The Final Day

Bring it...

And so it begins....

0340 - I'm up, turning off my alarm for what probably will the last time at this unGodly hour for a while... I've always been a morning person... I prefer sunrises to sunsets... maybe I will enjoy living on the east coast for a while... watching the sun rise on each new day.... hmm....

0505 - "If you're not 10 minutes early, you're 15 minutes late..." So today I was a bit late... distracted at home... futzed around for a while... plus I collected a bag of pens to bring back to the ED... so, yeah, I'm the reason you can't find a pen in this place... btw - Temp 97.3, still good...

0544 - My scribe just sneezed next to me, and after having her wash her hands and her sleeve with hand sanitizer, I realized we were not maintaining social distancing, and I immediately reached for my thermometer... it's like my talisman against the evil humors... maybe I should make her take her temperature... and spray Lysol around her and me...

0555 - The first ambulance comes in with what was described as a "chair throwing, hallucinating, psychotic patient that might be going through alcohol withdrawal..." ok, so let's see how well those blood draws and medication administrations are going to go... the patient seems calm... for the moment...

0630 - This I will not miss... breakfast at the hospital. The most excited I can get about breakfast are the days they have a country fried (I think it's) chicken patty... of course, the last time they had that, it was on a Friday... during lent... yeah

0645 -  The calm psychotic patient no longer is calm... here's to hoping they don't go psychotic

0710 - Called to the ICU to intubate a patient that's not breathing very well. Medications drawn, RT's in order, tube goes in, and it's back down to the ED where...

0727 - The psychotic patient has gone totally psychotic in my absence... so now they're being put in restraints and given medications to put them to sleep...

0730 - I take a bite of my now-cold breakfast and am told that I patient with a chainsaw injury that I spent almost an hour sewing back together has come back. The wound looks like it's starting to heal as expected. I am pleased with the result, as hopefully is the patient...

0800 - I'm trying to eat breakfast again

0810 - Complete pandemonium has commenced and all of the psych patients are now in 4 points and receiving medications... hoping the din in the ED diminishes... someone's going out for coffee... we're girding our loins people...

0830 - I attempted to eat my completely cold breakfast. That did not go as planned as I was being constantly interrupted for psychotic patients, triaging who gets tested for COVID based on symptoms and travel history, signing EKG's... the usual ED work stuff...

0850 - Temp 97.8 - still good

0916 - Have completely given up the idea of eating my icy cold breakfast and am instead going to test the limits of my diabetes medication by feasting on some of the apple fritters and donuts one of the PA's brought in honor of my last day... and the coffee finally arrived!

0935 - Finally got a patient out of here after reassuring them that there was nothing wrong within their belly... buh bye....

1002 - The sugar high is starting to kick in... either that or the caffeine in the Dutch Brothers coffee has gone straight to my head because I am buzzing around a department where I really don't have a lot of patients at the moment.... so I keep circling, and talking fast, and taking way too long to explain things...

blood sugar rising...

1035 - I'm discharging a very sweet senior who fell two days ago and is still having pain. They feel much better after the pain medications I gave them. They asked my name and if I was a traveler. When I said I wasn't, they told me "It's great that we have a fantastic doctor in the area" I almost choked up. "Well there are lots of us. Thank you."

1056 - One of our local police officers just brought us a dozen donuts... adding to the six boxes of donuts we already have... Thanks for thinking of us! Hmm... sugar rising according to my CGM... but maybe I need another one....

1130 - Where did the time go...? Temp is 97.8 and I just had to go back into the tent... full precautions... another person screened... so far no positive tests but we'll be getting results over the next several days. I think it's time for another half a donut...

1225 - "I just used a little bit" Yeah... that's why your blood sugar is over 500, you have ketones in your blood, I'm giving you tons of fluid and insulin... and it's not like it's your first time... #MethBeBad

1245 - The nurses are frantically texting and making phone calls to make my every EMS photo dream come true... they secured a fire truck, maybe an ambulance, some police contacts, and one of them, seriously girl, called to see if we could get a helicopter... would have honestly open mouthed French kissed all of them if that had happened...

1302 - Fire truck came and had to leave on a call almost as soon as it got to the back entrance... ambulance crew showed up and we shot a photo with them...

1325 - I checked out all my patients to the oncoming doc... I emptied out my mailbox and packed up my lab coat... Thank you, all, it has been my honor to work with all of you all of these years.

Dr. Bonales, signing off, Humboldt... stay safe out there...

The Final Countdown - Day 4 of 5

I'm Dr. B, and welcome to my world.

