How Was Your Shift?

*Details have been changed to protect the privacy of patients

She is 61 and she can’t help but smack her lips together repetitively. She has no teeth and the curvature of her spine makes her a miniature version of what she once was. Her frizzy hair is a purple-gray tone, and there are dark particles of something in the knots alongside her left temple. Her clothes are too loose and there are food stains on her shirt. The ambulance arrived at her home and there were pills strewn all over her floor and scattered pill bottles. She tells me that it wasn’t her. That someone had been in her apartment. That they were putting different pills in those bottles that weren’t hers. That pills were showing up on her floor. She was being followed when she went places. Her lips smacked harder as her anxiety mounted. She had to flush all the pills down the toilet because they weren’t her pills and so she didn’t have her own to take.   I ask if there is family I may call.  She stares back at me with hollowed eyes and does not respond.  She had just been released from the hospital a week ago for paranoid thoughts, but it is clear she will need to come back in.

He is 70 and his anxiety is like a storm cloud exploding in the room. He is overwhelmed because he cannot pay the bills and someone has stolen his identity. His furnace is broken and he is afraid the pipes will explode. He is concerned there is a carbon monoxide leak in their home and they are all being poisoned. At times he cannot speak because he is so overcome with his panic. He stutters and spits and cannot get the words out. I hold his hand and rock it back and forth as if to relieve the tremors that riddle his body.  I tell him it is okay over and over as I hold on; at times he appears momentarily calmed and is again able to speak until the next wave of emotions takes prey over him. His family arrives, and there are tears of fear, pain and love filling their eyes. None of this is real. No one has stolen his identity.  There are no broken furnaces and no carbon monoxide leaks. He paces at home and cannot eat or sleep. They have even called the fire department to the house to prove to him that there is no carbon monoxide leak. But it has not helped. These delusions have become his reality.

He is 57 and drinks every day and lives on the streets. He comes in one to two times a week for pain. Sometimes, he says his pain is so bad he wants to shoot himself. He says he has guns at his son’s house. This time he said he fell and his hip hurts. I help him take his pants off and he smells of urine and stool. Where can he go to take a shower? There are no bruises, scrapes, or cuts, but I x-ray his hip and there are no fractures. He says he won’t actually shoot himself if he can have a sandwich and bus tokens to go. He asks for a sandwich and bus tokens with every visit. He says his pain is 10 out of 10 and immediately falls asleep. It is the warmest and quietest place he will sleep until he comes back next week.

He is 20 and he overdosed on heroin. He was not breathing when the ambulance arrived. They gave him medication and resuscitated him and now his heart is racing and he looks bewildered as if he is on fire with anger. He says he knows it is dangerous. He has seen his friend dead in a car from a heroin overdose with the needle still in his arm. Maybe this is his rock bottom. I ask him if he is ready for me to help him get help so he doesn’t die too. He was really close this time. He says he understands what I am saying and he appreciates it. He says he is ready to stop, but he just doesn’t need help today.

These were four people I met on my evening shift last night. There are endless more stories like theirs. I don’t know where they were before they got to here, but I know life has not handed them anything. Their days are constant, steep uphill climbs. It may be addiction. It may be mental illness. It may be violence. It may be homelessness. It clasps its grip around them and won’t let them go. Day to day it swallows them and pulls them back down deep. There is little voice that advocates for and represents them. There is endless judgment that looks down upon them.

Friends and family will ask me how my shift went. I often don’t know what to say. Sometimes I feel I can help and do great things. Sometimes it is a vat of endless hopeless stories in a system with limited resources that continually seems to fail in one way or another. We will keep showing up and keep doing what we can, but it certainly is not enough.

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A Love Story

Most love stories we see in the movies begin with a young man, a young woman, a chance encounter, or these days—maybe a swipe right on an online profile. But the greatest love stories are those that go untold. And this love story—this is one of the greatest I have had the honor to witness, if only for a few hours of their story.

