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... 

NaBloPoMo 2018 - Day 2

When I stop and think about this prompt, I can't think of anything for myself.  Sure, I've had friends and family die where I've been surprised, but there wasn't that "Oh my God, if I'd only known that would be the last time I'd see them..."  I've not had an episode with a boyfriend or a lover where things suddenly ended and I've thought "Oh, if I'd only known that would be the last time we..."

But, as an Emergency Physician, I have seen that happen to a lot of other people.  That's why I'm a strong proponent of living wills, POLST forms, talking to your loved ones about uncomfortable topics, etc.  You never know when the "last time" might be.

A recent case I had reminds me of this.  The patient and their spouse came into the hospital for what was supposed to be a routine outpatient procedure.  During the procedure, while the spouse was in the cafeteria grabbing a coffee or a snack while waiting, the patient suddenly started to have a low heart beat and low pulses.  A "Rapid Response" alert was called overhead.  The Rapid Response team is comprised of a small team that tries to avert disasters by evaluating patients quickly and deciding on a course of action.

The Rapid Response team started IVF and decided to bring the patient down to the Emergency Department for further evaluation.  While they were in the elevator, the patient lost pulses and CPR was initiated.  I had been aware of the patient coming down to the ED but was surprised when the elevator doors opened to see someone doing chest compressions on the gurney.  We immediately called an overhead "Code Blue" and attempted resuscitation.

Meanwhile, the spouse had wandered back up to the waiting area.  Thought the procedure seemed to be taking a while and inquired about their spouse.  They were escorted down to the ED about the time I was looking at a still heart on the ultrasound and rechecking my list to make sure there wasn't anything else I thought I could do.  When the spouse was brought to the ED, I asked if they understood what had happened.  They just knew there was a complication.  When I asked about a living will or Do Not Resuscitate orders, the spouse let me know the patient had a diagnosis of cancer and didn't want any extraordinary measures.

I explained what had happened.  Brought them into the room and called the code.  Everyone except the patient's RN left the room while the spouse informed me that they had just celebrated their 59th wedding anniversary during the prior week.  They spent some time in the room and then walked out.  I asked about family, and they informed me that all of their children lived out of the area.  I asked if there was anything else I could for them, and the spouse politely thanked me for everything I had done and walked out of the department.

For the rest of the shift, I couldn't shake the image of this older person, walking down the hallway slowly, carrying the belongings of their spouse, headed out to the car to drive home alone and enter an empty house. From the few moments I spent with them, I know they had probably kissed their spouse as they went in to that routine procedure, said their "I love you's" and went about not knowing that would be the last time.  That brings me a little comfort, and I hope it does for them too.

#NaBloPoMo18

November Notes, Day 6

"The Death of George Bell"

I just read an interesting article in the New York Times about a man named George Bell.  He wasn't famous.  He had no famous relatives.  He wasn't famous for anything himself in life, but now has a name in death.  And, he died alone.

I think about people like him when I work in the emergency department.  The kind of people where you think "there but for the Grace of God go I."  The kind where you stop to wonder, who would morn them if they were gone?

Reading this, I thought back to a lot of patients who were regulars and then later died.  We know that they died and that they will not be coming back to the ED, but did anyone else care?  I started to think about "Cowboy" who I wrote about in residency.  I don't think he had a family.  The article made me think about all those patients who leave home in an ambulance and then never return.

It also made me think back to a cardiac surgery patient I had at the VA when I was in medical school.  A simple surgery led to a serious complication led to his death.  I remember telling the family, and their first question was "where are his car keys and where did he park the car?"  Suddenly, I wondered what happens to the cars that patients leave behind when they come to the hospital to check in and never check out?  Mind blown.

How prepared are we for our own deaths?  I'm not talking wills and estates, I'm talking what gets left behind and who's going to sort through it, and what are they going to think?  A good friend had to deal with his mother's belongings after she died.  A mother he wasn't particularly close to, and now he had to deal with her "mess."  And, it was a mess because she was a hoarder.  Seriously, what do you make of "collections" which were important to the person but have no meaning for the survivors?

I guess death is on my mind.  The code patient from my post of a few days ago was pulled off life support.  They were a regular.  I'd seen them multiple times in the ED.  Now, they're another name to be remembered and scratched off the list... but still remembered... at least they didn't die alone.

#275 - O is for Oops..!

On the road still, and didn't prepare a post,

but I thought you might enjoy this squirrel...

Still on the road tomorrow and limited internet,

so tomorrow might be boring as well... 

But today I also want to wish my Momma a happy Birthday!

I write about her often and use her as an example of the importance

of living wills and talking to your family members about

life and death issues before they become a problem.

So happy Birthday, Momma...

You are my inspiration and my guide.

#1611 - On Offspring

We get a lot from our parents.  Not just our genetic makeup, but our values and traditions.  Our self-esteem and our value.  They help us gain confidence an set the example for how we should live our lives.  I've been thinking about my mother a lot recently.  Especially since I started counting calories and working harder on living a healthier life style.

My mother was diagnosed with diabetes in her 40's.  By her 50's, she was suffering from peripheral neuropathy and could no longer wear the heels she so loved because of the danger of falling.  But her shoes still defined her style that was anything but sensible.  She started to develop diabetic retinopathy that caused her to quit driving for fear of being in an accident because of her sight problems.  And, around the time I was going to graduate from medical school, she was told her greatest fear.  That she was going into renal failure and should start planning for dialysis.

