“Umm, can I have a doc in this room? ”
The nurse was casual and collected. But anytime a nurse asks, “Can I have a doc in here?” you can be pretty certain there is some excitment in your near future.
She & I alternated glances between the patient and the monitor.
Patient: awake but confused. Monitor: Rapid heart rate, undetermined rhythm.
The nurse said, “I thought she may have been in vfib for a second, but she looks OK now.” For a brief moment I felt all knowledge leave my brain. I was unable to neatly categorize this patient into a diagnostic box. We knew nothing about her. The paramedics brought her in on a stretcher, provided no history and said, “She’s fine,” then they left.
As I ran out of the room to pull up an old EKG looking for a similar tachycardic rhythm the nurse rapidly stuck leads to the patients chest to run a 12 lead. I scanned through her old EKG images as if I were playing a game of concentration with a deck of children’s playing cards…no 2 EKG images looked alike. Fast, slow, narrow complex, wide complex…did this woman have any EKGs that looked “normal”?
The new EKG looked nearly identical to one I pulled up from a few months ago. Rapid Atrial Fibrillation. I was relived. Her blood pressure was in the 160s…plenty of room for some calcium channel blockers to slow her heart rate down. The only thing I didn’t have an explanation for was …
Massive Confusion. Suddenly her eyes got as wide as dinner plates as she gripped both bedrails with either hand. Her mouth gaped open as if she was trying to communicate…something…anything to us.
The nurse and I looked back at the monitor. Her heart rate had gone up to 200 and her blood pressure dropped to 70.
“Let’s shock her,” I quietly said to my reliable team of two nurses.
I felt myself getting hot as if a warm bucket of surreal had been poured over me. I asked for some ativan to be given before syncrhonizing her cardioversion, but I couldn’t wait any longer. In the old days, this is where I would have turned to the life pac monitor, grabbed the paddles from their holsters and had a nurse squirt conductive gel on the metal surfaces. I would have rubbed them together, placed then on the patient’s chest while I leaned in with my body weight yet avoiding all contact with the bed and any random patient body parts like wandering hands or floppy arms, shouting “SHOCKING ON THREE”. Cardiac resuscitation used to be so much more dramatic…TV show dramatic.
Instead, we gently placed adhesive pads to the patients chest & back. I turned to the crash cart and rotated the knob from “monitor” to “defibrillate” while the nurse pressed “synchronize”. After I saw the reasurring punctuation of the course LCD monitor identifying each QRS complex I checked the patient one more time. Heart rate 200, in a sine wave shape. She still had dinner plate eyes and her pressure continued to drop.
I hated to do it but I had to. “Shocking on three,” I quietly said to my team. One, two, three...I pressed the button and the unnerving pause that accompanies a synchronized cardioversion made my heart skip a few beats. After what seemed like an eternity, but was probably a fraction of a second, there was a click, followed by a shriek. Her body briefly convulsed but her eyes remained open. After a moment, she’d forgotten what happened entirely, but her heart had fallen into line in a rate controlled atrial fibrillation.
It’s not often we see someone’s rhythm convert right in front of us, and even less often that a single shock does what we are told it should do. Most often we see patients when they are far beyond reasonable methods of resuscitation, but today was different. Thanks to the nurse who was not too timid to ask for another set of eyeballs on her patient we were prepared to do what we are trained to do best…shocking on three, one, two three…
I invented blogging. No really. As a first year medical student in 1998, I was trying to develop a Visual basic application that would auto-publish entries from an access database on my home computer to my University web account, but alas, I was busy with things like anatomy and biochemistry.
The following year, a senior student introduced me to the idea of creating a blog, which at that time, was still an unheard of medium for creating web content (and who had ever heard of “content”?). Finally, by the end of my intern year, while sitting in the ICU trying to keep a twenty year old race car driver alive, I wrote my first blog post. Then I wrote another and another. I documented my revelations about learning medicine, the journey that my own patients revealed to me.
Daily as my sleep deprived mind both memorized standard practice and absorbed new journal articles, I was constantly writing. I’d care for a sick child and in my mind I was blogging about it. I performed my first trauma resuscitation and in my mind I was blogging. When the Amish family of a dying man sang in the ICU…I blogged about it.
At that point, my blog was one of the most popular medical blogs and the first emergency medical blog that I know of. As popularity increased I tried hard to both capture my thoughts, emotions and experiences while remaining anonymous. I shared my journey of becoming a physician with my readers..through the cold clinical discoveries, to saving my first life, to learning (again) that patients are people…my thoughts were all open. All of these things I shared publicly, with the world, with anyone who had an internet connection.
Interview requests from medical writers came and I declined. I did not want anyone to know who I was, I feared that I had shared too much about myself. But at the same time, my family felt closer to me than they ever had. My father still recounts stories from that time…stories I’d never told him personally, yet he’s got the words nearly memorized. My grandmother kept a printed stack of my stories on her reading table. When I miss my grandfather…I can just revisit my blog and the memories come flooding back (and I usually shed a tear or two).
