Tattoos

I realize that I don't have any "happy" posts. But it's kinda hard. I work in an environment that does not have people coming in just to hang out and visit. How many people do you know that go to the hospital for a good time? Probably not a whole lot. I wish I could think of some truly enlightening stories of hope, love, miracles in the ER. But I can't off the top of my head. I tend to remember the stuff that makes me test who I am, my beliefs, my fears...I honestly can't think of something that made me stop and think; "Wow, this is incredible." Not to say I haven't experienced it, I just don't remember it and it didn't stick out. I've made a vow to notice the little things, the happy things.  Try and find more of a balance. But for whatever reason it's the darker things that make an impression on me.

I always said I wanted to go into OB/GYN.

"Be a part of bringing life into the world, instead of watching it go out."

I don't want to do OB anymore. I love babies, I love pregnant women, I love life. However, I can't imagine getting close to a family or having a deep relationship with my patients. Especially ones who lose their baby. Because as I've mentioned before; people die, and people die a lot. I cannot handle the death of a life that hasn't gotten a chance to live. That would destroy me. As tough as I can be, I have my limits. I've recognized this as one of them.

The ER doesn't give you a good opportunity to get attached. It's quick and dirty. It's fantastic. It's a wham-bam-thank-you-ma'am kinda thing. It's what someone like me needs. I love people, I'm the kind of person that other gravitate to. I need an environment where people filter in and out constantly to prevent me getting attached.

The problem for me is graduate school. I don't even think I get an ER rotation, which is where I know already I will ultimately end up. This quarter I was in a medical rehab facility and heme/onc (cancer patients) floors. Places that are very dangerous for an emotional person like me.

However, this leads into a "happy" post. One about meeting one of the most incredible men I have ever had the privilege of getting to know. I'll call him John Smith for purposes of HIPPA and to keep him anonymous.

Nursing school has challenged my spectator sport and has made me a participant. This has been an incredibly hard adaption for me. I'm use to being on the back burner instead of having the spotlight on me in medical situations. For my clinical each of the students is paired with a patient for the day. We are to help dress, feed, do vitals, get histories and practice our health assessments. Basically tech stuff with a little nursing built in. This gave me a ton of anxiety not having a doctor's coat to hide behind or to look at for guidance. Had to put my big girl pants on.

I met Mr. Smith. And by all first impressions looked like a frazzled, crotchety old man who wanted absolutely nothing to do with the timid 16 year old appearing nursing student who he was stuck with.

He's in his 90's and was on the floor status post having a hip replacement after a fall the week prior. He looked me up and down, nodded for me to sit. I made small talk with him, with little reciprocation. Until I noticed his tattoo on his arm.  I couldn't make out what it said, years of sun and work had tanned his skin and gravity aided in making it unrecognizable to an untrained eye of a 22 year old kid.

He looks up from his breakfast and subconsciously rubbed his forearm. "It was for my mother. I got it when I joined the navy." I tell him about my own tattoo that I got for my grandfather. He looked at me with skeptical blue eyes, but this time actually looking at me and not through me. Being bad with filters and neverendingly curious I ask him if at in his 90's he regretting getting a tattoo. He laughs and gives it another rub. "Nah, not at all. Mother was mad as all hell when I got it at 16. But now, it's what I have left at her." He chuckles and continues on with his breakfast. I look around the room at magazines, food preferences, his clothes folded on a chair...I notice a picture of a dog on his table.

"Who's that?"

"That's my dog, Lady. You like dogs?"

And that did it. A spark lit up in his eyes as he told me all about his best friend Lady. How he got her from a shelter, her favorite past time, how "damn smart" she is, how she was waiting for him to get home. He asks me about dogs and I tell him about my old dog Reilly. Show him a picture, he laughs and says;

"Handsome dog, terrier of sorts huh?"

He's stopped eating by now. Not because he's finished but because he can't stop talking. He tells me all about his life. His tour in the navy during WWII, how he met wife, the birth of all 3 children, his 5 sisters, his past dogs, his home, the death of his wife whom he'd been married to 70 some years.

"She died of depression, lost her eye sight. Didn't want to live anymore."

I sit cross legged, engrossed in his stories of work, of a life beautifully and honestly lived. He tells me in a way you tell and old friend. As if we were in a bar sharing our lives over a beer.

"I'm going home on the 2nd. I can't wait to get home to Lady. Ya know, I go to physical therapy every morning. I'm getting stronger. I'm going to be able to climb my stairs again. I'm going to do it all. I need to get out to my garden and get it ready for next spring. These 2 weeks can't go by fast enough."

