ICU musings

There is a lot to see in the CICU- stories about families, love and loss. You get to see people at their most vulnerable, their weakest- not only the patients, but the families.

Some stay for weeks and never have anyone with them. Others never have family leave the hospital. The vented patients when coming up are so grateful, so aware of the love that surrounds them, and I feel it brings them back. Then those that are alone so often never wake up, their lives effectively over-  as no one that wants them to come back and resume their lives. Often these are the ones that I find compelling- what made them get to that point? What made them so alone?

Dr. W. remained vented for well over 2 months- his family loving him, his grandson driving up from Notre Dame to watch every game in his Granddads room, sitting next to him, giving him the blow by blow account of the game, cheering for the usual victory-sharing with his Granddad even though there was no obvious response.  Dr. W's neuro status was questionable at best. Late one night when I was in his room, he began to track and I told him what a wonderful dad and granddad he must be, as his family was there, had been there and was so obviously in love with him- his eyes lit up, and he smiled over the vent. 

Dr. W never made it home, but his change to his next life was bathed in love. His was a life well lived and more importantly,  loved.

This past weekend, we had a patient that had WNV- this in itself was surprising, as his is one of 4 cases we saw in MI 2 years ago. He had a caretaker that was amazing- his attention to Mr. J was more then impressive. Being somewhat slow, I did not figure out that they were actually lovers, or had been before this horrific event occurred. He blamed himself- no amount of convincing  and praise for his care was enough to change his mind. He made it out of the CICU, and became (surprisingly) floor status, and it was during this walk that his partner told me their story.

They had been together for over 18 years- met at a Jazz festival in early 1991- and he moved from Canada to be with Mr. J. They were happy and all things good until WNV hit in 2007. When this happened, it struck hard and fast, ravaging his body and brain equally. He went to n extended care facility and almost died in the 3 days he was there post initial hospitalization. 

At this point, his partner decided that he would take care of Mr. J - forgoing his life, even if he did not say this to even himself.  Mr. J was unable to communicate, save for small looks and a sly smile. He has the softest of laughs- one that spoke volumes about him, his being and why his lover stayed so close to his side.  It was clear to me- he did not sleep the entire time he was there- so aware of every move the staff made, being kind to all, yet ensuring that nothing would harm his love. I told him how lucky Mr. J was to have him, and his comment back brought tears to my eyes. 

"I am the lucky one- I want to keep him alive as long as possible, as when he goes, a larger part of me goes along with him."

Reflections and attraction

you have to place faith that nothing happens without a cause, reason or purpose. I believe this to be, even when I feel I am struggling the most. I am sure I do not know any of the answers with out the benefit of hindsight, (bless that beast...) and when I do see, it becomes oh-so-very clear to me.

I will say one thing- I like clarity.  Not a fan of muddy waters.

With that being said, how can illness be explained? What makes someone so sick they die in a hospital? Why would that happen? This seems to have no answers. It does make me think, however, that maybe sometimes we are tools for others. If turn-around is indeed fair play, perhaps that's what it's about. Now I admit fully here that I am unsure about this, but it does make me think.

When I was working in a step-down unit, run by SV, the unit, feeling and compassion was amazing. These people came into my life to learn something, and in the turnaround,  I learned from them.  For me, the floor was a better place to work, only because there was time for people to change their patterns- the life patterns that got them there in the first place. Certainly, having an episode is a wake up call, or it should be, for living better, both from a emotional as well as well as physical prospective. 

When you work on the floor, you get to spend a lot of time with these people- and got to know them fairly well. Some of the more memorable ones--the woman who would not get better- finding out her dad had been in the exact room, same bed, and never returned home. We moved her, and she got her pacer (I think that was it...) and she got better.

Then, the man who kept infecting his incision with his own feces as he was finally getting attention that he had wanted his whole life.  Psych got involved for that one....

One of the saddest, the CEO who collapsed crying against me in fear, saying he could run a million dollar company, but could not handle having a heart issue and was very scared of dying. (he didn't.)

The woman who came in who said NOTHING for days. She was in an odd, very perplexing rhythm.  Some family member came to visit and it was in this way we found out that her son had jumped to his death 3 days before she was admitted, and she actually missed his funeral. Her heart was indeed broken.

Then, one of the most amazing- the man who was slipping away from dementia,  in a rare moment of clarity,  grabbing my shirt and pulling me towards him saying the most amazing words I have ever heard from anyone..."I just want to hold them in my heart" when his family was leaving. For this was a rare moment where anything he said made sense and to have it carry such meaning....

There was the man who once being put on heartmate realized that he had been living his life as the wrong gender and felt that the gender transition surgery was more important then getting a new heart. He was an interesting guy anyway, and totally toothless, as all his teeth had to be removed before the transplant could happen. He put a mirror on the back side of his door, so we did not see it, and would dress in womans clothes...so funny, sad, too, I suppose, but funny, in a strange kind of way. So, - well, I can't say it, because is sounds mean, but ...well, to hear him talk about it. Put it this way, you need your teeth to talk!

The absolute love and commitment of J to her husband while he waited for his heart- day after long day staying with him and keeping him up even when he got down. He was the one that named my little $100.00 Flinstones  car "the speck", as he would wait for me in the morning to get to work and knew where I usually parked. I so wanted to put a "Hi there!" sign on my car- but the damn thing was so small, I am sure he never could have read it from the 7th floor. When he left, with his new heart, strong and tall, we all cheered and cried.

