Gentle Into That Good Night

Emergency Departments have their share of regulars.  The patients that come back time and time again. Some you don't mind. Some you inwardly cringe and say, "Oh, God, them again." Seriously, George, this is the second time this shift.

They come and they go until one day you notice that you haven't seen someone in a while. You don't say their name because there's an unspoken superstition that like saying "Beetlejuice" three times they'll reappear. We have staff members who's sole purpose is to work with community physicians and mental health agencies with a goal to keep these "frequent fliers" or "super utilizers" out of the ED, so sometimes you don't think too much about not seeing someone for a while.

Then one morning there's a code alert on the radio: patient found unresponsive lying in front of a business, Fire and EMS responding.

Is it a drug overdose? Narcan and a sternal rub and by the time they come to the ED they're awake and cursing you for taking away their high.

Is it one of our regular drunks? Brought in overly intoxicated wearing the same clothes they've been in since the last time you gave them some new ones, covered in their own bodily fluids and sometimes some accompanying unwanted guests that have to also be washed off.

Is it someone who had a coronary event? This early in the morning, someone on their way to work who's having the "Big One" and collapsed.

You sit and wait for the radio to sound again wondering. I look over the rack of patients waiting to be seen and the patient board and begin to mentally prepare for whatever comes... is this going to be a prolonged Code Blue or is it going to be a quick evaluation with a "metabolize to freedom" disposition.  It all depends on that next radio transmission.

The radio crackles again with "Patient update." That usually means they're coming in Code 3 with lights and sirens and CPR in progress... or it means 1144 - deceased on scene.  Today it's an 1144.  Someone didn't make it through the night. 

I relax a little, and I and the staff move on through the day not really giving a second thought about that life; we have other lives to save today.  Then the next day you hear it was one of the regulars;  someone who you'd seen come into the ED just a few days earlier with their regular complaint.  One of the "Oh, God" ones.  And, you start to wonder...

You begin to think about the movie "Groundhog Day" where Phil goes back each day working to keep the homeless man alive by doing something to change his final course... and every day he fails.  "Sometimes, people just die."  And, this reminds you of the quote in "M*A*S*H" where Col. Blake tells Hawkeye "...rule number one is young men die. And rule number two is, doctors can't change rule number one."  Was there anything you could have done? Sometimes the answer is, "no."

On the way home, I think about that person and my interactions with them. The debilitating addiction to drugs and alcohol that put them on this path. The multiple resources to try to help them. Their steadfast resolve to not change a thing about their life because it was their life, and that's all they had to call their own;  no family (those bridges having been burned a long time ago), no possessions (it's easier to be homeless when you don't have to worry about someone stealing what little you have, or keeping track of it when you've been on a three day bender), nothing except the few dollars in your pocket with which to buy that next bag of meth and the pint of vodka to keep away the demons in your mind.

I think about them laying down for the night, that coldest night of the year so far.  Did they dream?  Did they remember their dreams of being a child and all of their wishes for their life? Of being a young adult and experimenting and experiencing all that life had to offer?  Of being in their 30's, addicted, being separated from family and friends, raging against the world? Of their life now and anything beyond that next score or that next drink? Did they dream as their body failed for the last time to make it to morning, where someone would find them and EMS would be called to transport them to the ED again..? Where we'd recognize them and say "Oh, God, not them again..."

That's what haunts my dreams.

#297 to 264 - Z is for Zombie Apocalypse

Thank you for visiting my blog throughout this month.

I hope that some of you will stay and continue to follow

my blog throughout the rest of the year.

Although this month I focused on fun things

like travel and photography,

at the heart of it all, I am a doctor...

in the Emergency Department...

working in areas with high levels of

drug abuse,

homelessness,

unemployment,

and poor education.

There's a lot of trauma and drama

some of which I write about here.

I share stories and pictures when I can,

but I do work in a rural area some of the time,

so it's hard to keep HIPPA-compliant and

still give a complete story... 

Nevertheless, I do write a lot about my own experiences

and feelings.

And my beliefs on the importance of taking responsibility

for your health and that of others.

So I write about those things as well.

As for the Zombie Apocalypse..?

Well, methamphetamine abuse is high in the areas where I work.

If I could just videotape the patients that come in high on meth,

or the medical problems that meth brings

I'd have hours of tape to share to hopefully

keep someone from going down that road.

You can Google "meth mouth," "meth skin,"

"the faces of meth" to see what I see every day.

People prostitute themselves for meth.

They steal whatever they can for meth.

They come to the ED for drugs that they can then trade for meth.

I had a patient tell me yesterday that they lost their medical insurance

so they couldn't see their doctor for their chronic pain condition

so they were "self-treating" with meth.

I know they were going to take whatever prescription 

I wrote them and sell it.

Irony is, because they were homeless with no ID, the pharmacy

called to tell me they couldn't fill the script.

