Tuesday, April 22, 2008

Perceptions of pain, pt. II

From the depths of her contorted and decrepit frame, the woman screamed.

Every time I touched her she would shriek in some unintelligible manner, her tone wavering and exhausted as the last bit of her breath was forced to the effort. She was a mess. 89 years old and more co-morbidities than I had time to count, the dialysis staff where we found her told me that she "needs to just die." ...But for some reason, she wouldn't. Not a DNR, not four times a week hemodialysis, not cancer, not massive systemic infections would finish her off. Instead, she sat there in her chairs and stretchers, writhing in pain and suffering through every minute.

Her family calmy watched from the waiting room. This happens all the time, they say, but they don't want to give her too many pain medications because she "isn't herself" when she's on them. They've been cutting her oxycodone pills in half with a butter knife at home and feeding them to this woman slowly, as they deemed necessary. I stared at them in horror as they relayed the story.

The woman had advanced dementia. She was weak beyond helping herself and wasting away in a slow, agonizing manner. What personality this woman once had seemed to be long gone, or recessed so deep as to never be recovered. In front of me was a bag of bones, a writhing shell of a person who once was. If there was any consciousness within that body, and if it had any sense at all, it was probably pushing from the inside desperately trying to escape as soon as possible.

...But the pain was real. It had to be. She yelled so loudly when we moved her that the nurses had to apologize to the rest of the patients in the facility. It was a harsh, agonizing cry, and even though it was technically unintelligible it somehow, through seeming urgency or subconsciously perceived texture, spoke clearly to all who heard.

Let me go, it said. Let me go.

Thursday, April 17, 2008

Perceptions of Pain, pt. I

Pain, a subjective quality to which we are constantly trying to attribute objective value, is often a difficult symptom to fully understand. This is the first in a series of entries in which I will explore the way I have found my patients recognize their own pain, come to grips with it, and how they decide to outwardly project the experience towards the world.

Dispatched for the "possible heart attack," I arrive to find a tall, strong man in his 40's chatting with a police officer. He is walking around the small doctor's office, refusing to sit down and ignoring the nurse's increasingly frustrated attempts to apply a nasal cannula. "I'm fine," he insists, "I'm fine."

The doctor pulls me aside, rolling her eyes a bit as she shuts the door between us and the patient. "I don't care what he says," she tells me, "he's got something going on." The man came to the clinic because he has been waking up in the middle of the night drenched in sweat, short of breath with an "aching" feeling in the crook of his left elbow. At some point he admitted to some nausea as well, and the ECG taken today showed some mild ST elevations in the anterior leads. "After he realized that this might not be a simple sweating problem, he clammed right up," the doctor told me.

She was right about the clamming up. In fact the man was positively evasive when I tried to do my assessment. He would respond to specific questions with general answers, refusing to make eye contact at any point. When I asked him if he had any chest pain he replied "Well, yeah, I get pain all the time. Like when I work out, or if I fall down." He was probably one of the toughest patients that I've had to interview in a long while, and I was surprised to find that someone would so effectively try to sabotage his own care. I've heard of denial before, but there is usually a point where people - out of fear or whatever else - finally open up. This man simply would not, and we spent the ride to the hospital in tense discussion as I asked - and re-asked - each question.

The man was visibly shaken as we rolled him through the hissing doors at the emergency room entrance. His voice trembled as I asked him for his registration information, and despite my efforts to help him relax, his hands remained gripped tightly to the stretcher rails. We transferred his care to the hospital staff, and he released his grip from the stretcher only once: to shake my hand.

"I'm fine, but thank you," he says.

Monday, April 14, 2008

Ode to Mr. Jingles

A sigh of relief across all that work at this service. He is alive! He is alive!

It was an arduous journey no doubt. Months he was laid up, rendered alone to the cold with little more to comfort than that which he had prepared for himself in advance; our little friend was not seen for quite some time. Some feared him dead, some wondered if he had traveled far away for more hospitable climates, but there were those who maintained hope all the while. Though the cold, though his forlorn absence, though every unfinished nut, there remained a burning light of hope between us over the smothering, snowy months. He would return, we knew it, and there would be much rejoicing.

...And today, he did. Perched at the entrance to the Emergency Room doors today I found Mr. Jingles himself. A bit skinnier, a bit worse for wear, but alive nonetheless. Ready for another glorious summer of midday snacks and social sessions with the local EMT's, our mascot accepted a welcome back buffet of barbecue-flavored sunflower seeds and regaled us of winter months past.

Wise Mr. Jingles, many patients you have seen bustled past your doors. Here's to another season of summery survival.

Thursday, April 3, 2008


Clearly, it was an overdose. The EMTs we intercepted with said that they treated the same lady yesterday, at the same house in the same spot, with the same presentation and, likely, the same drug in her veins. The woman was hypoventillating at a rate of about eight, and her pupils were so small I had to check twice to make sure they were even there.