We talked at great length about what this would mean, and she asked me what it would take to stay off of dialysis.  I talked to her about medications that would help to remove the buildup of impurities and electrolytes (especially potassium) in her body.  I talked about low protein diets and drinking plenty of fluids.  I talked about exercise and doing whatever the doctor told her to do.  She went to her kidney doctor then and told him in no uncertain terms that she did not want dialysis, and that she was willing to do whatever he told her even if it included killing puppies, making them into milkshakes and drinking them on a daily basis. (Momma and I have a warped sense of humor)

He laid out a pill regimen (about 9 different ones) and told her that they would check her blood on a regular basis.  And so it went.  From 2003 to 2013, she continued the plan.  You couldn't get her to take a bite of anything that wasn't good for her.  She's a low meat, water-drinking, no sweets seriously disciplined patient.  And, her kidney function didn't worsen.

Over the last 6 months, however, the doctor told her that he's starting to see some changes in her lab work that concerns him again that she might be approaching the need for dialysis.  Again, we talked about it, and she says she doesn't want it.  Her kidney doctor told me to talk her into it.  And, I told him I have to respect her wishes.  I am sad to think I might lose her sooner without it, but proud and supportive that she wants to live life on her own terms.  Like she has always done.  And which inspires me on those days when I just want to throw away my salad and have a stack of pancakes, or french fries, or a Starbuck's caramel macchiato or any of the other 100 foods I love that I can't have right now.

If a woman can be so disciplined and focused that she has literally willed herself and her body into staying off dialysis, I know that as her offspring I have that within me too.  And, together we'll conquer any challenges that come along.  For hopefully many years to come.

Happy Birthday, Momma.

I love you and am inspired by you daily.

2013 A to Z Challenge Post:

O is for Oh, Momma, That'sa What I Like

D.N.R.

Can you see the "sad panda face"...?

This patient suffered a major hemorrhagic stroke 

leaving them unable to move the right side of their body.

They have a living will and DNR (Do Not Resuscitate) order in place.

Given their age and medical condition, they will most likely

never recover and will die soon.

And, they wanted it that way.

Their child didn't question the decision.

They had talked about it several times.

The child was their POA (Power of Attorney) for healthcare

and was in complete agreement with their parent's final wishes.

I wish everyone would do this.

I'm getting back up on my soapbox about DNR's and living wills because I spent

an hour during my last shift running a resuscitation on someone who

"maybe has a DNR, I don't know, you'll have to talk to their other child because 

even though they told me they didn't want anything done I can't make that decision."

I've talked about this before, once when I was on my CCU rotation during residency,

and another time when I was talking about conversations Momma and I have on the road.

It's difficult, but have the conversation.

Make a plan.

Put it in writing.

Make several copies.

Have them readily available.

(Put one on the fridge or in the kitchen drawer to hand to EMS.)

Designate someone to speak for you when you can no longer speak for yourself.

I've read several blog posts about advance directives mostly related to cancer patients

and end-stage disease, but tragedy can strike at any time.

I'm an organ donor, are you?

Does your family/partner/spouse/child know your wishes?

In some states even if you have the donor symbol on your driver's license

someone still has to sign for consent.

And, even more difficult to talk about,

the death of a child.

Are you and your spouse prepared to make a 

potentially life-saving decision for someone else?

Discuss it now.

Cry about it now.

It really does make it easier when/if something unexpected happens.

And, to end this little rant,

I send a shout out to my friend B

who talked to her husband about end of life plans

for their beloved pet.

A dying man needs to die, as a sleepy man needs to sleep, 

and there comes a time when it is wrong, 

as well as useless, to resist. 
Stewart Alsop 

North to South

Dodger  Stadium & LA Skyline

There's always something kind of surreal about going home.  My mother lives in Southern California in the home where I was raised.  I lived there until 1997 when I left for medical school.  I go back about 4 times a year.  It's both familiar and different every time I return.

Mom and I celebrated her birthday in Laughlin, Nevada.  We know the places we like to stop for meals;  how far apart the rest stops are.  We know the casino layouts as if we were in our own homes.  I know, scary.

We spend the first part of the trip on banal things:  like gossip.... or shopping.  We spend the second half of the trip on serious things:  money, health... living wills.  I know I've written about the importance of knowing your loved one's wishes ahead of time.  So many people come to the Emergency Room with a loved one that can no longer speak for themselves.

Mom and I have very morbid, albeit humorous, conversations on the subject.  Mostly about how she doesn't want to give me Power of Attorney for Health Care because she's afraid I'll "pull the plug" just to get the inheritance.  I told her since she didn't want a fancy coffin, I was just going to get a refrigerator box from the electronics store;  things like that.

But, seriously, it's important to know what your loved one would want;  from the clothes they want to be buried in to who gets the ugly turkey platter that gets pulled out every Thanksgiving.  In the E.D., I just want to know if they would want to be resuscitated (chest compressions, shocks, etc.) or to have a breathing tube put in and be placed in a ventilator.  Mom's already said she doesn't want "an artificial life."  I just want to be kept alive if there's a possibility of being an organ donor... 

Anyway, it was a successful trip by all accounts.  Mom got to gamble and show that's she's the Slot Machine Queen.  I got to come home and spend some time in the heat and traffic.  We discussed some future plans, some estate plans, some dinner plans.  And, now I leave back to my little house on the edge of the wilderness... wild cats, porcupines and bears, oh my!