I go to physical therapy with and watch as this tiny 90 something year old man works his ass off. He does more reps then he needs to. I can see the pain in his face as he walks, but he keeps pushing.

"You see me, Alli?"

He says looking over to me with a smile peeled across his face and blue eyes dancing. All around us others are in physical therapy. Young people (by this I mean 60's, 70's) and he is working the hardest. Pushing a little bit more. Stays a little bit longer.

He gets back to his room and holds the picture of his dog. Tells me about how she's "italian" and loves her pasta.

"Do you have any advice for me, about life or anything."

I of course ask, elbows on my knees leaning towards him.

"Always have a dog. Smoke a pipe every night when you watch TV. Let your kids handle the finances. Don't make a big deal out of the small stuff...but the dog, always have one." He laughs as he says this to me.

I admit that in the 23 years I've been around I haven't seen or experienced all that much. I'm still growing up, learning, making mistakes. Bur I have learned a thing or two and I have met my fair share of people. But never in my life have I ever met anyone with such zest for life. Such a passion for living. Even at 90 something he was excited to get home, he had shit to do and this wasn't about to stop him. The sort of drive and determination I saw in him I haven't seen in most people even my own age. He blew me away with his knowledge, wisdom and life. I felt honored to have gotten to know him and be a small part in this hiccup that he was overcoming.

I said my goodbyes and promised next week when I came I'd stop in.

He talked about me all week; to his nurses, his children and his old work buddies I later found out.

I wasn't assigned to him the next week. But I left my own patient to stop in and see him. He lit up when he saw me, his room had an air of electricity, of excitement. The energy was indescribable.

"I've been in a lot of pain today. Just feeling kinda down. But I remembered today you were coming in, and I can show you how far I've gotten. I can walk down the whole hallway now."

And he did. Strong, proud, and blue eyes twinkling.

He went home the next week. Just like he said. Meeting him was something special. My mom always told me that people come into and out of your life for a reason. Every single one teaches you something about life and about yourself. Whatever it may be.

I'll never forget him. And I don't think I'll ever meet someone quite like him again. I'm thankful for those hours he shared his life with me, his wisdom, his drive. I hope that someday when I'm 90 something I'm laughing about my life, showing some kid my tattoo and clucking about my grandbabies and dogs. And anytime I feel low or hopeless I'll think about his big ole smile, mother tattoo as he gripped that bar and walked. Truly something amazing.

How to save a life.

You can get use to anything. I've mentioned this before. Events that no normal person should ever be use to become absolutely routine for me. I've become jaded. It's an odd feeling to have when in so many regards the ER makes me feel human, alive and appreciative. And yet, I am completely and entirely jaded. It hit me with such force about a week ago. Made me upset about my complete lack of emotion, the fact I shrugged it off and was absolutely impartial. It's the whole separation of yourself from the situation.

Jaded: Tired, bored or lacking enthusiasm, typically after having had too much of something.  (The most perfect word for this situation)

I remember in high school I was in anatomy. We had to fully dissect a cat; skin, peel, identify, manipulate. "There's a thousand ways to skin a cat" my prof said. I disagree. You either do it right or not.

I panicked the first time I saw the cat. In a huge plastic bag, half full of formaldehyde, eyes slit open and tongue lolling out. They apparently get them from Mexico...I didn't ask questions after that... Not only did I just about have a panic attack looking at the bagged cat, but then had to go about the meticulous act of skinning. I found myself stroking the cats head as I did it. Maybe to comfort me, maybe to comfort the damn thing. But I got use to it. I had to convince myself it was fake. The cat was never real and was merely a tool for learning. Every day became easier. Cracking ribs, taking out organs, putting them all back in like a jigsaw puzzle. Get use to it or fail. 

How does this even remotely relate to the ER? That entire experience was pretty horrific, and I can remember just about every detail despite being 16 years old. The fact that on my practical I got "the functional unit of the kidney" wrong, and will ALWAYS remember that it's the nephron. Probably till the day I die. But it became routine. I've mentioned prior about people dying becoming routine. It bothers me to a point in that I don't like people dying and I don't like dead things (human, cat, etc). But the whole act of dying seems routine. I don't shutter anymore, I don't get a lump in my throat. It just is. 

We have new med students. Wonderful, smart, green, a little cocky. First time in an ER working. Everything is new and exciting and not text book. I love med students. They're like a science experiment. You get to watch them "grow" so to speak. My job is purely spectator and this is spectating at its finest. I like them because it tests my knowledge and allows me to play the "game" as I call it. The med students have a list of things they need to complete. One of which is CPR. Most of them don't get a chance to do CPR...it's not something like suturing or starting an IV which are a dime a dozen. Codes don't just waltz in. The med student my doc and I were working with was lucky enough to get code. An elder gentleman who went down at home. Was in asystole and despite the incredible work of EMS was still in that rhythm when he came in. 

