We weren't invited to the party?

2250: "Intoxicated male vomiting"

2253: "20s yom, passed out in the laundry room"

2355: "MVA auto vs tree, head injury, intoxicated"

0051: "18-20 yof, passed out, snoring"

0057: "18 yof, alcohol overdose, in the bathroom"

0058: "b/m on the side of the road, fell off his crutches, intoxicated"

0109: "20 yof, alcohol overdose, has vomited"

0116: "17 yof, alcohol overdose, not responding very well"

0124: "18 yom, vomiting, alcohol overdose

0141: "18 yof, alcohol overdose, slurred speech"

0155: "20 yof, passed out in a cab"

0235: "19 yof, alcohol OD"

0313: "female, passed out in a vehicle"

0320: "subject passed out against the building"

0324: "driver of vehicle passed out"

0325: "20 yom, throwing up and intoxicated, shivering"

Clearly, it was a good party night.

Dignity in death

My grandmother died this week. She was 86 years old. She was healthy well into her 80s, living independently, playing her cards games and watching Jeopardy with her grandkids. Two years ago she had an elective shoulder replacement. Therefore, she was luckily in the hospital from that procedure when the GIST tumor in her small intestines caused an obstruction and stretched enough to rupture her small bowel. She had her second surgery in a week at 84 years old, and still came through that well. So that's how we got her diagnosis and began treatment.

The treatment was just too much, and no one argued or disapproved when she elected to stop treatment and stay at home under the care of hospice. We got her a DNR. There were charts and meal wheels. She was never alone for the last 3-4 months. She stayed in her home, slept in her own bed. We gave her morphine and zofran when she needed them. All of us had strict orders NOT to call 911 if she fell or felt ill when we were with her.

She had good days and bad. The last day I saw her was an excellent one. She sat in the living room with several of her children and grandchildren sprawled on the floor around her, "having a party." (I brought the bourbon...) She was totally lucid, cracking jokes (telling my cousin she had a big mouth and couldn't keep a secret...!) The four days immediately after that, she stopped eating, stopped talking and didn't get out of bed until she died.

But she died in her bed, with a little morphine and haldol on board and my uncles at her side. What could be better than that?

I can tell you what's worse. What I do to my patients sometimes. Frequently, in the pursuit of a cure, patients and especially families, inadvertently torture the patient. Let me tell you, there's nothing less dignified than being flogged until your last breath in the ICU.

We put a breathing tube down your throat. If it says in for too long, we cut your throat open and put a trach in. You can't eat in this state, so we put a feeding tube down your nose or a PEG in your abdomen. You've got a foley in your bladder, or worse, you don't have one and are incontinent all over yourself. Similarly, you either have to endure frequently turns and cleaning when you're incontinent of stool or we stick a rectal tube up your rear end. Because you instinctively want to pull all of these things out, we tie your hands down with restraints.

Sometimes we put you on dialysis to help your kidneys. You're on the vent to breathe for you. If your heart is dying, we can pace you. Or put a ventricular assist device in. Or even throw you on ECMO.

The high doses of pressors may cause your toes to turn black and fall off. When your heart stops, I'm going to send high doses of electricity through you and pound on your chest, breaking ribs.

And a lot of times we can save people. Nothing makes me happier than seeing one of my critically ill patients get off dialysis, get their ETT out, regain their native heart rhythm. Then leave the ICU. Go to rehab. And sometimes come back to see us, walking and talking.

But that's not always the outcome. Especially for the elderly. Or the baseline infirm. Or those whose original diagnosis is terminal anyway.

If you ask most medical professionals how they want to die, it's usually more along the lines of how my grandmother did. At home. With family. Without tubes and lines and restraints. On their own terms.

The cure is worth it. But the cure isn't always achievable. We have to know when and where the line is.

Love you Grandmommy

No lights or sirens please

Communications: "Units be advised... the caller requests you not use lights and sirens in her neighborhood."

This drives me CRAZY. Likely a bit more than it should.

You called 911. Simply by that act, you are stating that you have an emergency. You need help emergently. That's the whole goal of calling 911 right?

But 1) it's not so emergent that you have time to think about things like our lights and sirens. Really sick people can't focus on much else besides how terrible they feel. And 2) it's not so emergent if you have time to worry about what the neighbors will say.

Sure it's embarassing to have everyone know you called 911. People stare at our big flashing toys. They'll probably ask you later if everything's ok in a 30% concerned/70% nosy neighbor fashion.