She started with her confusion four months ago. Initially, it started as small things that most would not have noticed. A misplaced purse. Forgetting where the car was parked. Forgetting to mix the eggs into the cake she was baking. Nothing any ordinary person hadn’t done. But soon it turned into something more, he explained.  Getting lost in their apartment. Realizing she had opened the closet door instead of the bathroom door and the shame that followed that he couldn’t shoulder for her. The full out heaves of tears he couldn’t calm when she couldn’t find the bathroom after all. The heart ache of watching her grab armfuls of clothes from the closet and place them on the floor with such purpose, knowing there was only a mass jumble of thoughts and hysteria behind her frantic actions. It was a test of stamina to care for her, to look after her, to help her find the way in this narrowing, dark tunnel of her mind. It tired her too. And she slept. She slept after breakfast, she slept after lunch, she slept after dinner. Her waking hours became so sparse, but when she was awake, it was so filled with hyperactive conviction and activities that were seemingly purposeless. He would spend her sleeping hours placing all her shirts, pants, and dresses back in the closet. Washing stains off her clothes that she had spilled soup on. Salvaging what he could out of the trash of the oranges he bought yesterday that she had thrown away.

And soon, she lost her ability to dress herself. And it angered her. With such frustration, she would pick a dress, throw it on the floor, not knowing how to put it on. She would pick something else out of the closet, throw it on the floor, acting as if it wasn’t that she didn’t know how to put it on, but that she no longer wanted to wear it. Yesterday, she settled after picking a towel, laying it neatly on the ground, and with a satisfied content look, declared that this towel was in fact the dress she had decided to wear that day. He told me this, then fell into silence; keeping his eyes locked on my reaction, as if he couldn’t believe his own words, as if he wanted me to tell him they were not true.

He shared most of these things with me in rapid succession, with the same low, quiet, monotonous voice. His eyes tired but gentle; he spoke with such tenderness and love for his wife. This was a love that had grown over 51 years of marriage. Four months of hardship was worthwhile so long as he still had her.

She lay in the hospital bed with her eyes closed. I talked to her softly as I examined her. He chuckled at me, “you know she is probably stone cold asleep, don’t you?” She awoke when I sat her up to listen to her lungs. “Marty?” She said, startled by my presence. “Yes, May? It’s okay. It’s just the doctor. She is just taking care of you.” “Hm.” she grunted as her shoulders relaxed.

Last night had frightened him. “It scared me the way she was acting.” For the first time, he had seemed to slip from her mind. It had been different when it was the location of her purse, the location of the bathroom, or even how to put on her pants. Last night, she couldn’t remember him. She had asked for her pain medication, and when he gave her only one tablet as prescribed, she had become upset. Looking straight at him, she had said, “I don’t know why Marty wouldn’t give me the whole bottle so I could take what I want. He would only give me one tablet! ONE tablet! Can you believe him?” she had shouted at Marty. She proceeded to ask him to call the police, as there was a man in their home. She tried to leave the apartment without her shoes on with the car keys in hand. “And she doesn’t drive. She’s never been like this. It scared me.”

They met 60 years ago in fifth grade. They spent much of their adolescent years getting to know one another, and at the age of 20, they married. They spent the next 51 years married, 20 of those years married with multiple sclerosis grabbing a hold of her and settling into their marriage with them—an unwanted, dreaded third wheel. There have been good days and bad days, early on the good days outnumbering the bad days and making them tolerable.   These days, the bad days like a storm cloud ravaging all their days. There are days with falls. There are days with anger. There are days with forgetfulness. And every day that slides by, he tenderly holds onto the girl he met all those years ago. His one love.

I walked into room 14 of our emergency department, 4 hours into their visit. I found him sitting still next to her bed holding her hand in silence. The TV off, her eyes closed, the lights dimmed. Her presence—even in these dark days that have consumed them, even when he is losing his ability to care for her in the way he has for 51 years—her presence still his greatest comfort.

Where they go outside of the doors of our emergency department will be a new chapter in their lives. Their story is one of the great love stories that deserves to be told. A love that knows no end.

Beyond The Final Breath

Republished at:  https://www.washingtonpost.com/national/health-science/we-didnt-save-his-life-but-we-didnt-disrespect-him-either/2017/02/03/74612afe-d1f6-11e6-9cb0-54ab630851e8_story.html?utm_term=.9e665c02ec43

Republished at:  http://www.kevinmd.com/blog/2016/12/didnt-save-life-better.html

“Well?  Did you save him?” “No. We did better than that.”

He came in pulseless. The machine performing chest compressions with the rhythmic thud, thwack, thump. His ribs heaving under the force of the compressor, keeping his heart artificially beating. The plastic tube secured in his airway forcing puffs of air to inflate his lungs.  His skin slightly purple-gray, on that narrow brink between life and death. His eyes like speckled round pieces of glass, with fixed pupils, staring nowhere.

Our team was assembled, prepared, ready. We worked deftly with experienced hands, our focus and determination fueled by adrenaline, a synchronized team, we worked side by side; this was our life to save and we were going to do everything.

