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.

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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.

Valentine’s Day

To my husband,

It’s Valentine’s Day, and I have something to tell you. I came home yesterday, and I didn’t tell you about the worst part of my day. I didn’t tell you, because it was so hard to say even once to that daughter yesterday that her father had colon cancer. It was hard to tell her that the reason he had been bleeding for months was because that cancer has been growing inside of him, undetected. When she brought in her father, the first thing she told me was, “I want a full work-up. We need answers. We cannot leave until you have done a full work-up and we have answers. Do everything. We need answers.” I wish what I found wasn’t the answer. I see her face, looking at me, slightly bewildered, in disbelief, as I told her the news that made her world cave in. Her tears followed, and so did mine.

I felt guilty to be able to damper my own emotions by leaving work. By not talking about them. I can make that choice, but she cannot. She will talk about it and talk about it, and continue to break down as she calls and tells her sisters, her mother that is at home, the rest of her family. I told her the news, and her world changed forever. Her dad was my last patient of the day. I saw him at the very end of my shift, and I stayed late to make sure he was taken care of. But that is all I did. Because then I left, and I came home to you. I came home to our beautiful, laughing, loud children, racing in our beautiful home. I came home to their squeals of “Mama!” and their hugs that nearly knock me over. I came home to our healthy, fortunate family.

I told her daughter first. I wanted to prepare her before I told her dad. When I went in to tell her dad, she started to cry. He said, “So, I’m going to surgery. Well. When I go to surgery, then you can go ahead and go home. Now, what are you crying about. There is nothing to cry about.” And this made her cry harder. Because there he was. Her dad at 89. Still her dad. Still taking care of her. He will always be her dad, and whether he is 35 or 89, he will love her with all his might. Sometimes he gets confused, and sometimes he can’t answer my questions because he doesn’t remember when he last ate or if he has been sick, but his love for his daughter—this he will not forget. He has loved her from the moment he met her. This is imprinted in who he is. This is their life together. This is their family.

My mind was wrapped around this family all evening. I came home and breathed in the smells of our 21 month old. I snuggled a little bit longer with our five year olds. I felt the comfort of your love and the way you busy yourself with taking care of me when you sense that I am limping along that last stretch of the day. I am eternally blessed with so much. And left at work, is a family sitting on the edge of those waiting room chairs. Waiting for answers. Hoping for the best, fearing for the worst. I feel thankful. I feel guilt. I feel happiness. I feel sadness.

I know Valentine’s Day is a contrived holiday, but I’ll happily take any reminders in whatever shape and whatever form they come. Today, I remind myself that there are so many people I love so deeply. I am thankful for their health and their presence in my life. Today, I remind myself, that above all else, I have you. You are my forever partner. You are the amazing father to my children.  You are my rock. Many decades from now, we may forget what we ate for lunch, we may forget if that cough was from last week or last month, but we will remember that we love each other. We will never stop taking care of one another. We will never stop putting each other first.

To be honest, I didn’t get you anything for Valentine’s Day, and I truly don’t want anything from you. All I want is time with you. All I want is to spend a day, just you and me. Because that is how all this wonderfully exhausting chaos all started, and at the end of every day, that is all that truly matters to me. Time spent with you. Time spent with our amazing kids. Because sometimes, tomorrow is the day that you hear the news that makes your walls crash. I hope that day is far away, but today, I will cherish what we have, I will love it all, thank my lucky stars, and count down the minutes until I get to see you after my work day.

I didn’t tell you about the worst part of my day yesterday.  I didn’t need that heaviness in my chest to grow heavier.  I just needed to be with my family. I watched you play with our squealing, joyful baby girl as she rolled around the floor with you, and called out, “Mama, look!” as she stood gleefully on your chest, bouncing up and down at your expense, listening to your overemphasized grunts to her jumps put her into fits of giggles.  I couldn’t help but imagine my patient with his daughter and feel comfort that they had had moments just like this one.

There are big things that happen. Big amazing things. Big devastating things. There are little petty things that bring our days down. But my favorite things are the every day mundane things that give us joy. That build our family. Today, I am reminded of this healthy, full life we have. This is our life together. This is our family.

Happy Valentine’s Day. I am thankful that today, we have nothing to cry about. I love you with all my might.

December 28, 2015

 

I met you on the worst day of your life. You will always remember the day. December 28, 2015. I walked into your patient room, I shook your hand, I told you who I was, and you told me your story. You told me why we were meeting that day. You told me that you were pregnant, 7 weeks along. You started bleeding that morning. But you didn’t have any pain. You looked anxious, but hopeful. You had your game face on. I told you what we were going to do. Some blood work. An ultrasound. These would be a long three hours for you to wait while fearing the worst and hoping for the best. To me, it was another day at work.

I didn’t know your whole story. I knew the man in the room was your husband. I could tell he was most worried about you. I could tell that he shared in your dreams. I didn’t want to pry. I let you tell me what you wanted to tell me.

Three hours passed. To me, it was a quick, fast-paced three hours. To you, it was the longest wait. You were trying to hang on to your patience. Why was this taking so long?

