Mr. Z

Mr. Z had a gangrenous toe. A dead toe. It was reddish orange and looked as though a pack of rats had nibbled it for weeks. The edges were frayed like an old sweater. Mr. Z possessed this unfortunate toe because he had insufficient blood coursing through his legs. Insufficient blood supply, known medically as ischemia, is excruciating. It is the pain that occurs when someone experiences a heart attack, which connotes lack of blood supply to the cardiac tissue. Mr. Z essentially had a never-ending heart attack of the legs.

He was old. Eighty-eight to be precise. "Old" is all relative though. I've seen eighty-eight year olds that could unquestionably cripple me in an arm wrestle. Mr. Z was not one of those. He was demented, incoherent, and frightened.

For two weeks I visited Mr. Z.  We had a well established routine.  I would shout in his ear to ask if he was in pain.  He would moan.  When I say he moaned, I don't mean he whimpered softly.  I mean he shouted his pain, with rhythm.  To be frank, Mr. Z would be moaning before I even entered the room.  He moaned day and night.  He never stopped moaning.  It was a constant vocalization that may not have even indicated pain, but was simply self-soothing noise. "OOOH, OOH, OOH!"  You could hear him from the elevator.  Sometimes he deviated from his monastic "OOH, OOH, OOH!" in favor of a more unsettling "MOM, MOM, MOM!"

We were concerned that Mr Z. was in pain, but he couldn't tell us. We tried an assortment of medications and remedies, but he kept on moaning. Personally, I think his pain was both ischemic and emotional. He knew he was dying. No one visited him. He was a frightened 88 year old child crying for his mother. He died alone in a drab Veterans hospital room with poor lighting, moaning to the very end.

Origins.

I am the Barber-Surgeon
Shave and a bloodletting,
Two bits.
Fashion and medicine
The not-so distant cousins
It seems.

Cowboys and Indians

While driving alone through vast Montanan landscapes I decided to stop for coffee in Billings, of all places.  A skeleton of former factory glory, Billings lacked character, lacked charm, lacked any reason to survive.  But they had darn good coffee.  After my cup of joe I stood by my car, stretching.  An indigent Native American in ripped and soiled jeans approached me with fearful and bloodshot eyes. He told me his mother was down the road, dying on the 4^th floor of the hospital.  He wept openly.  I consoled him.  I put my arm around him.  He said he was all she had left.  His brother had died in the rodeo years ago, he said.  I told him to go be with her.  He said he couldn’t bear to see her this way.  I urged him to see her.  He said ok.  We embraced—me, a white medical student from Michigan just passing through, and him, a poor Native American stranger from Billings.  His tears were on my shoulder. Then he asked for money, and I said no. Move along.  

Drunk birds.

Intoxicated patients are a dime a dozen in the ED.  They can be found slumbering on cots in the hallways, running naked through the resuscitation bays wearing a blanket like a cape, or simply shouting at the top of their lungs at all hours of the day. Many are “frequent flyers;” familiar faces that consume nothing but beer, medical resources and free sandwiches.  These individuals are received with palpable disdain in the ED.  Eye-rolling and off-color comments abound with their arrival. The goal is always to “get them out the door” as soon as possible. Emergency Department attitudes towards individuals with alcohol dependence and abuse verge on the unethical.  Alcoholics are not recognized as suffering from mental illness, but rather are more or less derided for their “choices.” Addiction is never addressed in the ED.   Undoubtedly, to do so would be time consuming,  resource heavy, and in many cases futile.  However, by ignoring the true illness we simply set these inebriated birds loose on rough winds. We throw these frequent flyers to the ominous skies, encouraging them to fly another day.

Gerty

There's a 95 year old woman dying in the intensive care unit in a community hospital about 20 miles from here.  Her body is a withered shell, a mere 60-70 lbs of bones and loose, bruised skin. Her mind, however, is vibrant, joyous, and sharp. When I walk in the room each morning and ask "how are you doing?" she invariably responds "I'm feeling better," even as she hacks up increasing amounts of thick phlegm. Equally invariably, she turns to me and squeaks out, "how are you this morning?" She says it with all the sincerity she can muster. She reaches out her feeble, skeleton-like hand while I talk to her about her ailment. Each morning, I take her hand in mine and she clasps her hand tightly, as if clinging to life itself. I lean in close to her--as her 95 year old ears don't hear as well as they used to-- and there we sit, chatting about her sons and her lifelong passion for football. I don't have the heart to tell her that I don't care much for the sport. Her mouth is dry and cracked, so each morning I swab her lips with a moistened sponge on a stick, and my mind drifts to the vinegar held to Jesus' lips in his last moments. After the sponge, I dab her lips gently with a tube of moisturizer, and I think how much more pleasant the cross would have been with some lip balm. Yesterday I was watching her breathe during her sleep, noting how her entire body seemed to gasp for air. She awoke, opened her eyes slightly, and turned in my direction. "Am I going to make it?" she asked. Suddenly my chest was in a vice, and the vice was squeezing me so hard that my eyes welled clear and full. I answered feebly, something about doing our best. Her hand squeezed my own. We smiled at each other, and she went back to sleep.

The Washington Patch

Many thanks to Brother Wrider for the brilliant idea. Allowed me to check out some new single track near my house. Perhaps not the smartest thing to do on a 1 dollar makeshift patch.

The Central Line

A "central line" is a type of intravenous catheter that is inserted into one of the larger veins of the body, typically the superior vena cava, which can be accessed by either the internal jugular vein or, more rarely, the subclavian vein.

A "central line" is also a great cause of fear and trepidation for many med students and junior residents. I recently successfully placed my first central line under with ultrasound guidance and close supervision on an intubated patient. Placement of the line requires inserting a 3-4 inch needle into the neck or chest while avoiding any of the following scenarios:

1) Nicking the carotid artery and watching your patient spurt blood from his neck like a cheap zombie apocalypse flick
2) Puncturing the lung (more likely with a subclavian line) and causing a pneumothorax in which the lung collapses as its surrounding negative pressure space fills with air.
3) Stabbing the heart itself with the long guidewire over which the catheter itself is slid; this is a particularly undesirable possibility as large hunks of raw meat typically do not respond well to poking and prodding. Ask any cow.
4) Failing. In this scenario you can't get your needle in the vein and the patient either dies or (and possibly more dreadfully for many individuals) a more senior medical staff has to save your incompetent derriere.
5) Incurring the wrath of a sickly patient who does not take kindly to being treated as a pin cushion; in this scenario the patient may run the risk of breaking the sterile field by squirming, spitting, swinging fists at your petrified face, or possibly snatching the needle from your trembling hand and attempting to place a central line in YOUR neck.