So, the challenge continued. In just about a week's time, I've gone from fun-loving, cool ED doc to expected specialist in epidemiology, infection control, risk stratifier, and it's gotten to the point I've actually started keeping up with the medical literature on a daily basis just so I can have the latest information about this whole thing... it's becoming very stressful, and I am so glad that I only have one more day of this before I take a long six week hiatus. Hopefully, on the other end of that, this will have been a true learning experience for all of us.

You don't think about illness much when you become a doctor. I mean in terms of what can happen to you. Sure, you're careful to avoid needle sticks. Work place violence has become more prominent. You know when cold and flu season starts, you'll inevitably get coughed on by that 2 year old just as you lean in to listen to their heart, and BAM! about a week later you're coughing with a runny nose... or worse, what we used to call in residency "the pedi flu" which you'd always get during that first week of your rotation back at Children's Hospital and which had you running to the bathroom for one thing or another. That was the worse.

But in terms of being scared about something, I don't think we are. At least, I can't think of anyone on my staff that would back down in the face of an epidemic, or pandemic, or whatever is before us at the time. We come to work, we gown up, and get to moving. We help each other. We support each other. We work together.

And, that was always the draw for me when it came to Emergency Medicine. While I loved the challenge and instant gratification of surgery, it felt more like a soloist instead of a chorus. We may squawk and balk at each other from time to time, but when there's a code, when there's a patient in need, when there's a catastrophe of any kind, the team pulls together to make things happen.

One of the best compliments I ever got from an RN was that they would "always be glad to follow me over any hill." You always think about the doctor sort of running the show, but there's a difference between a director and a leader. The director tells you what to do, while the leader shows you what to do by their example. My codes are generally calm and not chaotic. I listen when the nurses tell me their concerns about their patients because they're the ones spending more time with them. I take the time to teach whenever I can so that we always know and understand what we're doing together...

Like today... I electrocardioverted (shocked) someone out of an irregular rhythm. I diagnosed two people with abscesses and infections (one got to go home, the other had to stay for a more serious infection), I saw my meth patient back again for a dressing change and antibiotics (they actually looked like they'd showered and had done a bit of grooming), I saw and worked up and discharged two chest pains, I dealt with a patient who seemed to want to have something wrong with them (they stated they'd been having abdominal pains for "years" and had just seen their doctor 2 days ago after which they went to the another ED where they got a full work-up and evaluation, then came to my ED because they wanted a "second opinion, I reviewed everything from the prior ED, went over their results, and every time they brought up a new complaint - abdominal pain became chest pain became "are you sure I don't have a tumor" which I reassured them they didn't because the CT scan would have shown it, and I had worked up their chest pain because that had been their initial complaint at triage even though they told me they'd come in for abdominal pain, I referred them back to their PCP and to GI for evaluation of their multiple complaints), I had the drunk that had to sober up,  I had the drunk that was sobering up and going into DT's, I had the singing psychotic decide suddenly that clothing was optional and wanted to run around the department showing this to everyone, and I had a couple of patients that required me to put on my new body armor and go into the big scary tent... now I have to check my temperature every couple of hours, but I'll still be back to work tomorrow for that last day at this hospital... then I'll self quarantine, sort of, for the next several weeks... 

The Final Countdown - Day 3 of 5

A quote by Emerson states: "To finish the moment, to find the journey's end in every step of the road, to live the greatest number of good hours, is Wisdom."

As many of you know, I'm probably at my happiest when I'm traveling. Just the thought of that next voyage or road trip keeps my mind wandering to what next adventure am I going to have? Will I be going someplace familiar, or will I be going someplace new to explore?  Who will I meet along the way? What new places will I find to eat, and how many photos am I going to take? 

Alas, with the new travel restrictions, I really don't have a travel plan until I start working my new job somewhere in the Mid West. To be honest, I'm not quite sure where actually since licensing is up in the air. And, travel for work really isn't a journey. It's more like commuting. Don't get me wrong, I love to fly. I love to check out new places. But it loses some of its luster when it's for work, because, well, you're going to work. Still, I love to sit and people watch at the airport. I create scenarios for some of the people I see. Mostly I can't wait to get to the end of the trip just to be done with the getting there. Certainly not as exciting as heading out for vacation, but for the time being it will have to do.

Anyway, today was a crazy day. It's not like I saw a lot of patients because, even though there were a lot of patients, we can't bring people back to a room when there aren't any because the rooms are full of other people... 