Ah, then, the whiney man who coded. For some reason, I was at his head, and made it VERY clear that he was not leaving on my watch, get back here- it's not your time, buddy.... The next week, he says that is the only thing he remembered- his wife told me that it was the first thing he said when he woke up. To this day, I swear he coded just because he felt lazy...yes, I know that's not true, but he was that sort of person. What a kick in the ass I must have been. :-)

The poor guy who sat quietly in his room, never asking for anything at all, covers always pulled way up to his neck, finally getting a heart. He was out of the ICU in 3 days- remarkable to say the least.  I went to see him on the surg step down the next day. He was so happy and looked so alive- and boy, was he talkative- I believe he said more words in that short time then the entire month or more he was waiting on our unit. As I was there with the PA, he got a strange look and said "I have a headache". He was rushed to CT- it was massive bleed and nothing could be done. As each sense left him, and it was indeed each sense, you could tick them off, he still was grateful even while knowing he was dying. His last words were "Please tell everyone thank you...."

The boyfriend and girlfriend- she loved him so, and when he came back from being cardioverted (what is the spelling on that??) she kept saying that something was not right- she could not pinpoint it...but, indeed, something was not right. He ended up on ECMO, and did indeed die. If the RN's had just listened to her....

I watched med students become amazing MD's- Sanjay for sure, he was exceptional from the very beginning- clear, communicated well, was funny as well as very kind for the patients and never seemed rushed.  Brad Dyke- who remains at the U- not only an exceptional person, but an amazing MD- who truly cared about each and every patient that he took care of as if it were the only one. I miss working with that team- impressive care, great compassion and an honesty that is missing often in residents that I see on midnights.  

This all leads me to why I am doing this. Why I press on, why I push to learn things that I should have learned years ago, and why I am putting myself in a position that is, to say the least, difficult at 46. I love making the connection, I love letting someone have another chance, and if the end is the way it is to be, I want that transition to be as easy for them, both patient and family, as possible. I respect and value life and have a fairly strong believe that this life is not what it's all about. There is more....

When that gut feeling occurs, listen...

We were sending a pt off to the OR, and my resident came up as transport was taking him down. He stopped them- and said..." I just don't feel it's safe right now...something is bothering me."  He sat at that monitor for ever, staring at it, staring at the tapes. "It's sinus, but there is something." People were very irritated...this guy was a PITA, and his family worse. Very intense, very critical. Frankly, we wanted him gone. I spoke to B and said..."trust it, it's okay, don't worry about what people say. It is you that has to make the decision." He said back "I don't understand what is it, but he keeps popping in and out and something is just not right."

He is one of the "good ones" right now. I really like him a lot. When Mrs. X told me she wanted to withdraw, I called him in to her room. As she was telling both of us, we both began to cry. This woman had been fighting for so long and the only reason she was fighting was for her husband. She had been on the list for ever, but no heart came thru- she kept getting sicker and sicker. She touched so many lives with her strength. But she was done.  It was past hard for her, and understandable. But the compassion that he showed....

So, I just found out that the patient died during the procedure. B was indeed right. That 6th sense is one to be listened to, isn't it?

At 98, you SHOULD win

It seems, on every level, that at 98, you would be able to win if you say "no". No to C-pap, no to being in the hospital, and her only positive, yes, it's time to die.

You have to wonder WHY her kids, both men very much into adulthood, keep on pushing- and she keeps saying (in her own garbled, missing her teeth, obviously pissed off way) "I want to go home!" This is VERY clear. The only thing that seems clear to me in this scenario.

Each turn hurts, each move is excruciating for her. She is weeping everywhere, and has no control. Since we are trying to keep her alive, she has had no sleep, so the ICU psychosis is setting in. Starting an IV in someone this age? Well, it's one thing that no one wants to do. RT is annoyed at the decisions being made. RN's and MDs are just amazed. She is DNR, she is miserable, she is 98.... good God, what is the logic here?

Giving it the what for....

I wrote the other day about the man we had in the unit- Perhaps a racial issue, perhaps a big black man having an RN that was gay? Not sure. But whatever it was, this man was NOT clueing us in on what was going on with him. He was in obvious pain (and obvious cardiac issues- you don't get a room with us that easily....Viral- sucks, I think, of all the horrific things...3 months ago, fine- now? Waiting for a heart and getting worse.)

I gave him the Annika Pep Talk- one that I reserve for times when I know I am stepping over the line, know that it might not be in my best interests, but, doesn't matter. I am compelled. And so, in I go, sit right in front of him and give him "the" talk.  The poor guy can hardly look at me- still in pain (did not help he had stepped on his cath, as he was trying to get up...MAJOR pain, there- and well, I can only imagine. Luckily, was able to deflate and push back and things appeared okay....)

"You MUST tell us what is going on. We cannot read your mind- and you are here to get better- and we want to help." He seemed to listen, and then right before I left, I said. "Look, I want you to get better, and I care that you get better, and your wife cares, and...well, just so you know." With this, he looked up and said "Thank you."

So, the thought was he had an abdominal bleed, or something. He was to be sent to CT- and of course, I went home.

When I came in, I talked to his wife and told her I gave him the what for. She asked why, and she listened, and said he does not communicate well- and she thanked me.

This is before we found out he is VRE, and...I am not sure about the actual details, but he is throwing clots into his brain, and they fear that he is just filled with pockets of infection. I don't know why, as it was busy when K told me this, and I don't understand exactly what the deal is, but whatever it is, it's not good. Not good at all. And damn it. Damn it. I sit here crying- because it's just the most horrible thing- his kids came in, and could not face him, as he had changed so. And, he is not going to get out...just not going to. And none of it is his fault at all. Younger then I am....

Before I left this AM, I went in to say goodbye and told him I'd see him in 5 days. He was still in the same place he has been for the past 2 days- sitting on the edge of his bed, unable to lay back, as he begins to choke. I just rubbed his shoulder for a moment- and tried to give him something that would make the coming week easier....

He is going to be one of those that people forget- and I don't want that to happen- because...no one should ever be forgotten. 