But if you're sick enough to need an ambulance, that trumps everything else. Otherwise, maybe a taxi is a more appropriate mode of transportation.


PS: If you hadn't asked, likely I would've turned my lights off when I pulled in your driveway/off the road...

The 0-10 pain scale, as my patients understand it

"My abdominal pain? It's a 10/10."

"The pain? Oh yea, it's about a 9... Can you come back when you have my medicine? I've got to finish this tweet."

Zzzzzzzzz... zzzzzzzzzzz... zzzzzzzzz... "Hey! Weren't you supposed to bring me more drugs? I have 10/10 pa..." zzzzzzzzz

"Well, I've had this cold for awhile. My sore throat is at least a 6 all the time, but when I cough it's definitely a 10/10."

"Only out of 10? Oh no girl, it's a 20."

"Don't... worry... about... me. It's only like a 3/10. I'm sure... you have... sicker... people... to help."

Patient's Words of Wisdom

"Only in the hospital do people come wake you up just to ask if you're sleeping."

Who gets turned down?

Where I work, we get a lot of organ transplants. I love that patient population. They're my favorites actually. I think organ transplant is an amazing and miraculous advance of modern medicine. But organs are a scarce and precious commodity. Thus, there are rules in place that govern the allocation of organs and who gets a new organ. Not only does the potential recipient have to qualify medically under strict guidelines, but they also have to qualify from a psychosocial standpoint. This is to ensure that the scarce commodity that is that organ is not squandered. Being a transplant recipient is a lot of work, even and especially after being discharged from the hospital.

Mr. N is one of our recent kidney transplant recipients. Medically, he was an appropriate candidate for this new kidney. But the more I learned about him throughout his stay, I became more and more shocked that he qualified with his psychosocial background.

1. He is illiterate. 
• Literacy is important, especially for managing medication at home. Transplant medications are complex and the regimen must be follow strictly. 
2. He is estranged from most of his family, including three ex-wives and multiple children who he's "cut out of his life." His visitors were restricted to the one daughter he was not estranged from and his girlfriend.
• A recipient needs support, basically for life. Someone needs to be intimately aware of the potential complications that the patient faces, when to get the patient to the hospital, when to call a doctor, their medication regimen, etc, etc, etc. This takes on more importance when #1 is in play.
3. He's homeless. He lost his trailer recently when it was foreclosed upon. He's been sleeping on couches and in his car. 
• Maintaining health, especially after a transplant, is expensive. I'm inferring from this series of events that his financial portfolio isn't exactly sound. The concern here is that a transplant recipient's life-sustaining medications could fall to the wayside in lieu of other financial responsibilities. I've seen that happen with people who are much more financial stable. Direct path to rejection of said organ.
4.  He might be going to jail. For reals. He'd been found guilty of a crime and is out on bail, awaiting sentencing. The way I understand it, he could get anything from probation to a 4 year jail sentence.
• I feel like the problem with this one is pretty self-explanatory.

I realize that I sound like an elitist who is judging this man. I'm really not. I just want our transplants to succeed in the long term. Hard decisions need to be made to ensure the highest likelihood of success of the transplant. Tough love?

But my real question is, if this guy didn't get turned down... what's going on with guys who do get turned down?!

I'm having a heart attack

Me: "Hello there sir. Did you call 911?"

Mr. Dextrocardia: "Yeaaa, I'm having a heart attack."

Me: "Oh ok... what's bothering you that you think you're having a heart attack?"

Mr. DC, vaguely gesturing towards his chest: "My heart hurts. It hurts real bad. You gotta give me something!"

Me: "Chest pain you say? Anything else bother you? Shortness of breath, nausea? Where is that pain located exactly?"

Mr. DC: "It hurts where my heart is!!"

Me: "So where? Show me where."

Mr. DC, pauses to think about this for a minute: "It's... uhhh... over here." Gestures to his right anterior chest. "Your heart is on the right... so that's where my pain is."

Me: "That's where your pain is or that's where your heart is?"

Mr. DC: "Both because your heart is on the right... right?"

Me: "Your heart is on the left... ish."

Mr. DC: "Oh well that's where my pain is. I forgot."

Oh sure. Let me draw up your fentanyl now. I bet you're "allergic" to nitro.



Fun fact of the day: dextrocardia occurs in <1% of the population. Having dextrocardia without other other congenital defects is even more rare. I've seen it once. Pretty freaking cool.