 - people like my meth addict who came back again but this time stayed long enough for me to actually evaluate their wound, give them antibiotics and actually ask them to come back again so that we can try to get social work to help get them the resources they need to keep their foot from getting so infected it would have to be amputated.

 - people like my really bad pneumonia that had to be intubated. Once, again, please have the discussion with your family members about your final wishes. And, while I appreciated that they had a Living Will, it wasn't very clear about CPR versus no CPR, or being on a ventilator. Sure I can say I think it's possible they might come off the vent once the pneumonia is clear, but I can't guarantee it. I wasn't not hopeful for this patient, but I can't promise that they won't need to be on it long term. We'll see how they do.

 - people like my 60-something, meth'd up patient who dislocated their hip... again... somehow "in their sleep..." my back and hip are feeling the effects of yorking on that leg "Captain Morgan style" and getting it back into place. That actually was a "yeah for me" kind of moment because initially a colleague attempted to reduce it and didn't... and I did... yeah, that's right, I did it, 5ft 1in me who had to practically climb on the bed... pat on the back for me.

- people like the transfer from the smaller hospital that needed hemodialysis which they don't do in the smaller hospital, the three psych patients who are in the midst of their varied psychoses and either suicidal, severely depressed, or floridly psychotic... at least I was entertained by their Cardi B impression... they received a clap for that...

And, speaking of entertainment, we had two police take downs this morning. One was drunk and decided that they weren't going to cooperate with a legal blood draw. The second was another of our repeat customers who decided they were bored of sitting in the waiting room and did some kind of substance then proceeded to act crazily which then required three police officers to take them down and away to jail. Funny thing: this patient has a pretty serious heart infection from their IV drug use but keeps leaving the hospital to... shoot up drugs... then returns because somewhere in their brain they know they need IV antibiotics... but the last time they were successfully treated was while they were in jail because they actually got their full course of antibiotics. Fancy that.

- I had the usual chest pains, the falling down, the miscarriage, and, I'm sure a couple I'm forgetting... probably because my head is thinking I should be thinking about the Pacific Ocean and sipping a piña colada on the deck of a ship... 

But, for a while I'm not sure what I'll be imagining other than I've got two more shifts then six weeks to contemplate... and plan... because I never stop planning for that next big adventure... 

The Final Countdown - Day 2 of 5

And, so it's come to this...

A tent just outside of the ED to help contain the flood of

sick, maybe sick and worried well.

And, just when I thought I just had to make it through

3 more shifts and escape from all this craziness...

So, now I have a whole month off to sit and ponder my future.

Well, according to my DH, not actually sit, but pack

and start getting ready for a cross country move a little sooner than expected.

Without any massages or facials or body wraps... sigh... 

Hey, at least, all of our suitcases were packed.

Now we can just load those up and be ready to go...

anywhere...

But, for the next three days, it'll just be more of:

- known drunk comes back in... drumroll... drunk; seriously, I just saw you yesterday

- known infection comes back in with infection after leaving the hospital to go do meth;

surprisingly, not the same one as yesterday, although the one from yesterday did come back too,

they just left because they weren't being see fast enough

and that's because my nurses, in full hazard gear, were swabbing noses and throats

out in people's cars... the ones that met criteria... there were a lot that didn't...

anyway...

- saw a kid with a viral infection

- saw another kid with pink eye

- saw an elderly person that's been on chronic pain meds and switched over to suboxone by their primary care doc and wasn't handling the switch very well

- there was a pneumonia

- there was a stroke

- there was a mystery diagnosis solved by one of my internal medicine colleagues because 

they see stuff we never see

- there was an allergic reaction that came in covered in hives

- and there was the patient that was seen a couple of days prior, had a negative

work-up, came back because they left before they were given discharge instructions 

and were actually feeling better but still wanted to know what was wrong with them

because Google told them that they might have a "blood clot" that "migrated from between their shoulder blades to their pectoralis muscle" and made them cough... I tried to explain to them that

yeah, that's not how that works... and they told me I didn't understand because I hadn't heard the "whole story" at which point I heard every small detail of their life from sleeping on the floor,

to taking their kids to school, to having something to eat, then taking a nap, then the "blood clots" migration from back to front and now gone, and how they were sure it was a "heart attack" because they felt their heart "exploding into pieces" that one time they were in a meth-induced haze

and how they've had many "undiagnosed heart attacks" because they felt that way 

several times... that was when my head exploded...

when I walked out of the room I was imagining myself on a long ocean cruise... 

which is now not to be... sigh...