Through my anonymous blogging life I made friends, grieved for friends, watched friends rise to (relative fame) and yet I retreated. At points in my life my blog was my solace, my retreat and my joy. My blog sits now docile for the most part, a series of a thousand or so tiny milestones in the process of becoming a physician. It will always be a part of who I’ve become, who I was then and who I’ll be tomorrow.
Blogging is a powerful tool.
I did not write this. But I should have…
Sunday Forum: Suck it up, America
We have become a nation of whining hypochondriacs, and the only way to fix a broken health-care system is for all of us to get a grip, says DR. THOMAS A. DOYLE
Sunday, October 11, 2009
Emergency departments are distilleries that boil complex blends of trauma, stress and emotion down to the essence of immediacy: What needs to be done, right now, to fix the problem. Working the past 20 years in such environments has shown me with great clarity what is wrong (and right) with our nation’s medical system.
It’s obvious to me that despite all the furor and rancor, what is being debated in Washington currently is not health-care reform. It’s only health-care insurance reform. It addresses the undeniably important issues of who is going to pay and how, but completely misses the point of why.
Health care costs too much in our country because we deliver too much health care. We deliver too much because we demand too much. And we demand it for all the wrong reasons. We’re turning into a nation of anxious wimps.
I still love my job; very few things are as emotionally rewarding as relieving true pain and suffering, sharing compassionate care and actually saving lives. Illness and injury will always require the best efforts our medical system can provide. But emergency departments nationwide are being overwhelmed by the non-emergent, and doctors in general are asked to treat what doesn’t need treatment.
In a single night I had patients come in to our emergency department, most brought by ambulance, for the following complaints: I smoked marijuana and got dizzy; I got stung by a bee and it hurts; I got drunk and have a hangover; I sat out in the sun and got sunburn; I ate Mexican food and threw up; I picked my nose and it bled, but now it stopped; I just had sex and want to know if I’m pregnant.
Since all my colleagues and I have worked our shifts while suffering from worse symptoms than these (well, not the marijuana, I hope), we have understandably lost some of our natural empathy for such patients. When working with a cold, flu or headache, I often feel I am like one of those cute little animal signs in amusement parks that say “you must be taller than me to ride this ride” only mine should read “you must be sicker than me to come to our emergency department.” You’d be surprised how many patients wouldn’t qualify.
At a time when we have an unprecedented obsession with health (Dr. Oz, “The Doctors,” Oprah and a host of daytime talk shows make the smallest issues seem like apocalyptic pandemics) we have substandard national wellness. This is largely because the media focuses on the exotic and the sensational and ignores the mundane.
Our society has warped our perception of true risk. We are taught to fear vaccinations, mold, shark attacks, airplanes and breast implants when we really should worry about smoking, drug abuse, obesity, cars and basic hygiene. If you go by pharmaceutical advertisement budgets, our most critical health needs are to have sex and fall asleep.
Somehow we have developed an expectation that our health should always be perfect, and if it isn’t, there should be a pill to fix it. With every ache and sniffle we run to the doctor or purchase useless quackery such as the dietary supplement Airborne or homeopathic cures (to the tune of tens of billions of dollars a year). We demand unnecessary diagnostic testing, narcotics for bruises and sprains, antibiotics for our viruses (which do absolutely no good). And due to time constraints on physicians, fear of lawsuits and the pressure to keep patients satisfied, we usually get them.
Yet the great secret of medicine is that almost everything we see will get better (or worse) no matter how we treat it. Usually better.
The human body is exquisitely talented at healing. If bodies didn’t heal by themselves, we’d be up the creek. Even in an intensive care unit, with our most advanced techniques applied, all we’re really doing is optimizing the conditions under which natural healing can occur. We give oxygen and fluids in the right proportions, raise or lower the blood pressure as needed and allow the natural healing mechanisms time to do their work. It’s as if you could put your car in the service garage, make sure you give it plenty of gas, oil and brake fluid and that transmission should fix itself in no time.
The bottom line is that most conditions are self-limited. This doesn’t mesh well with our immediate-gratification, instant-action society. But usually that bronchitis or back ache or poison ivy or stomach flu just needs time to get better. Take two aspirin and call me in the morning wasn’t your doctor being lazy in the middle of the night; it was sound medical practice. As a wise pediatrician colleague of mine once told me, “Our best medicines are Tincture of Time and Elixir of Neglect.” Taking drugs for things that go away on their own is rarely helpful and often harmful.
We’ve become a nation of hypochondriacs. Every sneeze is swine flu, every headache a tumor. And at great expense, we deliver fantastically prompt, thorough and largely unnecessary care.