And then I got the results. And it was what you had been fearing. You were no longer pregnant. It was a jab to my heart. I sat at my desk and looked at the results. I paused. My shoulders slightly slumped, and I took a deep breath and walked to your room. I knocked. I sat down. And I told you the news.

It was your worst nightmare.   It has been your greatest daydream to have a baby. You stared at me, hanging onto my every word. Maybe hoping I had made some type of mistake. Maybe waiting to hear what was to come next. Maybe to comprehend every bit of what was going on. Maybe to distract yourself from your heartache.

I didn’t know your whole story. I told you what I knew, and then I sat in silence. I waited. Your husband said, “We’ve been trying for five years. This was our last embryo.” You didn’t take your eyes off of me, you reflexively said, “but it’s okay.” Because you had said it before, and it was an easy way to fill the silence.  But it truly wasn’t okay to you. This was your last embryo. That slight jab in my heart now felt like daggers. I wish I could help. I so wish I could help. I wish you had cut your finger instead and I could stitch it up. I wish you had broken your leg so I could put it in a cast.

But this. This was it. This was the end of your dream to become pregnant. Maybe down the line, it truly would be okay. Maybe you would decide to adopt and never look back. Maybe you would decide to travel the world and live an unexpected, but still wonderful life. Maybe you wouldn’t.

All I know, is that at that moment, you were devastated. I met you, and it was the worst day of your life. It hit me: everyday, I am meeting people for the first time on their worst days.   I wish it wasn’t that way.

It was another day at work, and I wouldn’t remember the date, but you would. As I processed the events of my day on my drive home, I felt that aching heaviness that hovers over me in these dark moments.  I vowed to remember this date with you. For you. For all my patients on the worst day of their lives. December 28, 2015. I’ll remember this date. I wish I could do more.

 

 

Let Grief Be

A 23 year old girl is roomed with abdominal pain. It is a busy Friday evening in the emergency department and on my mind is my patient that I just told is having a heart attack and am having sent to the cardiac procedure center where they can determine where the blockage is and hopefully open up the blockage before any more of his heart tissue is damaged.

I walk in to see my 23 year old patient, and see her near hysterics, writhing in pain on the hospital bed. She grabs the railings and thrashes back and forth yelling out in pain. I ask her quickly where her pain is, and she yells, “My stomach! My stomach! Please! Help! My stomach!” I try to get more of a story, but she is in so much pain. I find out that she thinks she may be pregnant but she doesn’t know how far along she is. She appears to be having contractions, lower back pain, maybe she is in labor, but she seems early along in her possible pregnancy. I tell her I am going to find her nurse so we can start an IV and get her some pain medication while I try to figure out what else is going on . So, I step into the hallway and look up and down, and see no one in sight. I step out further and see that all my nurses are in patients’ rooms taking care of other people.   I step back into the room, and see my patient sitting slightly up against the incline of the bed with her legs bent at the knees. She is calm. I also see under the edge of her hospital gown, an image I will never forget.  She has miscarried her baby.

I look up again at my patient. I’m not sure if she knows what has happened. I sit down next to her and rest my hand on her arm. “I am so sorry, but you have miscarried your baby.” I stare intently at her face, trying to read her expression. She stares at the warm glow of her smart phone. I want to throw my arms around her, comfort her, talk to her. She says, “Ok.” I tell her I am going to have to deliver the rest of her pregnancy, that I’ll need to deliver the placenta. She responds monotonously, “Ok. But please. I don’t want to see. Please don’t tell me how far along I was.” She never looks up from her phone. I finish taking care of her and sit back down next to her. I explain what I have done, but am sure to honor her wishes. I explain the next steps and what to expect. She nods, she is void of any expression. I ask her what questions she has, what concerns she has, how I can help, what resources she needs. She needs nothing. She has no questions. No concerns. How long until she can leave. Please don’t tell her boyfriend who is waiting in the lobby. I say again, “I am so sorry.” I linger. She nods again. I have so much empathy and support to give. She would rather not have any.

I think about her often. I wonder what I could have done differently. I wonder if she had questions or concerns. I wonder what thoughts were spinning through her head.

What I have learned over the years, is that everyone grieves differently. Some cry. Some panic. Some act brave. Some become frustrated and angry. Some are in denial. Some use humor to get them through. Some ask questions repetitively and talk in circles, as they are slowly processing this big moment in their lives. And some are like her. Expressionless. Detached. Dealing with whatever it may be in their own ways. And that’s the exact thing about grief. It presents in different ways. No two people grieve the exact same way. I may have wanted to throw my arms around her and I may have expected tears, but that is not what she needed. She needed space. She needed me to stop talking. And that is okay. Her grief and my grief and your grief are not the same. We need to respect that of one another and let each person take the lead on how they need to react and how they need to heal. No quick judgments that because there were no tears or outbursts, that she is not in pain. There is no need for her to explain her reaction.

I still wonder what more I could have done. But I was there. And I will be there again and again for my patients. And that is the best I can do and what I will promise to continue to do. I will wonder and ask what more I can do and be there however they need me to be there.