But his glassy, fixed eyes spoke to me. As we regained a heartbeat, and we halted the chest compressions, and our adrenaline settled–here he lay, not out of the woods, but heart back from a standstill. His glassy eyes told me his heart was back, but his life of living was gone. The life that laughed, that smiled, that held his wife’s hand–there was no amount of life saving measures that could bring that part of him back.  We didn’t know how long ago he had stopped breathing. But it was long enough to have robbed him of his mind, his memory, of everything that made him that man his family loved.

His wife and only daughter arrived. I left him in my able teams’ hands and sat down with them. I looked them in the eyes. I told them the story of his final hour of life, from the perspective of his fighting, beating heart.

His heart was here with us, but his  brain had gone too long without oxygen before we could reach him. He would never walk out of this hospital. They listened to my words.  Words spinning and exploding beyond comprehension. They nodded their heads, as if to ask me to keep talking.  So long as I was talking, we didn’t have to move.  Tears were inevitable. It was so sudden. How could they be asked to make a decision of whether to continue with the resuscitation or to just let life walk its final march.

Yes, this was about them, but this was ultimately about him. What would he want? It is true it was sudden. It is true it is the toughest decision anyone will make.  But with the return of his heartbeat, the decision to continue resuscitation is as big, as active a decision as it is to stop all aggressive measures and let him be comfortable. These are both big decisions with big paths for us to travel down.  I needed them to understand that this wasn’t their decision to shoulder. It was their time to respect–in the most selfless of ways–the man they loved.  To step outside themselves, slip into his shoes and honor his wishes in the greatest way possible.  What would he have wanted if he saw himself in this moment?  Representing him in this way is a responsibility no one cares to bear, but this final act is the biggest, most giving way they could love and honor him.

His daughter immediately said, “oh, he would want none of this. He would want you to stop.”

They stood by his bedside. We withdrew all aggressive cares. We turned off the beeping monitors, we stopped artificially putting oxygen in his lungs, we turned off all pumps, we covered him with warm blankets, we let him be comfortable with his wife holding his hand for his final minutes, and his daughter stroking his hair.

And that’s how he left us.

Did we save his life?  No we did not.  Not today.  We did better than that. We upheld our promise to continue to respect his wishes beyond his final breath.

About A Boy

8 years old. Blond hair, neatly cut. Fair skin with flushed cheeks. Curious, trusting, clear blue eyes. Rosy, red lips in a perfectly content, relaxed grin. Wearing a plain red cotton t-shirt and blue jeans with the elastic waist and Velcro sneakers. I meet you in your wheelchair. I asked your dad what was the best way to get you onto the hospital bed to examine you. He picked you up easily in a bear hug, and your lanky, skinny arms wrapped around him, as your tight, contracted legs held their bent position as he plopped you gingerly on the bed. I listened to your heart and lungs, I pressed on your soft tummy, I noted the pull-up you wore with Buzz Light Year printed on the front. You never took those calm, trusting eyes off of me. You never smiled, but your whole face smiled at me. You never spoke, but your whole being spoke to me.

This was maybe two weeks ago, but my visit with you still pops into my mind frequently. It’s unpredictable which patients stay with us. We see patient after patient, and some just settle into our hearts and mind, lingering in our thoughts, reminding us that after they leave our care, they are still here.

What I remember about you is how sweet and happy you are. How you didn’t have to say a thing to let me know you trusted me. You trusted your dad. You trusted this world that you live in. On this day when you weren’t feeling well, you still smiled with your whole face.

What I remember is how well cared for you are. Your styled hair. Your clean clothes and newly changed pull-up. Your new Velcro sneakers and socks without holes.

What I remember about you is how much you are like my own son. Your lanky arms, your lanky legs, your fair skin with flushed cheeks. Your big, curious eyes, trusting me.

You came in for nausea and vomiting.  While this is something that has plagued you in the past, this time, it was just a stomach bug rippling through your daycare.  Your dad relayed this in sighs of relief.  Because this was something common. This was something other kids were going through. This was a “just-like-everyone-else” problem and not a “just-unique-to-you” phenomenon.

See, there are milestones that you and your family have not experienced. Your first word. Your first steps. Your first laugh. But there are milestones that are like gold. Those first hugs. Those first nods of understanding and communication. The realization that you are taking it all in, and those eyes are your window to experiencing and memorizing this whole world around you.