Then the Quad down the hall- dirty young man (41), and he is PROUD of it! I could understand him as I lip read, and he was filled with things to tell me. Funny guy, been a quad for 20 years- was hanging his head out of a car and hit a guardrail. Drinking- yet, this man, in his words, shitty to have happen, but he would probably have died if this hadn't happened...in some other way that would have been a lot worse. He was sweet in his own way, and knew that his being taken care of well depended on his being a nice person. He was very successful. 

The KFC lady- has a husband that is a sloth, too and she is hyper. We had good stories to share!

 Then, watching the SuperBowl with my lovely txp w/u lady- (but...not to be, but she doesn't know that yet. Pressures just too high.) She wanted the Cardinals- me, too, I always like the underdog. 

 Then, Mr. C, at 25, one eye (he is the one that says I have a big butt- in total jest, but it's really funny- the story is just great- but for another time...) and his family- wow.

One quick thing- Black family groups have it all over us. They are so committed to each other, so intact when they are a unit. It's impressive. Care is the primary thing. I think it's because they are a matriarchal society- so the female values of care/love/compassion with a certain amount of "attitude"  are stressed above all others. Just an observation from the past years of taking care of people. It's amazing.

 And it's very fun to talk about the cultural differences between white butts and black butts. Apparently we have it all wrong....

90 year old love

At work, its been kind of nuts. I do have this lovely woman who is 90. When someone tells you they love you and they are 90, it's all good with me. She knows that her end is near, and it is. I thought we were there, but she rebounded. I just held her- K is her RN, and we sat with her and when she was having the most trouble, she just sat up so I could hold her. She must weigh about 90 lbs. She had the sense she would not make it thru the night- even though her numbers are good. She kept saying "Thank you," and was so kind. Her docs are okay- but what can you do? so, comfort care, and hopefully a kind, sweet end. She wants to see her husband, and her son (who was killed by a drunk driver on Dec 23rd, many years ago. He was 28.) Her husband died a few years ago, and I heard about her life with him, too. It was a very lovely and happy life. She was fairly dismayed at the lack of dignity she experienced in the ED- "Everyone saw Everything! I was so embarrassed!" and then she told me a bit more about her husband- they must have had a very nice life :-)!! She is ready as I have ever seen anyone. She only has 10cc's out thus far this evening- so, hopefully....

I got a bit more about my other, very quiet man from K- his entire situation has been caused by...3...bad...teeth. Yup- and, pretty sure he is not going to make it. He is VRE, so, it's hard for me to spend a lot of time with him because of precautions, but I have gone in and spoken to him a couple of times tonight. He has been very kind, and thankful for everything we have done. He also has spinal involvement now- from the pacer lead that got infected. So, he is one sick man. 36 years old. I guess there have been some interesting family dynamics that have occurred since I have been gone. From what I understand, wife number 2 is not actually his wife, but was signing his papers as his wife. Wife number 1 got offended.... oops!

Otis

Okay, O - as we now know he is called, is out of our unit. He is in step-down, and as of this AM, should have been in OR getting a valve. Whatever happened to get him from waiting to die to this, I don't care. The man is getting better, in spite of the dire predictions. So, he is a happy one.

I have enjoyed thinking about him and hoping for him and praying for him. I did make him the center of thoughts- and if that was anything that helped, then good for him.  I am glad he is getting out. I do think that he will be changed for the better when he leaves- he is talking, and more outgoing. I am glad. I hope I get to see him again.

Mrs. R did indeed die on Monday. I hope her passing was okay. Mr. W died this morning- I was with his wife as she said goodbye. She wanted to be alone when he passed, and she held his face, kissing him as he took his last labored breath. It was very peaceful- his pressure just kept dropping, and then asystole ... nothing dramatic, thank God, just quiet. She will be okay. And, she will see him soon.  

It's so very strange that we have so many patients on comfort care right now. I am not sure where this is coming from- but odd, and very atypical for us. We have two still there that are heading towards comfort care. I am not sure why we are keeping them- well actually, their 02 requirements are too high for hospice. So, we get them. It's okay, but I worry that we may miss a point where a patient that needs a bed does not get a bed.

Mr W continued to run into V-tach- I guess they had the same issue all weekend, too. I took a picture of him for his family and sent it to them- he looked great; this was before his horrific run of tach-flutter (!) and his at least 6 shocks- just last night. Talk about PTSS....  He was so grateful for that to occur- seems as if we should make computers available for patients in the hospital so they can stay in contact. His wife was just out of hip-replacement surgery and can not visit him. He heads to OR for LVD on Wed- I hope he makes it there. He is also on the list.  So praying for him, too.

So, here is the quote for the weekend. From Dr N-  "Do not trust anyone who is wearing a bow tie in a code. Just don't".  Point taken. Patient did not even make it to us.... He was a bit pissed.... 

The eyes

There is nothing as amazing to me as the eyes of someone that is vented- where you know that the person is there- ready to enter back into life and take over their own breathing. There are some patients that just grab you with their eyes, pulling you closer and asking the hardest question of all-why?

Those patients are the ones that I take with me when I leave. I have never been a person that things about prayer as a way, often resorting to the COTHism of jingles. For these patients, the ones that stay in my vision, these are the ones that I think about during my days off.

I think that being able to be an active part in these patients lives will be one of the best parts of being a PA....

A few that touched my heart

(disclaimer- Clive knows he is in this blog and was very excited about it!)

This is Clive', or CJ as his friends and family know him.  CJ is one of those very special patients that will not be forgotten, and deserve serious mention. 

He came to our unit (CICU) and is being worked up for a few issues. CJ is legally blind... and very VERY shy. He is 19 years old. To say that the past several years of his life have been hard would really be an understatement.