There is tremendous financial pressure on physicians to keep patients happy. But unlike business, in medicine the customer isn’t always right. Sometimes a doctor needs to show tough love and deny patients the quick fix.
A good physician needs to have the guts to stand up to people and tell them that their baby gets ear infections because they smoke cigarettes. That it’s time to admit they are alcoholics. That they need to suck it up and deal with discomfort because narcotics will just make everything worse. That what’s really wrong with them is that they are just too damned fat. Unfortunately, this type of advice rarely leads to high patient satisfaction scores.
Modern medicine is a blessing which improves all our lives. But until we start educating the general populace about what really affects health and what a doctor is capable (and more importantly, incapable) of fixing, we will continue to waste a large portion of our health-care dollar on treatments which just don’t make any difference.
Dr. Thomas A. Doyle is a specialist in emergency medicine who practices in Sewickley (firstname.lastname@example.org
). This is an excerpt from a book he is writing called “Suck It Up, America: The Tough Choices Needed for Real Health-Care Reform.”
Read more: http://www.post-gazette.com/pg/09284/1004304-109.stm#ixzz0TgtnEINR
He was a funny little man. The black leather chaps and jacket almost hung off his body even though I’m sure they were a size small. On his way to the Sturgis Motorcycle rally he had veered off the road while admiring the view and slid on the gravel at the side of the road. His left thumb took all the force and rapidly popped out of joint. While he wasn’t in that much pain, there was no way he could drive his motorcycle twenty miles to the nearest hospital.
As soon as he climbed out of the ambulance, you couldn’t help but laugh. He had a smile from ear to ear and despite his bike touring vacation being potentially ruined by a ride ending injury, he was all about enjoying himself in the moment, no worries about the past or future. But if appearances were everything, he might not be someone you’d want to admit you were friends with… or at least not take home to mother.
What would otherwise be called a sunshine smile revealed yellowed nubs of teeth barely long enough to chew a piece of bread. When he laughed, a raspy smokey breath of air filled the space in front of him…you could almost see the years of cigarette smoke that had built up in his lungs.
His friends were equally as happy and easy going. I really can’t explain why this little man was so fascinating to me. I guess because in my role as an ER doc, I get to see all sides of people. Normally I wouldn’t have given this man and his friends the time of day. I mean, based on appearances alone, he was kind of gross. And if you judged a man by the stickers on his black motorcycle skull cap, well, he was downright disgusting. When he went to xray for his thumb, I took photos of the bumper stickers on his helmet.
“I was born with nothing, and still have plenty of it left”
“I’m looking for the perfect woman, a nymphomaniac who owns a liquor store”
“Could you drive any better if that phone was up your a**”
“I’ll be sober tomorrow, but you’ll still be ugly”
And perhaps the most disgusting of al and yet somehow amusing…
“9 out of 10 women are battered, but I’m still eatin’ mine plain”
After he returned from x-ray, he asked if he could go outside and have a cigarette while he waited for the results. So he and his buddies headed out to the ambulance bay and smoked and laughed and laughed and smoked. I guess what was really intersting was that despite all the messages he carried around on his helmet and the tough persona he emulated in the motorcycle outfit and mannerisms, the whole group of them was just downright nice.
They were polite and thankful and optimistic about the rest of their trip to Sturgis. I placed a splint on his left hand, and he hopped on the back of his buddy’s motorcycle and they rode off into the mountains together, both of them wearing helmets even though not required by law.
Hmm…been reading through my archives, sharing stories with different folks. I’ve always wanted to cull down the archives and self publish a book. But what would I call it? How about “Every Patient has a Story…” What do you think? It would need a subtitle for sure.
This is my 5th summer working in the Rocky Mountains at a small rural ER. Since last year, the ER has been totally renovated. It now has the appearance of a modern, urban ER with trauma bays, sliding glass doors providing privacy in each room, a psych observation room with the ability to lock down all supply doors, an orthopedic room and more. Its beautiful, but I miss having a true “Emergency Room” which provided a stark contrast to my urban inner city and referral hospital environments.
I worked the first four days upon arriving here, so it wasn’t until yesterday that I had a chance to go out for a ride. I was all ready to hit the road when I looked at the fork on my bike, and it was a bit crooked. I pushed down and uh oh…Fork screwed. Headset broken. Head tube cracked. Damn.
On the drive out west, i had run into a metal “warning” bar while going through a drive through and heard an awful noise on the roof. The mountain bike rolled backward over it’s front wheel holder and was simply thrown free of the impact with no frame damage to the bike that I can tell. The road bike was not so lucky as the forks were securely locked into the fork mount carrier.
I called my bike shop back home and had them super-stat a new bike build that should be here by the weekend. An expensive mistake all in the name of a quick breakfast. Guess I know where I”ll be spending this month’s paycheck.