And, because of the effects on the brain, there's no

reasoning with these patients.

They don't understand that methamphetamines will lead to being tired

or weak or shaky because the effects are like running a marathon, full out,

without important things like eating or keeping hydrated.

They don't understand that the "worms under the skin" that they see or feel

are because of the effects on the nervous system.

So they pick at their skin to the point of causing bleeding

which leads to scarring and, worse yet, infection.

Which can lead to sepsis, possible amputation and sometimes death.

Pain management is a huge issue with these patients

as meth has fried out all of their pain receptors so now

pain which to you and I might be handled with a Tylenol now

requires large amounts of narcotics.

Don't even get me started on the dental problems...

Whew!  I thought we needed a nice pastoral scene from

the little chunk of Earth I call home...

Chickens and geese, I write about them too....

Hope to see you again soon...!

p.s. In July I do a birthday iPod shuffle where I write the whole month

about songs on my iPod, and I participate in NaBloPoMo in November

All the Lonely People

This is cross-posted from the professional blog I write for....

I know that the holidays can get really depressing for a lot of people, but I had three patients over the weekend that really got me depressed because of their situations. I always said that I would never make a good psychiatrist because I would tend to internalize and identify with my patients, and so that’s why I enjoyed surgery so much. There’s quite a bit of distancing that happens when you’re behind a mask looking at a square of skin.

As an E.D. doc, though, we’re up close and personal with a lot of our patients, so it’s back to internalizing and not having the luxury of a sterile sheet between you and your patient.

Patient One crashed their car. They are homeless, so their car is like their home. Everything they own is in there. They had just gotten kicked out of one “fleabag” motel and were on their way to find something better along the coast when they lost control on a curve. Now, all they have is the clothes on their backs. Well, actually in a hospital bag because they were stripped down to a hospital gown when they arrived. They’re bruised and battered and slightly torn. And, they have no one and no where to go. I can discharge them because, luckily, they didn’t suffer any major injuries. But, they have nothing. So they get admitted. Social Work and Discharge Planning can figure out what to do with them in the morning.

They used to have a life, and friends, and a home. But then they were forced to take early retirement from their work. They lost their home and their social network. They can’t afford housing on a fixed income. So they roam… in their car… from place to place.

Patient Two had a nice home, and a wife. Then their wife died and a part of them died too. So they turned to alcohol to help deal with the pain. Soon their nice home deteriorated as did their health. They have a neighbor who checks on them from time to time. Their neighbor brings them in whenever things get too bad. Patient Two can’t see their PCP because they have an outstanding bill, so the E.D. becomes their PCP. Diabetes out of control again? Yep. Bad cellulitis on your legs again? Yep. Anything new? Yep, pressure ulcers on my bottom from not getting up out of my chair for the last three days because my legs felt too bad. Am I going to be admitted? Yep.

Patient Three has a psych history. They’ve been in and out of the system their entire life which is only 50+ years long so far. They have the look of a 90 year old man. A neighbor stopped by because they hadn’t seen them for a few days and found them looking slightly worse than usual. Not eating or drinking. Somehow, though, they continue to smoke despite the rattling cough in their lungs. How the cigarette paper doesn’t just rip their Sahara Desert dry and cracked lips to shreds is beyond me. Must be the warm stale beer that somehow is within reach. Another admission for “Failure to Thrive.” It’s the least I can do.

Three hots and cot… at least for tonight… at least for today…

All the Lonely People

Losing Faith in Humanity...

So every once in a while I come across a patient that really affects me.  There's been this couple who over the course of the last year have been coming in periodically to the E.D.  Usually, one or the other of them is sick.  Really sick.  Respiratory type problems:  pneumonia, the flu, difficulty breathing.

They're usually dirty.  Unkempt is what I dictate.  Or poor hygiene.  But they always seem grateful for what we can do for them.  A meal, a ride, free medications.

The woman came in again the other night.  Shortness of breath.  Smelling of motor oil.  A friend was letting them stay in their garage since she's been sick.  Because you see, they're homeless.  Living under a bridge by the river.  As, I was leaving that night, driving past the spot where they've told me they live, I felt bad.  Felt like I should do something more.

You always maintain professional distance from your patients, but there's some patients that just affect you.  I started to wonder what I could do.  Not a hand out, but a job offer.  Maybe something simple like yard work, maybe.  The thought stays with me throughout the night.

The next day I hear the patient was discharged to home;  she'd come in feeling short of breath from all the meth she used.  Then I get angry.  Seriously?  You're homeless, you couldn't stay in the hospital the last time because you had to go back to your campground and "feed the dogs;"  you already spend your money on cigarettes and now you're also using meth.

Seriously?  Sometimes I wish I was back in surgery.  A piece of skin under the drape.  See the problem, remove/replace/fix the problem.  Because sometimes the things I hear about my patients just makes me wonder, seriously?