Let's all pray together as we wash our hands that soon "this too shall pass"

The Final Countdown - Day 1 of 5

So about 9 years, 5 months and a week ago I started as an attending

at a small hospital in Northern California.

This is how it went.

Today I started the last of 5 shifts that I will be working

at the slightly bigger sister hospital.

This is how today went:

cardiac arrest came in, after about 30 minutes of CPR and putting in a breathing tube

we got back pulses... then I had to stop the ventilator because we found out the patient had a DNR (do not resuscitate) and the family member let us know that they had wished to not have anything done,

so that was a little frustrating

during that time, a patient came in with a really low blood pressure and fast heart beat,

hung some IVF and some pressor medications and got them under control,

admission to the ICU

then I had to clean up the mass of patients that had come in while I was working on the cardiac arrest and patient with low heart beat

they included:

  - a chronic drunk who was drunk again and needed a room to sleep it off

 - poison oak allergic reaction

 - patient with shingles

 - patient with problem with their ostomy

 - a chronic meth user that left the hospital to smoke meth and was now returning

because their infected foot somehow did not magically get better without 

antibiotics and wound care, not to mention running on it barefoot in the woods

while high on meth

 - an elderly couple both with dementia that went on a joy ride and ended up driving down

an embankment

- a patient who passed out and hit their head and who could now not move their leg

AND

I had to manage the patients signed out to me by my colleague in the morning

which included:

- an appy

 - a pregnant appy

- a car crash victim with abnormal vitals

and a couple of people who didn't like their lives any more

so needed psychiatric help 

AND

in the midst of all this a code was called on the hospital floor

and I had to run upstairs and put a breathing tube in that patient

while they were doing CPR...

... the patient later coded again in the ICU and didn't make it...

AND

not to mention a lot of phone calls where we had to triage and decide

which patients actually needed COVID testing... OMG

The one bright spot in my day was a visit from a patient

who'd had a serious brain infection which had to be transferred down to 

the big city children's hospital where they underwent

brain, eye and sinus surgery,

IV antibiotics,

physical therapy to help them be able to walk and move

their right side again

and here they are a month later looking

bright and a lot healthier than the day I saw them...

this is them:

I hope he does amazing things... 

*photo posted with permission*

NaBloPoMo - Day 29 - Loss of Control

Imagine that you are trapped inside your own brain.

Imagine that you can hear and understand what is said to you,

but you can't answer because the word you want to say won't come out.

Imagine that you're given something on a written piece of paper,

but the letters seem alien, foreign, 

even though you've known them since you were a child.

Imagine that your limb won't function the way it's supposed to.

Imagine that you can't control how it moves,

and sometimes it moves even if you don't want it to.

If you're not imagining this, and it's happening to you

you've just had a stroke.

I mentioned a couple of days ago that I really hate working the holidays

because there's always one case amoungst the myriad of patients

that come in that affects you more than most.

I figured the code of the young patient would be 

the sad case of the holiday,

but this stroke patient is pretty close.

Of course they had a great family.

Of course they were pretty healthy up until they weren't.

Of course they had been intelligent, hard-working, a loving parent...

And since the law of the ED dictates that bad things happen to good people

now they've had a stroke.

They came in too late to receive the clot-buster drug.

They didn't have an operable lesion.

They'll have to wait and see what function returns.

I gave their family some hope of partial recovery

with the expectation of long weeks of physical and occupational therapy.

Only time will tell...

Sigh...

I hate working the holidays...

NaBloPoMo - Day 27 - Holiday Shifts

There's a reason I don't like working any of the holidays.

Unfortunately, sometimes you have to and then, for me, 

the expected happens.

There will always be that sad case that will be devastating for some family:

 - grandparent doesn't look so good and comes into hospital and dies

- a family traveling to/from their loved ones gets involved in a car crash

- random act of violence strikes

or, like yesterday,

- a young, healthy parent will come into the ED in cardiac arrest and not make it

During my career in medicine, I've seen all of these and more.

Don't get me wrong, sometimes something funny happens,

and you know that family will be laughing around a table

a few years from now saying,

"remember that time you had to go to the ED for that..?"

But, unluckily for me, and for most families,

it's the tragedy that will be remembered.

It's the screams of a young wife asking her husband

whom you know is beyond help to not leave her...

to think of their kids...

to think of all the years they've been together...

"Come back to me..."

They look to me with pleading eyes, but while I can help prolong life,

while I can sometimes pull life back from the brink,

I can't bring back someone who's already gone beyond my reach...