But look at this smile. That smile only peeked out a few times, but with this smile, CJ could move mountains. I really hope that he one day sees himself in the same sort of lovely light that we saw in him. He was very worried about pain, and felt scared. I was there when he got his PICC and thereby was able to see just what a lovely young man he is.

Yesterday was Easter. CJ had no family to visit him. I had some easter candy I was going to offer up for the night shift, I decided (knowing that I might be in trouble, but oh well...)  to make him an Easter Basket. I was lucky enough to find a basket that suited in our cabinets, and proceeded to fill it with as many goodies as I could find. I carried it over to CVC and presented it to CJ. Now, imagine that smile with the light of lots of candy...chocolate...jelly beans....! That hug he gave me made up for all those exhausting nights working, those back to backs that made my head pound. Thank you CJ...for making my last day as a Tech one of my best days.

So, I will look at CJ's picture in the coming months, and this will help me remember why I am walking down my path. Because it's this smile that makes everything worth it.

A thank you to those that mentor

to all that were kind enough to mentor me during this process.  I realize that this was an invasion of your work day, time away from getting your job done efficiently. I realize that with each patient that came in the door, you realized, as did I, that my being there was an invasion of their lives- their most private lives. In this, I must also that the patients that accepted me and allowed me to eavesdrop into their visit.

By allowing someone to shadow, to experience what the real word of being a PA, you have given a gift both to the future PA but also to the profession. It is not surprising that it's a requirement to shadow a PA for acceptance into most programs. The day to day life of each PA and their particular area of practice is vastly different from each other. By looking at each particular PA I shadowed and what their careers entailed, I was able to see the possibilities for my own career, and honestly, give me some "oomph" in the rather tedious process of pre-reqs.

I had wonderful PA's to shadow. I sat in on  morning rounds, grand rounds, the weekly trauma meetings, and cardio-thoracic meetings. I was in the hospital, in clinics, in private offices and in the Student Health center. I saw a lot- stitches, a very interesting I & D, burns,  a freshy pregnant woman, a first pelvic, numerous UTI's,  skeletal issues, and things I just had never thought of- how does someone get something stuck in their ear? Especially if they are over the age of six?

So, thank you. Thank you for your time, your advice, your support. Thank you for offering an ear and saying "if you need anything, just drop on email!" Thanks for the tips on surviving school, for the copies of notes taken, for the books passed on. Thanks for taking your time, both for and with me, but for the profession itself.

What the patient says means a lot

So I did indeed say I wanted to write more in the blog. I have evidence that this is a good thing -The Academic  Life in Emergency Medicine Blog- which has reference to blogging as being good for medical education and promoting self awareness, increasing compassion...which everyone needs more of, but I seem to have in abundance and actually gets in my way at times (how's that for a sentence!). The ED rotation work has shown me that I had best pick up the speed....but I care if they are anxious about their kids and their work and their...I digress again Argh!

Obviously I have not done this better blogging thing. But I have thought about it. That road to hell is indeed paved with good intentions. So, here I am. And I have over 100 pts to log, a garden to ready, and a week of grandkids, kids, graduation, parties, and...more. But the strange thing is I have been thinking about a few patients -a lot.

What has stuck is the patients that stick. Yeah, I know-terrible prose. But I have experienced a few patients with stories that have really stayed with me over the years-the ones that wake me and I think- what went wrong? Or right? or what could I have done now that might have made the outcome better? And so, I'll mention them again, maybe some for the first time but...and hopefully, when I have some time, I will expand on their stories as I remember them.  But for now....

There was the man who came in the the unit late one night- he was youngish, 50's? Had a hx of cardiac issues. He came in with his with his family-  all were scared. As the medics wheeled him past, he looked at me, and said...I am really scared I am going to die. 

Anyone that knows and heard this statement knows it's not one that you want to hear. Especially in this sort of pt. You'd think he'd be fine- he should be fine. But that sense of forebearing makes me nervous- always evokes that "thump" in the pit of my stomach. I was hooking him up and looked him right in the eye and said "we are going to do everything we can to make sure that does not happen."  Dangerous statement- because while we can do everything, some things can't get fixed.

So without details, he did indeed die. I, of course, felt I had let him down. But the strange thing was this: He was still there. I mean it. Still in the room, still felt totally alive. His heart pumped nothing, his lungs exchanged no O2, his brain had not one discernible electrical wave. I have wrapped many a body, and some I believe were long gone in spirit before we readied them for the family and the final visit.  This man was very much there, as confused as the other humans in the room when the code was called. This is a man that was not ready to die. Wanted to live. Wanted to see his kids grow, marry, and carry his grandkids. He wanted to do what most get to do, and don't even appreciate. His body died long before his soul was ready.

Often when wrapping a body, there is light talk, and sometimes laughter- it's a horrible task, really. That last zip as we close them inside the bag- it is so horribly finite. So, laughter can ease the time and stress of the task. There are some realities that happen at the end of everyones life that have to be taken care of. Some are not so nice, and really rather smelly. So, yes, while it seems terrible, there are some very bad jokes told- some bad situations that we've gotten into that do cause giggles to escape when it seems quite wrong.

For this gentleman, there was no talk, just whispers, and then, a soft prayer-for the transition he so badly did not want to take to go smoothly, because he was kicking and fighting the entire way. I spoke to him when doing my work- and I admit, tears were there. Because I really had let him down- a promise made that I could not keep...medical science had let him down. But finally, it was his body that had really let him down- while there are some things that can be fixed, so many can't. He could not be fixed.

He I will never forget.

Peds

I am currently in the beginning of my peds rotation in Ann Arbor. I have an amazing preceptor, who loves to teach (there is so much to be said for that!) and the practice is far more varied than I expected in Ann Arbor.

