Happy moments in EM, #1

This year, Ash Wednesday and Valentine's Day coincided.

One of the last patients I saw was a woman with a cross of ashes etched onto her forehead. She wore a blue mask over her mouth and nose; her primary care provider had alarmed her into thinking that her headache might be due to bacterial meningitis – which means that patients get a lumbar puncture and are admitted to the hospital for IV antibiotics.

This patient was very somber and afraid, in contrast to her husband, whose forehead was crossless. He was quite upbeat and quite drawn to the glass doorway of her room, where he could appreciate with morbid fascination all of the psychotic patients acting out, screaming, having fake seizures, and yanking and beating on their restraints on their stretchers.

I have become thoroughly desensitized to these noises, which comprise the background rhythm of the Emergency Department.

This husband, on the other hand, was like a baby discovering a mirror, reveling in this completely novel and human experience. He couldn't control his laughter. His wife immediately scolded him and told him not to watch and to sit back down. It brought a smile to my face, which was hidden behind my own blue mask.

The woman's headache turned out to be a tension headache, and she was relieved that she got to go home.

At the end of the night, I joked with them that they had spent their Valentine's Day in the most romantic of places. And that brought a smile to both of their faces.

Pain

Just having a little anthropological thought experiment about pain.

Sometimes we have to hurt patients to "help" them. About half of the people I did ultrasounds on today were in pain when I scanned them, and my scan caused them distress. A tattooed black man who had just been shot in the chest and I had to press the probe into his tensing muscles to get a subxiphoid view. A young white woman who had just had knee surgery and gripped the bedrails, shaking, while I glided the probe up and down her leg and all around her knee to look for clots. A gray-haired old lady who had been backed over and then run over by a car who cried out when I swept the probe over her bladder.

There was also an old man slowly oozing blood from his rectum, heart rate increasing, pressure dropping, and yelling and flailing in pain from a finicky peripheral IV insertion, working himself up into a panic attack, hyperventilating. He begged us not to do it. He said he'd rather die than get stuck again. I knew he meant it but didn't mean it. I knew he was not himself. Pain makes us not ourselves. It makes us not our best selves. And my voice slid into the loud, firm tone that makes me sound more American than I really am, that's not me in real life, but is me in doctor life, and talked him down. That voice cares, but it also doesn't.

"I know this is hard, but you're losing a lot of blood and we really need you to have this IV, all right? We have your best interests in mind here, okay?"

He nods, incoherently. His eyes seem teary and I'm embarrassed for him and he's embarrassed for himself.

Their pain makes you detach.

At first, you're a novice, and you try not to press hard. And then you realize that it's better to press hard and get your image and get it over with than to torture them with a light touch. It's better to just rip off the bandaid in one fell swoop.

You don't want to cause them pain. You don't want to cause anyone pain. That's not why you entered this profession. But you are causing them pain. Even if it's with the intention of helping heal them, whatever that means in modern biomedicine, you are causing them pain.

So the easiest thing to do is detach. I pay attention to your pain but I also don't. I pay attention to my job and getting my job done. If there is someone else in the room--a nurse, a tech, a student, another doctor--who can console you, I'm not going to use my energy to do it, I'll just let them handle it. I'm just going to focus on my job.

And now I feel your humanity, but only in an abstract sense. I'm still present to you. But I'm present to you the patient, not you the person.

The old man got transferred to the trauma bay soon after his pressures tanked. I walked by and I thought his eyes were closed. He looked asleep. But he waved to me.

"Hi there," I said.

"Hi there," he responded.

the selfish altruist

My experimentation with daily mindfulness of happy moments has been ongoing, but as I feel uninspired to produce poetry, I'm taking the step of putting it into writing. Best parts of today: 1. Youtube video of baby who throws his hands in the air whenever freed from his swaddle, put to appropriate music 2. Youtube video of baby who holds out a piece of fruit to another baby, and just when he's about to take her offering, she promptly sticks the fruit into her own mouth 3. Immediately recognizing 2:1 2nd degree and 3rd degree block on a patient's rhythm strip, and feeling like I can sometimes read EKGs

birthdays

birthdays
half of the world doesn’t celebrate them
in my birth lottery they were streamers and candles and cake
children screaming with delight in cone-shaped cardboard hats
and thin chin-prickling elastic strings
and then they were yearning for firsts
windows down and wind whooshing by your ears into the sunset
red white and blue stickers and anti-war ballots
and then they were dinner parties and regretted drinks
and then glass stems between the fingers of others but not your own
and then they were nothing
because half of the world doesn't celebrate them and neither should you.

and then they were the plastic oven knob crumbling in your palm,
improvising as homo sapiens with scotch tape in a house of cards.
the daily pleasure of chalky antacids, preferentially pink, and two pillows.
the spanx that cruelly indent your skin, itching
hours after you’ve stripped them off and abandoned them
on the bedroom floor you used to keep vacuumed and clean.

then every day became a birthday
a reminder of age, of youth, moons, eggs drifting away
and with them your heart
afloat in a canoe on the muddy waters of the mississippi
or maybe the styx

a poem for the placeholder

my morning thoughts flow from spinnerets
crafting half-dream-fantasies in which even pain
is preferable to the present

somewhere along the way through the desert
i paid homage to the forebears
of the cactuses and succulents i murdered with water in the midwest
and i lost the meaning of true love

i wandered into this web where i am the trapped human
i always imagined i'd be

the lost hours melted just as salvador painted them
and the sunrise and sunset grew indistinct

there is still hope

Sometimes I can think about Judith Butler and Michel Foucault after I step out of a patient's room.

Today I was the harbinger of bad news to a Mexican man who was likely an undocumented immigrant with no good source of longitudinal clinic care. The rules about what hospitals vs. clinics can do for you seemed very silly to me as I explained them, even though I know these institutions have different functions for good reasons.

Things in medicine that make you feel soulless: referring someone who you're pretty sure is unlikely to follow up.

Does this feeling get less shitty with time?

Do Guatemalan clinicians in government hospitals feel bad about this? Do they become blunted from repetitive interactions like this? Will I?

Today's amazing thing

This madrugada, I walked to the hospital under a storm and got drenched on my way in. This evening, I walked home from the hospital under the same storm and got drenched on my way back. Something about this felt beautifully cyclic and metaphoric for how we enter and exit this world.

A few blocks from my apartment, I found myself appreciating a yellowing gingko sapling under the light of a lamppost, resisting shedding its leaves in the downpour. Just a few fainted onto the sidewalk. And the rest clung on gracefully.

Trees. So resilient. So magnificent.