When I was finished, I slid into the passenger seat of the car and my wife began the long drive home.
My eyes felt heavy and my head woozy. A spasm of nausea started in my abdomen and worked its way up my throat. The saliva spilled into my mouth as I gulped to keep from vomiting.
*
It's just a concussion. It's just a concussion.
I kept repeating as I crawled into bed. The nausea abating only in complete stillness. My head was pulsating. My eyes felt heavy as they rotated to survey my surroundings.
I fell asleep hoping that I would feel well enough to make the long drive to work the next morning. Every few hours I awoke and choked back the uncomfortable feeling in my belly.
As morning came, I arose and walked down the stairs to get a Tylenol. I stumbled over the ledge. I felt like each step was another turn on a roller coaster. I walked past the bathroom but thought better and turned back quickly.
As I lay on the ground in front of the toilet my body heaved and convulsed rhythmically. Each wretch sent spasms of pain up my spine and down my forehead. After a few minutes I was able to get up and flush the toilet. I wandered up the stairs and woke up my wife. It was time to go to the emergency room.
*
The ER is such a different place seen through the eyes of a patient. I slumped in the chair at the front desk as the intake person took my insurance information. As she asked me questions, I tried my best to control the war that was raging in my abdomen.
I was walked quickly back to a bed. The gown was cold and the bed had neither sheets nor pillow. I laid flat and moved as little as possible. A nurse came in and placed an IV. The blood trickled down my arm as she applied pressure.
Sorry we hit a bleeder!
Zofran and ativan were pushed through my IV. The nurse dutifully scanned my wrist band after each new medication as If I was a box of cereal being checked out of the grocery.
The attending came in and checked me over. I fidgeted at the thought of the radiation of the suggested cat scan, but I felt too sick to argue. This is what I would have suggested for my patient.
*
The cat scan was negative and I was sent home with an anti emetic. After sleeping most of the day I finally feel well enough to sit up and write this blog.
Tomorrow I will return to work and forget this day as if nothing happened.
But maybe I'll be just a little bit more understanding of what it's like to be sent to the emergency room.
Maybe, from now on I'll avoid crawl spaces.
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