He has been practicing for over 30 years. But, he stays young, and strong, and everyone loves him. They are not dependent, however, on him, and he is busy enough that having people call in, or only RV when needed is the norm. As I said he loves to teach, and takes a lot of moments to teach, which are great and welcome for me. 

I've seen 2 mono's (one clear case of mono, and one not-so-clear but both spot tested +) and 2 cases of Pityriasis rosea. Mono, I expected, but pityriasis not so much. I always figured it would be a board question and that's that. But the herald patch was noted in one kid, and the other one not as clear a beginning, but the christmas tree pattern was clear. "Score!"  

I think this is my last easy rotation, so I hope that I use the time well. Other than that, things are heading towards Nick leaving, and I am heading towards being an empty nester.  Feels kind of good! At least today it does....

Mrs A

I had not been back at the U for long, so had not acquired my ICU shoes all that well yet when a pt entered my life in a way that few patients ever will.

She was on "the list" and had been several times. Each time, you get to "stay on" for a certain amount of time, and then, get taken off, moved out of the ICU (usually at least), have another full work up, and get re-listed. This happens several times for some patients, and it, I am sure, is most frustrating. Our unit remains one of the few that have not been renovated to the degree that being in the 2010+ years seems that it should be- and whomever designed the rooms clearly had never taken care of a patient that was on precautions. 

Mrs. A had done the List Dance several times by the time I had really gotten to know her and her family. She had a devoted husband who kept her laughing, and family that cared. She was lucky that way. What she was not so lucky in, however, is exactly how sick she was. Obviously, being on the list meant something was seriously wrong, but also she kept getting those little annoying nosocomial infections. Okay, that is a huge understatement; she never came down with one of the Big Ones (MRSA, VRSA, C-Diff) but the ones that take one off the list but aren't that terrible to actually have.

Her husband had left for the evening, and she called me into her room. I asked her what she wanted and she said "I don't want to be re-listed". It was more than that, really but the end result was she was done. She had had it, and just was tired. At this point, she thought she had been in the hospital for about 6 months. I called in our Fellow (after explaining that I was not the person who needed to know this, but someone that might be able to actually DO something about this needed to hear this from her.) We all cried but clearly, we all understood. One can only take so much. Her reason for staying the path thus far had been for her husband- as I remember it, she said she was really ready months earlier, but she knew he would not want her to make that decision. I was not there the day of the family meeting, but clearly, when one loves as deeply as they loved each other, the decision was made.

Problem was- she had to stay with us. Her meds were not ones that could be stopped quickly and she could not be D/C'd to hospice on the meds. So, weaning began. She did well, and things went as smoothly as can be.

Mrs. A comes back to me a lot during my thoughts of special patients. But this weekend I had a very special Mrs. A moment. Ann Arbor has a lovely thing called Top Of The Park where local musicians play. There is some serious talent in the area. A man named Levi Johnson  and his band played this past weekend. As I am wont to do, I began to dance- his was a funky, motown sound that makes even the most tired of feet move. He began (as a black man) to sing "Play That Funky Music White Boy" which brought me back to the last time I saw Mrs. A.

I asked Mrs. A what she wanted most of all and her answer was some good music. Her husband was there- and I asked what that was exactly. I was thinking my Jack Johnson and Michael Fronti might not be it.  I was right- They wanted some good soul or funk-  70's type music like- oh- "Play That Funky Music White Boy" So, thank you to  iTunes, I downloaded a few songs, we closed the curtains and turned the iPhone up as loud as we could  and danced. Well, she moved in her bed and her husband and I danced. I remember that moment, and knew then that this was to be one of those moments I'd never forget- a white woman, in scrubs, in a tiny ICU room, dancing with a black man, and his wife moving as best she could, to the sounds of Motown.  I realized  then and know now, how absolutely lucky I am to have known them, their love, their courage.

Mrs. A died a week or so later. Her husband was there as were a few of our nurses that went to stay with her at the end.  Someone posted a picture of her before she got ill- and she was startling in her beauty. The thing was, I saw that beauty from the inside of her, and it remains one of the most beautiful things I have ever known. My memory of her lives to this day.

Peds find...

On the "interesting cases" kind of note- Saw an honest to God spontaneous Pneumo ("Large" according to the radiologist...wish I could have seen the films, to correlate PE findings with visual understanding).

Yes, Tall, skinny kid. But No SOB, nor any other serious "OH DEAR GOD" signs. Just an amazing MD who caught it during (yup) a routine PE. I'd bet that the kid was kind of miserable and made the appt. He had not been in for 3 years.  I did notice fairly pink (red?) cheeks, which I remember seeing in my CO2 pts before. No ABG or BG to see, I am sure they did that at the ED. I'd also like to have seen that, but honestly, I am hoping it's venous, as this kid was already scared enough. Just writing about it gives me the heeby-geebies. My biggest issue is knowing that he might be in for a world of pain. And, came into the office without family attached to his side. In his car.

Ugh.  But nods to an amazing peds MD who A) Caught it, and B) called me in to hear it. Did not say "This is what this is" but let me listen, and think. What I heard was cracking, and "far away" sounds on auscultation. Only way I could describe it.

Rotations and the blues

I am currently in my surgical rotation. Parts, I love. Parts I dislike. I have seen a lot of what I do not like in me coming out- dealing with one of the team members is quite challenging for me. I have 2 more weeks. I canwill be nice, and think good thoughts about this person and know at the end of it all, I would rather have me than that person taking care of my patients. And if you "know" me, that's saying a lot.