Our med student stood coatless, gloved up and anxious. I remember my doc saying "don't worry, you can't do any worse to him. He's already dead. Remember if you crack ribs you're doing something right." Poor med student looked at me for reassurance, which I attempted to give through a smile and nod while she turned as gray as the guy who was wheeled in.

The beautiful chaos that is a code ensued. My doc intubated him, nurses pushed epi,  and med student went work. She was determined and from my 3 rounds of CPR training she did a damn good job. But he was old, and medicine doesn't stop the inevitable.  My doc ultrasounded his heart which quivered but wasn't compatible for life. And he passed. The formalities began. I went out of the room to do my work, my doc went to speak with the family but the med student disappeared. About 10 minutes later the med student surfaced. Her eyed welled up and nose red.

"That's the first time I've had someone die."

"Oh hun, I'm so sorry..."

"I don't get it."

"Get what?"

"He died."

"...."

"I did CPR, I did it right. He died. He didn't come back. I don't understand."

Tears start streaming down her face, and the breathing pattern became that of near hyperventilation. I get up and hug her.

"They normally don't come back."

"What?"

"If EMS doesn't get them back, it is incredibly slim that the team will here. I can't think of one patient I've seen come in as a full code still in arrest come back if they hadn't en route."

I felt upset watching her heart break, and her coming to a realization that this horrible situation was the norm. How do you explain to someone in her shoes who came in thinking she could save him, work on him, give it a 110% that this is normal. I have no medical school back ground. I haven't had 3 years of lectures and texts telling me X, Y, Z for success. People die. People die a lot actually. 

I steal her ice cream from pediatrics and sit down with her. 

"I was thinking about his family. His life, everything he's left now."

"You can't. You have to separate yourself. He's a patient. Know his name but keep him nameless. If you don't this will consume you."

She eats her ice cream and stares at me blotchy from crying. I'm still dry eyed, wearing a smile on my face and working on his chart. His past medical history, social history, time of death.

And it hits me. 

I'm jaded. 

And I hate it. I hate that I can separate myself, I hate that something like this is normal. I hate that she is over come by emotion and all I can think about is getting myself chipotle after work. I wish to be in tears with her or even feel some sort of emotion towards this man. But I don't. I feel hungry and sad for the med student's realization. And that's it. But that's the way it is. And that's how it has to be if the ER is your home, your niche, your comfort zone. It's disturbing but it's life in the ER.

Argggg

I have ingenious ways of remembering the differences between different inflictions. Scabies and scurvy?

Scurvy-pirates
Scabies-holocaust

Horrible? Perhaps. But I'm a Jew ands it's ok.

The Achilles Heel

My cousin said something to me not too long ago that really resonated with me:

"Your normal, even good day in the ER is somebody else's worst."

It's weird to think about, that my typical work day where I'm laughing, happy and going about my normal routine is a patient's last day or most traumatic day in their life.  It's sobering to think of it that way. I was trying to explain what it was like working in an Emergency Room today, especially a level 1 trauma.  I explained that you have to be desensitized to it all and allow it to be a normalcy to be able to continue working there.  If everything became personal you wouldn't be able to emotionally survive.  It's a coping mechanism.  You either adapt, or get consumed.

This doesn't come immediately, which I think is evident when I talked about the first time I saw someone die.  I'd say the first month I was in the ER I was at a constant state of on edge and emotional overflow. But the more times you see something the more routine it gets.

You can honestly get used to anything.

Sometimes that scares me.

Every once in awhile though you'll get that patient or that family that hits your achilles heel and you're human again. The funny thing is, it's not the most graphic event or even the most traumatic.  It's something that all of sudden ties you to that person and makes their tragedy yours too.

There is one that sticks out for me that happened maybe 5 months ago. I was working a Friday night and it was around dinner time. I was working with one of my favorite docs and was in a disgustingly good mood, which I normally am at work. We had an ambulance come in, on our board it said "SOB" or shortness of breath.  I watched them wheel her in, and remembering how it was eerily somber.  The patient was around my mom's age who had end stage breast cancer that had metastasized to her lungs.  She was still living at home with her family and just having comfort measures instead of treatment anymore.  She was also a DNR. We walked into the room and on the gurney she was laying motionless, eyes open and lifeless. That was the first thing I noticed. Her eyes were dull and partially open. When people say "All the life in their eyes were gone" it's true.  I don't know how to better explain it than that, the person is no longer there.