I cannot begin to comprehend how hard this life is for you, for your parents, for the three brothers that came before you. I also cannot speak for the immense beauty and happiness in your life.  But the one thing that I do know is that you are loved. You are enriching and touching the lives of your family, of those like me that have had the honor of meeting you. This I have experienced first hand.  You are louder than you could ever be in your steadfast ways.

You didn’t have to say a word, but you have touched me. I see you the way I see my son. A wonderful boy that is filled with love and that is loved.

Life is hard. It is hard in different ways for different people. But it is these moments of strong, quiet beauty that keep it tender and keep it worth our hardest work.

The Best Friend You Never Wanted

This moment has been rolling around and around in my head. I sat down on the stool. I turned to my patient. He was intoxicated. I realized I had seen him here in my emergency department just six days ago. “Hey.” I said gently. “What happened?” Tears welled in his eyes. He went into the story of his past six days. I had seen him six days ago, and he had begged to go to rehab. As he had innumerable times in the past. He really wanted help. He needed help. But it never helped. He had gone to a Detoxification Center and had stayed there three days where they ensured he went through withdrawals safely. Then he went home. And he started drinking again. And here he was. Back again. “Please. I need help.”

I leaned in. I listened. I nodded. I felt his sadness. He suddenly stopped talking abruptly. And he just stared at me. “Why do you care so much?”

The question startled me. Took me off guard. No one had ever asked me that. And trust me. I have been asked some fairly awkward questions. Why do I care. How do I even answer that question? Isn’t it just a fundamental part of what I do?   At the time, I had no eloquent answer.  I just stared back.  And dumbly said, “I just DO. I care because I know you need me to.”  At the time, I thought, I care because you are hurting. I care because you are human and everyone makes mistakes. And I believe you. You need help. This is your hellish cycle: You get help. It fails you, or maybe you slipped back away yourself.  Or maybe it is a combination of both.  It doesn’t matter. Then you need help again. I don’t know. The system is broken. It is so broken. And for you, something is failing, time and time again.  I do care. I don’t know. I can’t explain it, really.

But when he asked that question, I felt it knock the wind out of me. All of the caring I had bottled and neatly packaged into some crevice of my chest resurfaced into this avalanche of emotions. Yesterday, I saved a life. I brought his heart back from a standstill just as my daughter and son’s kindergarten open house was starting. I missed the open house waiting for his brother to arrive so I could talk to him. But I got there (mostly) in time for the kindergarten meeting. I sprinted up the walkway to the elementary school entrance, out of breath, just in time to see my daughter’s face light up when she saw me.  I mouthed an apologetic “sorry” to my son’s kindergarten teacher who was in the middle of addressing all the on-time parents as I slipped into a seat in the back of her classroom.

Before I walked into this room, I delivered a 16-week-old baby that the mother had spontaneously miscarried. I left her to grieve in private with her husband. And her baby girl. Tiny fingers. Tiny toes. Lifeless. Limp. Wrapped in a warm blanket. I’ll remember my heart-broken patient’s face. Stunned, sweaty, strong, brave. So many questions. So many fears. So much loss.

I care because it is all so much bigger than me. It is about lives. It is about families. It is about death. It is about surviving. It is about hopes.  It is about milestones. And I don’t know how to make sense of it all, how it all strings together and falls into place. Sometimes, I don’t know what else to do but care. To be present. To listen. It seems so very, very surreal that I can grieve the return-to-life of someone that I am not sure will make it to tomorrow as I race in the door, breathless, to my son and daughter’s kindergarten meeting.

I care because I am the best friend you never wanted.  You come into my space and tell me your most personal thoughts.  You tell me how this was unexpected.  How this is a horrible day.  How you had so many exciting hopes and daydreams for this growing baby in your womb.  How ecstatic you were to be a cozy family of three.  You tell me that my dying patient is your brother and you are the only family he has and how you wished he and his daughter had made amends.  You tell me you have been in and out of 14 different rehabs and you just want help.  You just want help.  Is there anything else I can do?  These are all the things you want to tell your best friend.  The best friend that you haven’t had a chance to call yet as you were rushing to the hospital.  The best friend you never had but wished you did.  The best friend that has given up on you because you have had one too many chances.  But here we are, just you and me, staring at one another.  So, you tell me your story.  It is about your hopes, your fallen dreams, your gut-wrenching day of heartbreak.  And it is all so real and I can’t help but feel fallen with you.