I finished psych. Outstanding preceptor, but horrible rotation. I am rotating in an area where despair is the norm, and the genetic pool is riddled with mutations. Psych is a hard one for me, because we can't fix it. Not one bit. Our meds might make a difference, but does it really change the illness? No, it'd be a fix, but not a change. In many ways, it's like a cancer, but a never-ending-never-changing sort of cancer. Lifelong CLL. But worse. I admit wanting to fix things, to make things better. Inpatient psych, esp as a consult service really can't do that, nor does it pretend to do this. Perhaps that's why there are so many tools and ways to pigeon hole the patients. A DX is essential, and knowing what their GAF is becomes important. How does axis III change axis II?  I? Perhaps intellectualizing all this allows for the MP to keep some distance, and allows for better care. I don't know, and I know that I am not going into psych.

That's okay. I am ok with that- there are so many things I want to go into, ruling one out is in my best interest right now.

Surgery rotation

So, as I said in the previous post, I am in surgery.  I am surprised to say that I love the ED part most of all. I mentioned before that I had considered a residency in ED- one focused on Rural medicine that is in NY. I kind of dropped the thought off of my local radar, just because A)money-I need to make some of that green stuff and the sooner the better! and B) thinking that not having the continuity of patient care might limit my enjoyment.

 Nope. Not so. It's actually good- I can care, and deeply care, about getting the patient better enough to get them to the next step of their recovery and that is good. I love the intensity, the need to bring all aspects of my (limited) training to the forepart of my brain, balancing the medicine, surgical aspects in the resus bay. I of course am watching and learning right now. But, my head is swimming with thoughts.

So, the thought of the residency is back. Strongly. I think it might be great. I think I might like it. And since nothing else has really grabbed me yet during rotations, maybe this is it. Stay tuned.

I also admit feeling like I have not learned nearly enough thus far in my rotations. Not nearly enough. I also admit that I wanted to be at UMMC for many of my rotations. Thus far, I have gotten none of them. Zero. I miss the U, miss the environment that that place provides. There were endless opportunities to learn there- endless. I miss that a lot. I also miss the caring that the U seems to have at the center. I am not seeing that out in the "real" world, and I find that sad.

So help me GOD....If I see/hear of another person slamming a NG tube down someone, without lube, and hurricane spray--forgetting lido-jelly even for a moment as a possible assist-and then wonder why the patient was so miserable and refusing another NG tube, I wish the NG curse on them some day. Because when I asked, I was told "it takes too much time".  Oh boy...If I were not a student, and somehow could mention what I really thought, they'd get an earful.  Say whatever you want, it's the wrong thing to do.

I have seen several surgeries but none of the usual suspects...no appy, lapchole, bowel obs for me! Nope, was in on a massive lac to the back of the neck where the C-spine was...right... there...and the clot that had formed was as big as a small baby. I kid you not. I have seen orbit repair with screws, plates, mesh. I have seen more I and D's- seemingly the bread and butter of surgery-forget hernias! I have seen an exploration of an orbit from a possible self-inflicted GSW...I'll tell that story at another date.

I have learned a lot I admit. Most of what I have learned is this:

• Who you work with is as important as what you're doing
• Driving over an hour to work is plain and simple NOT for me
• I need to be someplace where patient centered care is at the fore-front at all times
• I need to be someplace where you're striving to always be better, so the patients get better
• I need to always be able to learn, to push past what I get and enter into areas that I feel lost and need the compass of those wiser than me to survive and thrive
• Saying I don't know is okay as long as you make sure you will know soon

Till later. I have a hot date with First Aid and Surgery Recall, never mind Casefiles!

Thanks for being here

Yesterday I observed a surgery that was not performed by one of our surgeons, but one from another service. We had had this patient for as long as I have been there, and has been my patient since getting to our hospital. I asked the if I could observe the day before, and was told to page the attending to ask.

I don't do that. Call me chicken if you want. I'll take that rather than the wrath of an irate attending that is about to perform miracles in the OR on a patient I care about. I want that attending to be in a really good, balanced mood when they take that blade into their hand, not irritated with a student-much less a lowly PA student.

So, I went down to pre-op with the pt and waited for someone who knew something about anything. The resident showed up and I asked him when the attending might be there. He said..."I'm glad you're here. I already talked to him about it- he's cool with it."

I admit- I got a bit hot and bothered. In a good way. Those words made my day. Quite possibly my rotation. Not one other person has said that to me since starting rotations;I miss that feeling of being a valued part of the team. Even as a tech, the RN's would comment on my being there- that they were glad to be working with me that night. I know I make a point of telling people that their presence is a good thing- that I appreciate them caring if I see them do something above and beyond. When teching, I have even emailed a RID (Really Important Doc) and said how much I appreciate their care of a patient. That might have been a bit too "annika" but I don't really care.

So, thank you Dr. C, you made my week. I stayed late to watch the surgery, but instead got a boost of needed energy.

The Entire Patient

is what we treat.

A pt came in to us. Seriously hurt because they had done something stupid when consuming a bit too much alcohol. Well, a lot too much, really. Lucky because no one else got killed. He hurt himself worst of all, but his companion will be feeling the pain for days.  He ended up being surgical to fix some seriously broken bones in his face.

(you ortho-gods, bones, bone fragments, breaking bones, moving bones-def not for me.... I give you credit.)

As a good PA student, I researched his EMR thoroughly. It had been mentioned that he had an ID band on his wrist from our hospital when he came in. I asked him when he was alert enough if this was so, and it was indeed the case- he had been DC'd just a couple of weeks before.  Shocking- admitted for another trauma that was associated with ETOH. And further back, in the past 6 months he had been in our ED over 6 times. Not always admits, but always trashed.

Each time for ETOH abuse/issues. Levels were all over 200. Each time. Some MUCH higher. And most of these incidents were involving a several thousand pound vehicle traveling at high rates of speed. Anyone seeing any red flags?? I was holding his hand, and thinking how much he had cost our system, how close he has come to killing people. According to his EMR, he would spit at MD's when angry. None of that right now, he was a scared kid.