We were caught up to speed by EMS, she was at home with her family and got short of breath. Family called EMS and she passed away en route. All of this was fine, I was emotionally unconnected. It was tragic, sad, as it always is when someone dies, but not something I would particularly remember otherwise a month from them.

Until her daughter came in.

Her daughter was close to my age.  She had come with her sibling and father thinking that her Mom was just short of breath, was going to the ER because she had a hard time breathing. Never imagining that she wouldn't see her mom alive again. I was still in the room when she came in, walking into the same scene as me; lifeless pale body, eyes partially open and dull, dead still.

"Mommy?"

It felt as if all of the air had been sucked out of the room. She walked to the gurney, put one hand on her leg while a paramedic said he was so sorry that she didn't make it.  She looked at our faces in disbelief and lost it.

"No...No...Mommy, no, she's not dead. Don't leave me. Mommy?"

Then it hit me.

All I could think of was my own mom and how at 22 I couldn't imagine a life without her. I couldn't imagine her being alive one minute and dead the next. I couldn't imagine going through this stage of growing up not having her by my side. I couldn't imagine her not at my graduation, watching me walk down the aisle some day, or her holding my first child. It was such a terrible feeling I still can't even fathom it. All I could see was someone my age in shoes I hope to never fill.

Suddenly it became personal.  Her loss was now mine now too.  The pain she was feeling washed over me, and I had to walk out before I completely lost my composure. Even now writing this it brings me to tears, it became real. I would have done anything to bring her mom back.

It's crazy how in a split second how something can go from being routine to knocking you flat on your ass.

I'm grateful for it.

The rest of my night had a heaviness to it.  I was no longer laughing or smiling, just doing my job so I could go home. The minute I got into my car I sobbed.  Sobbed because I was so heartbroken for that girl.  I sobbed because I was thankful that my mom was at home, that my family was healthy. When I got home I gave my mom the biggest hug and reminded her for probably the 5th time that day that I loved her.

I love the ER. It keeps you grounded. It humbles you and makes you human in a way that no other profession or experience can.  It reminds me constantly just how lucky and blessed that I am.

DNR (Do not resuscitate)- A person who is a DNR has legally stated that they do not want CPR, mechanical breathing or outstanding measures done if their heart stops or if they stop breathing. 

Lessons Part 1

Things I've learned to do to have a healthy life. Taught by the numerous patients in the ED

1. Don't become an alcoholic

Unless you hate you liver, love the color yellow and want to puke blood.

2. Don't be a smoker

Unless you want to look 75 when you're 55 or enjoy COPD/lung cancer/O2 machines.

3. Don't get old

Yes, this is unavoidable. But a major cause of problems

4. Wear your seatbelt

Unless you enjoy superman-ing out of your windshield

5. Don't ride motorcycles

There is no good way to crash one and you will do major damage. On the plus side you may be a great organ donor.

6. Don't get fat

Hypertension and diabetes suck. HTN can give you a stroke and DM can kill your kidneys

7.  Don't play Russian Roulette

You have a 1 in 6 chance of shooting yourself, this chance increases if you have been drinking with your buddies. 

What's Up Doc?

I can't stress how much I've learned in the ER. For example:

"Psoriasis" and "Cirrhosis"while sounding incredibly similar are not the same thing.  Psoriasis are dry patches on the skin while cirrhosis has to do with a scarred fibrous liver. Yep. Not the same thing.

This particular story happened on my second training shift.  I was being trained by one of my company's bosses and was already incredibly nervous.  We have an electronic tracking board that shows the patient's room number, name, age, chief complaint, and so on and so forth. The doc I was working with signed up for a male with the CC of Priapism. Now, being green with only 2 shifts under my belt and an anatomy class for reference, I had no freaking clue what this was.

"What's priapism?"

"I'm not going to tell you. You'll just see what's up."

We walked into this poor man's room, it didn't take a doctor to figure out what this patient's issue was. I could tell by the small tent made from the man's sheet. 

Priapism- is fancy for an erection that lasts longer than 4 hours.

His had lasted 10 days.  Immediately I turn bright red.  All I could think about was how awful this must be for this middle aged guy that a girl, who looks roughly 16, had to witness.  I did my best to keep a straight face, completely red, but impartial, while my doc took his history and did the physical.  Apparently he hadn't taken any male performance drugs, and this was spontaneous. But 10 days? What the hell do you do with a boner for 10 days?

Ring toss....I like to think ring toss.