This is what we do. My colleagues and I. We care. We care more than you know. We don’t know the best way to express it all the time, but we do. We wonder if you have already started setting up the nursery that you will now have to let sit empty.  And we secretly hope you have not, as we can’t imagine the heartache of deciding whether to leave it as is or take it down.  We wonder if you will live to walk out of the hospital.  We wonder if this time, maybe this time, you will get the help you need.

We are far from your best friends.  But today, we will be who you need us to be in your life.  We will time and again–without question–put our lives on hold for yours. We will grapple with the balance between life at home with lives at work. But we know what is important. I can’t explain it better than to say, our hearts are with you.

Your Last 24

There are those 25 minutes before my work day begins that I either drive in silence, or blare the radio and jam out to pop hits priming myself for the unexpected hours ahead. When the music is loud and the tempo is upbeat, it transports me back to being 21 on a summer day in Chicago, before kids and bills, headed nowhere too important, definitely not too fast, stuck in traffic on Lake Shore Drive. But lately, I’ve trended more towards driving in silence. Calmed by the gentle hum of the engine, feeling the gentle pull of the turns in the road, letting my mind settle. And lately, my mind has been on you.

My heart settles into a dull ache. It pulls me in and hollows me out. I feel unjustified in feeling this way. These are not my feelings to feel. These are not my emotions to own and declare. There are people more deserving of telling this story. It is not me. But here I am. These emotions clinging onto me for the past 5 weeks now, and I don’t want it just to be in my mind. I don’t want this hollowness in my chest to go unidentified. It means too much. So, I’m going to talk about you.

I met you on a busy night in the emergency department. You were short of breath, you were sweaty, your heart rate was going too fast. I thought within seconds of meeting you, “He is sick.”

When emergency medicine providers say someone is sick, it doesn’t mean the usual sick.  We do not throw around the word “sick” haphazardly.  It does not mean you have the sniffles, or a bad cough, or fever, or appendicitis, or a broken leg. When we say “sick”, we are on high alert. Our heads turn.  Our focus shifts from everyone else in the emergency department to you. You are the one that needs us most. We will take care of everyone else, but you have taken priority over everything else that must be done. Bluntly put, when we say “sick”, we realize–perhaps before you do–that you are struggling for your life.  We are worried that you may get worse and die.

Everything had happened so suddenly, your wife told me. You had seemed fine. Maybe a little fever. Maybe a bit of body aches. Then tonight, you were suddenly short of breath. Sweating. Feeling your heart beat out of your chest.   You have no idea what suddenly changed. I don’t want to get into the medical specifics. Though I replay them over and over in my mind. I pour over your chart again and again. What more could I have done? I’ve talked to my closest colleagues. I’ve lay in bed at night and replayed everything.

I remember exactly how you looked when I walked in the room. I remember your wife sitting there on the edge of her seat.   I remember you said you have three kids. Two boys and a girl. I remember how old they are. I remember the name of your youngest. I remember the puzzled look your wife gave me, “What is going on?” I remember explaining to the both of you what was happening. How infection was taking over your body, taking over your organs, shutting down your body. You asked me how long you would be in the emergency department. I explained you needed to be admitted to the intensive care unit. You both were a bit puzzled. How could a healthy 43-year-old become sick so fast? I explained that I was worried about you.

I don’t worry about a lot in the emergency department. I can handle it. I can fix it. But you. I was worried about. I did everything my training had taught me to do.  You were getting better. I felt slight hope that maybe things would turn around. You were admitted to the intensive care unit.

The next day, I checked on your chart when I got to work. You had died.

You have a beautiful wife. You have three amazing kids. You are the nicest of people. You are hard working.

You are no longer with us.

My heart aches. My heart aches, but when it aches, it is an unworthy ache. Because the heart ache of those that love you, those that were your life: your wife, your children, your parents, your siblings, your nieces and nephews, those are the ones that are truly hurting. And this makes my heart ache more. I wish you were alive. They wish so more than my words can do justice.

I did everything I knew how to.  But it wasn’t enough to save your life.  I wish I could have done more. I am so, so sorry.

I was maybe one of the final ten people you met in your life. For you, I was only part of those last 24 hours. For me, you will be in my heart a lifetime. I can’t even say this without grimacing, because what you mean to me doesn’t even compare to those that love you most. But I just want you to know, you have affected me. You will stay with me. You will live on in every one you touched along the way. Even in your last 24 hours of life.

The Sound of Resiliency

As Previously Published:  http://www.kevinmd.com/blog/2016/08/laughter-thats-sound-resiliency-hear.html

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 9-1-1. 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 de-stress 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.