He was younger than my daughter, older than my son. I talked to him about quitting. He said he wants to, but he tried and he couldn't do it alone. I told him this meant NEVER drinking. He said he knows. He said he wanted that. He wanted rehab.

I accompanied him down to the OR later. He was polite, we kind of knew each other at this point in time. I admit still being irritated with him, and feeling cynical- he was driving without a license,  he was responsible for several other injuries we were treating that day.  What made me think my simple little "You GOTTA stop drinking before you kill yourself or someone else" talk would make any sort of dent in his disease?

A family member was escorted into the room to see him. It was a woman, who right away went to his side and started to rub his back. I introduced myself and she told me she was his grandmother. She asked me a bit about his injuries, and what to expect. I reiterated to her some of what I knew, and what I had told him- his physical injuries were serious, but the most important thing was that he must stop drinking.

She looked right at me and said "He has to learn to love himself first, then the rest will be easy. I want him to get through this- he has a lot to deal with when he gets out of here. My only concern today is that he knows he is loved, and that he is loveable, and that I am here for him. That's my only concern today for him today. The rest will come."

She proceeded to tell him some of that, and I watched her bend over him, whisper to him, rub his back. While he was in and out of awareness, she told me a bit more about him.  She was his dad's mom, that his mom was not a loving person, and that she had said to him after he had come into us that she wished he had died. Her son just had been getting help with an addiction to drugs. "He's stepping upto the plate- it's taken him a long time, but he's here."  Her grandson had worked for the city but had gotten laid off with the latest cuts. When telling me the background, we both were teary. She then prayed over him-for his recovery, the surgeons hands and the calmness that is needed in the OR to make her grandson better. Her faith, despite mine being questionable, filled that cubicle. It was bigger than anything else in that hospital at that point.

His mom came, clearly inebriated. Grandma left then, so the rest of the family could come in.

During his post-op check, he was doing very well. He responded well, wounds looked great. I told him that his grandma had been there- and what a remarkable woman she was. He said he loved her.

I then told him this: To have someone love you so much is a gift. It's a gift very few have. It's provides more riches than most have. It may not put food on the table, but it puts something into your soul, your heart that is just not possible to reproduce. It's not something one should ever take lightly, and indeed it's a kind of responsibility to know that someone loves you that much.

For me, it was a reminder. A chuck under the chin to remember that the story is far more than the EMR might indicate. It's complex, sad, heartbreaking. But there are threads of golden woven through that glint thru the ugliness that permeates so many stories we see. Keep looking for the golden. You might find it.

LOL surgical consult

Call nights are long- often filled with incredibly boring periods, peppered by intense moments of trauma codes. This night was no different,  we had more ER consults than trauma codes. A good thing for the people involved, but for us, at hour 19, well, a bit of trauma does the exhausted body good-caffeine? Ha! No need with a healthy dose of adrenaline- stabbing, gunshot or 3, housefire with a pregnant woman- that'll getcha going.

I got a consult on an older AA woman. She had an abscess- but it was not specified where. I have learned that getting in on the bread and butter cases, the ones that the interns and residents don't want, are the ones that I want. I can DO them- and learn from them.

I did my H & P. the history revealed no major medical issues. No surgeries or injuries save a broken tooth or so. 3 kids, all normal vaginal deliveries. +FM of the typical DM, CAD, HTN- but thus far, she had none of the above. Did not smoke, drink, do drugs.  No waving red flags.  Okay! I can DO this! So, her issuse seemed to be just isolated- painful and isolated.

This poor, tiny 78 year old woman had an abscess on her mons pubis. Big one. Denied waxing, was not sexually active.  She was married, but her "man" had been living with another woman for the past 20 years. She was a-okay with this. No one else in her life-lived alone.  She did call her husband when I was interviewing her to ask him what other meds she took- Vit e was pretty much it.

The PE revealed she had the worst...um...well, yeast infection that I had ever seen, and honestly, guys, hope never see again. It was..."impressive". Put that in your admission note and that'll catch someone's attention. As I said, she  denied DM, however, just as I was beginning to ask all the questions, leading at least my differential that such an infection tends to come from in a woman who denied ever being sick, the RN pops her head in "Her BGL is 511". As I was being told this, she was grabbing her Big Oreo Pack out of her purse to munch on. I told her that Oreos are probably off the menu for a bit.

At least I had one answer to one of her problems.

Clearly, however, the other issue was going to be done in the OR. Poor thing. She had a red, hot, fluctuant mass, about 6cmX10cm.  It did not go thru to bone from what we were able to assess in the ED.

 Here is where it gets funny.

She had never been in the hospital. She wanted to take EVERYTHING home- the empty IV bags, the chucks, her phone was out-she was snapping pictures everywhere. I have one of her-she wanted to have one of both of us on my phone too so I'd never forget her. (Not like I could forget her...).

She was so cheerful, so optimistic, and upbeat. She was sitting up in the OR when we got in, talking to everyone a mile a minute. I am sure she was nervous, but none the less, a truly bright spot in the rotation for everyone who touched her that night.

Later, I found out she had been putting Icy-Hot on her "'fected part". I came into her room for her post op check and she had it out to apply it to the open drainage area.  I can only imagine the pain that would have been. I had asked her on initial interview if she had done anything to make it feel better, I guess I needed to ask if she did anything to make it feel better that failed. That I would consider a fail to be sure. She then admitted to putting cabbage compresses on her "'fected part" too. Her post op went smoothly- her BGL were labile as would be expected, but medicine did their magic and they were eventually controlled.

And now, in all the ways that so many of the rotations went in Detroit, her story is so much deeper, sadder and still astounding to me.

Frankly, Sad.