My Parade and Me

Republished at http://www.kevinmd.com/blog/2015/12/physicians-jaded-keeps-medicine.html

Republished at http://www.scarymommy.com/life-as-a-doctor-and-mother/

I am constantly coming across articles written by physicians with strong voices.  Physicians that are jaded. Physicians that didn’t go into medicine to be dictated by patient satisfaction surveys. Physicians that didn’t go into medicine expecting that people wouldn’t trust in their training because “WebMD” begs to differ. Physicians that cringe at the drive-through mentality that patients can present with diagnoses in hand and demands for tests to be done. Physicians that want out.

As I read these articles, their sentiments resonate with my own experiences. But what we don’t talk about is what pulls us back in.

My patient in room 7 is 10 weeks pregnant, terrified she might be miscarrying. She hides her thoughts by pre-occupying herself with her blonde, curly-haired 2-year-old daughter. Ultrasound and blood tests confirm that she is in fact miscarrying. She busies herself with readjusting her daughter’s perfectly buttoned shirt while I confirm her worst fears are true. Willing away eyes welled with tears, she nods and smiles, keeping a brave face for her daughter. I sit by her side and hold her hand. I try to give her hope. Before I leave, she squeezes my hand.

My patient in room 1 is dying. She is 92 years old and her daughter is at her bedside. She celebrated Thanksgiving with her family, including her 17 great grandchildren. But her disease is progressing, and she has declined further intervention, because if this is her time, she wants to enjoy her remaining days at home with her family. And today, during my shift, is her time. Her son comes later, and asks me to please let his mom die with dignity. So we turn off all the monitors, dim the fluorescent lights, and remove her from all the wires, and let her be a mother, grandmother, great grandmother enjoying her last breaths flooded by memories of all the love of her family. Her daughter holds onto the necklace we had removed from her neck in our initial attempts. She sits at her mom’s side, this 57-year-old daughter and mother of four. She cries with her eyes clamped shut, and she rocks back and forth and murmurs repeatedly between sucked in breaths of air, “Mommy, Mommy, Mommy. Oh, Mommy, Mommy, Mommy.” I rub her back. I am sure she has forgotten I am there until she turns to me and asks me to put her mother’s necklace with a small angel charm around her neck. I take the necklace and drop it through my fumbling fingers. I pick it up and drop it again. She just has one simple request. Can’t I just do this one thing for her?  The fast pace of the emergency department slows, every beep of a monitor, every hurried set of footsteps, every ring of the ambulance phone seems to muffle and all I want is to put this necklace around a grieving daughter’s neck. One month later, I receive a holiday card from the patient’s son. It has evergreens with snow and glitter and a cardinal on the front. It reminds me the holidays for this family are forever changed. “Thank you for allowing my mother to die with dignity.”   Three years later, this card lies in my box of cherished cards and pictures from close friends, my husband, and my kids.

In room 11, first-time parents bring in their son. He is 3 months old and he won’t stop crying. He cries during the day, he cries through the night, he won’t stop crying. Why won’t he stop crying? They have been to their pediatrician innumerable times. But right now, it is 2 in the morning, and there is nowhere to bring him but to the emergency department, and we have found nothing wrong. How could there be nothing wrong? The three of us hold a quiet conference as to not wake the semi-sleeping baby. We talk, not about medicine, but about my own experience with my son who was 3-years-old at the time. We talk about how he cried too, and he wouldn’t stop unless we held him all the time. And we were so exhausted. My husband was so sleep deprived he was having visual hallucinations. We took turns on which day we would brush our teeth and shower. The three of us laugh (cackle quietly) at what absurd things sleep deprivation can do to a person. We talk about how I never thought it would end. But it did end. One day, he just started sleeping. We were so exhausted that we didn’t even notice until we had slept for four consecutive hours and woke up in a frantic panic. They listen intently. They sigh a tired kind of relief. There is someone that knows what they are going through. They are not alone. They leave with the same son they love deeply that still won’t stop crying, but feeling some sense of peace–or maybe even hope–they hadn’t had before. I didn’t figure anything out for them, but it was worth the visit.

Here is the truth. I went into medicine because I believed that if I put hard work into learning about illness and treatments, I could help people at their greatest times of need. What I know now is that medicine is about caring for people. But it is also about confrontation and conflict. It is about taking things in stride. It is about leaving your work at work so you can come home and be a mother or daughter or wife so you can preserve balance and your sanity.

Except for those moments that hit me in the gut, the heart, the soul. I hold onto those moments. Correction: they hold onto me. They roll over and over in my mind. They replay in my mind when there are quiet gaps in time. They are the parade growing and marching behind me five months later, 3 years later, 8 years later. They keep me going.

I acknowledge that those creeping feelings of wanting out are there. I sometimes hold my breath anticipating my cracking point. But then something happens. I get a squeeze of the hand. A card with evergreens and glitter snow. A couple that just needs to know they are not alone. And it is a big red reset button. And it is worth it. And I keep going, parade and all.