Did I mention I hate working the holidays...?

NaBloPoMo - Day 18 - Seriously...?

I haven't watched "Grey's Anatomy" in the longest time, 

but one of the taglines from the show that I remember vividly

was "seriously..?"

It covered everything from boy problems, to work problems, to all general life problems.

Often, when I pick up a chart in the ED, I read the presenting complaint of

(what the patient came into the ED for) and immediately go "seriously?"

Others, I go in and interview the patient then walk out and go... "seriously?"

Still others are given the benefit of the doubt, worked up,

found to have, um, something like meth or cocaine in their system,

to which I say, "Seriously...?"

I really wish I could say it to the patient...

As in,

"Seriously..? You came in concerned that you were having a stroke because

you "couldn't think straight," or couldn't "find the right words,"

and your head and your body hurts and you're not sure why...

Well, let's see... your CT of the head was negative...

your EKG, labs, vitals are all normal...

oh, but let's focus on that drug test:

positive for cocaine

positive for methamphetamines

positive for benzodiazepines

positive for methadone (which you're not prescribed, by the way)

and you wonder why you alternatively:

don't feel right...

have been really tired...

can't seem to focus...

etc...

Seriously...?

People wonder why health care costs are so high...

I think it's in part because of all the patients like this I see on a daily basis...

Today it was like this for three different patients...

All different genders and age ranges...

I can't discount you're not having some physical symptoms which are bothering you,

but if you had initially just been a little honest about your social habits

I probably could have avoided about $5000 worth of a work-up.

Don't do drugs, seriously...

And, especially, don't do uppers which you then take downers for

which leads to more uppers, then downers, then uppers, etc, ad nauseum...

I wish we did have levels instead of just positive/negative for drugs

because I think some patients have perfected the meth/heroin ratio...

However, combining uppers and downers can 

lead to a potentially lethal combination...

Then there's the "what's this on my body...?"

Seriously, you came in for that...?

NaBloPoMo - Day 13 - Please Don't Touch the Doctor

I am not a hugger...

Never really have been.

I'll allow certain people to hug me

but it took a long time to really get used to being

touched by other people.

Even now I have a very small select

group of people whom I'll tolerate hugging me,

Very small...

At the hospital, I don't shake hands, 

mostly because I immediately have to wash my hands

because I can't get the sensation of having been touched

removed from my hands fast enough...

Hugs, yeah, nope...

Today a patient's family hugged me...

A family that I gave bad news to...

A family that understands that their loved one may not survive

despite all our best efforts...

And they hugged me...

I explained what needed to happen,

what was going to happen,

asked what else I could do for them

and they thanked me for everything I had already done...

And then they hugged me...

I stood for a moment stunned as they put their arms around me...

As I patted their back, the hug grew tighter and I felt the familiar

heaves as their tears started...

And, even I have to admit I got a little misty...

I guess it's the ultimate in trust...

this family trusted that I had done everything I could,

the rest they (and I) believed is in God's hands

because their loved one is in a serious condition,

and those few moments I gave them before I put a breathing tube

in their loved one I sincerely feel may be their last chance

to let the patient know how they feel...

And despite being uncomfortable,

at least I could feel good about that...

Q is for Quiet

I think I've written multiple times before about how

we're superstitious in the ED and there are certain

words we don't use...

like slow...

or quiet...

Tonight is definitely not quiet...

It's a full moon Friday night and the crazies are out in force.

So I better get back to them...

someone must have said "quiet..."

I'm sure they did.

J is for Journalism

Storyblocks.com

A few people know that I actually started off life as a journalism major.  I wanted to write about other people and their life’s stories.  What ended up happening is I ended up as a doctor writing charts about other people and their current events.  I always said I enjoyed the back story as much as the actual medical reason they came to the Emergency Department:

 - like the couple who got into a car crash... they wanted to start over so they packed everything they owned into a U-Haul and started driving across the state. They didn’t quite reach their destination because he fell asleep at the wheel.

 - like the man whose “date” stole his car while he was in the ED and then held it for ransom so that he had to run out of the ED and write her a check so that he could get his car back.

 - like the son who crashed into his dad’s car because he discovered that his girlfriend was, um, getting to “know his dad” in the biblical sense in the car.

 - like the patient who crashed their car into various road signs, was given a ride home after which they got into another car which they crashed into a mail truck then backed up onto a curb, thinking the car wasn’t driveable they got out only to have the car run over them.

 ... and on, and on, and on... seriously, some times you can’t make these stories up...