Remember that phone? All those pictures? She had a chronicle of her life in pictures on her phone. If anyone ever got her phone, the things that they would see. She could hardly see her phone, but she took pictures still. When she was showing them to me, about 1/2 way back was a picture of a man in a casket.

 I was taken aback...what in Gods name did she have that for?  I asked of course (I always ask...just my nature). She knew him- he was her neighbor. He had been shot, in front of her, outside her apt. And yes, she had pictures of him on the sidewalk, dead. She knew who shot him.  While telling me about this, she covered her mouth, asked if she was going to Hell because she had lied to the "Po-lease" because she knew that if she admitted she knew, she might be next. You don't live that long on the east side of D-Town if you're a dummy. She clearly is no dummy.  If there is a God, this woman is certainly not going to Hell. She has been there- but her cheerfulness and joy in the world was bigger and greater than what surrounded her.

She said she had pictures of all the people she had seen at funerals. All her friends kids who had died. All the people in her building who had been shot and killed over the years.

She told me that she slept in front of the window now, watching to see if anyone was coming. I am a white girl from the country and I have one thought about guns besides ban 'em. I want FAR away from them- esp if someone I don't know is carrying them.  Her thought was that if she saw who was coming, she could get away. She was scared but it is what she knew. Me? I'da picked a door. A solid door.

I don't remember her name, I have her picture still. I hope she is okay. She was discharged home after 2 days stay to get her glucose under control. I hope she followed up- and I hope that somehow she has found some peace and quiet in her life.  Yes, I asked SW if they could somehow help, but no- nothing to do. She was A&OX3. Frankly, she was a great example of survivor, strong, beautiful, an optimist in the light of all that is so difficult about D-Town.

This happened well over 2 months ago. I am ending my stint of being in Detroit for rotations. Overall, I have gained such an appreciation of the deep recesses of humanity that exist downtown. Yes, it's a terrible place, but under the layer of grime and filth, there really is something very special about the city. The grit, the simple acts of survival that profoundly effected my rotations there. Certainly I learned something about medicine or at least I hope so, but I also learned a lot about people. I actually do believe that the city can be brought back.

There are a lot more stories- more blog posts to come. It's a lot of driving to get to and from- easy 2 1/2-3 hrs a day. I won't miss that! Makes for no time to write anything. A2 next month....

Babies!

This is not going to be an "in order" post, because I am really behind (and yes, I was taught do NOT start anything with an apology but I am starting this with one because clearly I didn't listen.)

I am with Dr. M  I was told (perhaps warned??) that I was going to love him.  I do. It is one of the best rotations I have had, just because his patients adore him, he gives them every second they need, and he gives us every second WE need. How many people can do that? A lot to look up to and learn from.

First day? A lovely OP vaginal birth. Since it was my first birth that I was not...um...being the center stage of, it was interesting. And beautiful. And the baby was perfect. Hard birth (OP means, at least from what I a can tell thus far is that is it going to be hard, and pushing a face up baby is often REALLY hard.) But she did it with a lot of coaching.  I am pretty sure I was more happy than she was at that point in time.

Monday brings a lot of scheduled births that are from high risk moms. Several were from clinic patients that we saw on Friday. I am very glad I get to see those births. I am really excited and I must say that being a part of bring life into the world is just...amazing.

There is a lot more to write, and I think I will be writing a bit more "personal" stuff soon, because a lot of personal stuff is happening. Not all of it's good (ah- a very atypical Annika Sentence!) so deserves a bit more explanation. But that will come next...

Another flower added

Last night I worked with my next amazing PA. The service I am rotating with  has a roster of impressive, bright PA's that bring a lot to the table, including their absolute willingness to teach, impart wisdom, pearls and other delights that bring me to a new level of excitement about becoming a PA. I was lucky to get this rotation, and I am thrilled being there. I count down the days, not because I am looking towards the end, but because I am sad that it is going to end.

My first two patients were easy ones. I made the DX, and it was quite simple. Reassured them they were not going to die, and off they went, hopefully relieved. Since the rest of the ED was hopping, I felt a bit like a good luck charm. Ah, the joys of being naive. ;-)

My third was a young woman who was placed in a hall bed. Ah...not a good thing for anyone. Complaints of N/V, general exhaustion. Her history reveled that she had missed her last period. Further questioning also indicated that her mom had died less than a year ago, from HIV. No smoking, drugs, ETOH herself-mom contracted HIV from a boyfriend a few years ago and the disease progressed rapidly.

She was living in her moms house, taking care of her brother who was younger than she was. Simple math showed that her brother was a minor when her mom died, herself just barely into adulthood. Dad was long gone. She had no other relatives that were involved in care of herself or her brother. She had insurance, and worked at a nearby fast food restaurant supporting them both. She was an example of an upstanding citizen.

And indeed, she was 6 weeks pregnant. I sat next to her, and told her the news. I asked her if she considered this a good thing, and she nodded yes. The supervising PA ordered the rest of the tests, and all came back fine. She was given prenatal vitamins and we spoke a bit about good prenatal care, and the importance of this. Her boyfriend was steady, a good guy, looking for work. When I gave her the results of the ultrasound, her bottom lip trembled slightly, but the joy on her face was not able to be disguised.

She was scared, but happy. She clearly realized that this was major, life altering event. A beautiful girl by anyones standards, she somehow emanated that internal strength and courage that some just have and can draw on at the right life moments. She was drawing on it, and it was doing her well.

When it came time to discharge her, still in her hall bed, I hugged her and told her that I knew her mom was watching. She said that she thought her mom probably knew and wanted it to happen. She said her mom was a great woman, a wonderful mom, and she missed her a lot. I got her email address, probably the first and only time I will ever do so with a patient.

Another patient that I will never forget, another flower added to my lifes bouquet.