We walk out of the room, I gain composure, but not before being asked by my doc to CONFIRM with the patient that he had this erection for 10 days.  In case you're wondering what they do for a 10 day erection, they have surgically reduce it. As a result you spend the rest of your life impotent.

Lesson for males: If this happens to you seek medical attention immediately.

Priapism, that's what's up.

ER Superstitions

I always thought it was funny that doctors would have superstitions, mainly because it seems opposite of what they're taught in medical school about science and logic. However, I now believe in superstitions.  There are two in particular.

1. Never say it's slow.
The second you say it is slow 25 people show up in the waiting room along with 3 ambulances, one of which is a trauma. Also if you're the perpetrator and caught....guess who has new patients.
2. Never say a frequent flyer's name out loud.
The minute you say a regular's name they come in. Most likely asking for diluadid. If you say their name they're yours to deal with. And no one wants that.

Without fail if either of these things are mentioned you get the result. Which came make your day a hell of a lot more painful.

Code

Yesterday I worked the 9p-4a while incredibly sick and training a new hire. I've been in the ER now for a little over a year and a half, things that used to shock me no longer do. Sometimes I forget these new hires have never seen any of this stuff before which prompts me into telling "my first...so on so forth".

Last night we had a full code come in, that was not a first for me, nor was the patient dying. What was my first was the first time I had ever seen my ER in such chaos. We had literally 30 seconds from when they called the code to the paramedics wheeling him in. Normally there is a few minutes to get resp therapy down, meds, crash carts, xray and bodies in the room ready. There was none of that last night, it included me running around and grabbing stuff for my doc while the chaos unfolded around us. I typically stay silent, invisible and in the background. Last night I wasn't. That kind of chaos makes me anxious.

My new hire stood and watched, doing what I normally do, dutifully taking notes and making the chart. Stone faced, taking the situation in. While it was not my first death, it was hers.

After my doc called TOD and went to speak with the family I went and sat down with the new hire to discuss what happened and how to make the record. She looked at me with a face I can only imagine mine looked like after the same scene over a year before.

"That's the first time I've seen someone die."

There is not much you can to say to someone after their first experience with something like this other than share your story.

The first time I saw someone die was surreal. We had gotten the call for a full code and were in the room ready for what was to come.  The man came in on auto-pulse...an automatic CPR device that mechanically heaves the chest in and out.  The team went to work while I stood in the corner, alone, and observed.  The first thing I noticed was that his face was blue. Cyanotic is what it's called, from the lack of oxygen bound to the hemoglobin.  I didn't believe that people could be blue, I was wrong. The organized chaos around him pushed epi and atropine, gave CPR, pumped the ambu bag.  It was speculated he took long acting cardiac medicine because he would code, come back, code, come back, code, come back.....it went on for an hour. Zombie-like almost.

I always thought my reaction in this situation would be adrenaline, wanting to do everything I could to save him.  Except my brain didn't think that way. The first thing I did was pray. I'm not a religious person and that was my initial reaction. It wasn't even praying for him to live. I prayed that it would end. Some sort of resolve, either way, as long as it stopped. The team rushed around diligently trying to save his life, walking the tightrope between life and death. He lay there, perfectly still except for the rise of his chest as a tech did compressions. I stood perfectly still in the corner. Him and I were the only two not moving. He was alone in a crowded room and I was the spectator. All I wanted to do was hold his hand.  Make this whole thing easier, show him that regardless of the turnout someone had his hand through it. He died an hour after he was wheeled in.

I remember coming out of room 35 stoic, sitting down and taking a deep breath before the gravity of the situation hit me, that I had just witnessed one of the most intimate and solitary moments of life. Death.

The ER is an unique place. From childhood we are taught to think before we act. Weigh our thoughts, our heart and our head, make the best choice. Life in an ER does not work that way. It's reactive. It pulls out the most raw emotions, thoughts and feelings from ones being. You have to think quick, process immediately and do. I have learned more about myself in the last year and a half than I have in my entire life.

I tell this story to my new hire as her eyes get red, either from exhaustion or emotion...maybe both. I explain to her that people dying does not get easier or better, or even less tragic. It gets less shocking. I know she was dealing with her own emotions, and she'll figure out how to handle it. Or she'll leave the ER.

While I can't remember every person who has died, every single one leaves a mark. I become more humble, I appreciate my life a little bit more and I remind every person in my life how much I love them. I'm thankful for that.

Beginning

I always wanted to start writing publically. Give a little glimpse of what my life entailed.  Graduate school seems like an appropriate time. A lot is changing and shifting in my life, and writing is the best way I know how. So here it goes. Welcome to the beautiful life.