The call was so easy, so routine that I relaxed more than I normally would. We didn't move slowly, but certainly didn't rush. We where deliberate with our actions, and didn't make any mistakes. Nothing got tangled, nothing got in the way. One of the EMTs managed the airway with a bag-valve mask and an OPA, while the rest of us walked on the side of the stretcher towards the ambulance. Everyone, having been there before, was completely calm and comforted in the transparency of the situation. She'll be up in no time, a little vitamin N and we'll be cooking with gas.

We were right. 0.8 milligrams in the muscle, and then 0.8 more though the line and she was breathing well on her own, satting at 100% with just a nonrebreather mask and dreamily enjoying the ride to the hospital. It was the perfect amount of Narcan: that sweet spot between respiratory function and a pleasant patient. We hit a bullseye.

One might imagine that at this point I would, as I have many times before, launch into a lengthy discussion about the perils of overconfidence. ...Perhaps this patient might turn out to have something else going on, some terribly elusive pathology that I might've missed weren't it for some stroke of luck or moment of brilliance. I could write about myself being embarrassed by the hospital staff for a simple mistake, or relieved by a close call and reeling from the experience. All of these things have happened before, and it would be easy to weave these experiences into this story to make the point that I have made many times before.

Not this patient, though. Nope. She looked like an overdose, she presented like an overdose, and - lo and behold - she was an overdose. The drug worked, and all was well.

Sometimes its really nice to have things cut so cleanly. I probably can't expect the same from my next patient - and part of that is what I love about this job - but every once in a while, it ain't so bad to catch an easy touchdown.

Tuesday, April 1, 2008


They made us wait.

For almost 2 hours we sat with sweaty palms playing board games in the sequester room waiting for our turn. It was probably the most disinterested I'd ever been in Monopoly, but I couldn't help from thinking my way though the scenarios they'd told us we would be confronted with. A HAZMAT identification, difficult airway, ACLS resuscitation, c-spine and carry. Each step would be individually scrutinized, points attached and pitfalls set in place. We needed to get the airway established within four minutes from the start, and that included time to identify the hazard, climb through and obstacle, and get all our equipment through.

In time, though, the buzzer went off and we went through our motions. The hazard was quick, next throwing ourselves up and through the obstacle, back down onto our knees for the airway. It was calm and easy for only a minute, and then things started to get difficult. The air from the bag valve mask wasn't going in, and despite abdominal thrusts and even direct laryngoscopy, we couldn't find the obstruction. We tried to pass a tube but there were no lung sounds still, even though the positioning seemed good from the view, we couldn't hear a thing. Aware of the ticking clock, we yanked our scopes from our ears and questioned the judges.

"Are we supposed to be hearing lung sounds on the dummy if the tube is good?"

"You hear what you hear," they answered flatly.

(Me on the tube)

I looked one more time with the laryngoscope, desperately checking the tube one more time as our last few seconds ticked away. All I could see, though, was mannequin skin. I repositioned the blade slightly more anterior, lifting higher and forcing a larger view. There it was. A little plastic baggy filled with some yellow material. My partner handed me the magills and I pulled it out, but even then I knew that we were sunk. Four minutes had more than elapsed, and though we were able to establish a patent airway, we were dead in the water.

The next stage, the patient resuscitation, didn't go well either. We like to say that we are used to stress on the job, that we are practiced in dealing with unusual circumstances, but this situation seemed to push us back to our heels. It was a VT arrest on a simulation mannequin, and though we got our IV line, pushed drugs, and did good CPR like we were supposed to, we did it all sloppily. It felt a mess.

(Me on compressions)

Aware of the judges over our shoulders, we messed up things that we never would have otherwise. We made simple mistakes and forgot the order of things. After a bradycardic return of spontaneous circulation, we decided to try atropine first instead of pacing. Because we deviated from the established ACLS algorithm, we weren't released from the station until we realized our mistake, and pacing brought the blood pressure back to acceptable levels. More time wasted, more mistakes made.

Exhausted from the stress and the extended resuscitation, we strapped the 175lb dummy to a long spine board and performed the physical tasks required of us. We pulled it through a tunnel, up and over some stairs, and strapped everything down to the stretcher. Into the ambulance we went, and a honk from the horn indicated we were done.

We each flipped off our gloves, let out a sigh of relief, and collected our equipment.

The fact was already clear to us, but it wasn't until two days later into the conference did we find out that we were disqualified. I'm still not sure exactly which station we were knocked out for (JEMS is sending an evaluation in the mail), but the news was far from a surprise. We learned quite a bit, though, and the competition was great fun. This was the first time we had ever done anything like this, and -rationalizing afterwards - we all agreed that it was inexperience with the format that surely caused our errors. True or not, each of us learned some lessons that we will take home with us, and, next year, we will be a different team. JEMS Games: we will be back!

The rest of the conference was a great time. We attended a whole lot of lectures, some of which were absolutely phenomenal. The electrolyte talk by Corey Slovis was one of the best, and Bob Page, as usual, did not disappoint. A "Street Doc" Q&A session lead by Bryan Bledsoe got us asking some good questions and getting some good answers. All in all, like last year, I feel that I am returning back to my hometown better prepared to do my job well. That alone makes it all worth it.

Some photos I took from the JEMS Games finals: