Sunday, March 29, 2009

I am Kind of a Big Deal You Know

So Jerry and I were discussing 'ego' last week. It seems to be a theme with our sushi meals of late. We tend to talk about it because he's Mr. Eastern Philosophy Guy and I quite enjoy getting a dose of the 'its not always about you' talk q weekly.

During dinner he told me about a dear elderly friend of his who had died years ago that had made the observation to him that just about every conversation can be distilled down to the speaker saying (cloaked in anecdotes, humor, facts, etc.):

"I am kinda a big deal you know"

The listeners replying in equally cloaked social niceties various responses ranging from:

"Yeah you are kinda a big deal, but I am a big deal too--this is why"

"Well, you are not really that big of a deal, but I know this guy--HE'S a big deal--this is why"

"I am a big deal, you are a big deal, that is why we get along so well"

"You were a big deal that one time, remember that time when I was a SUPER big deal?"

and so on.

Of course the hospital abounds with places to take part in/eavesdrop on conversations that will show this to be true time and time again. I was stifling a giggle last night as I heard it play out over and over again in comments such as

"Remember that time I told MD so-and-so that I wasn't a nurse to be messed with and he couldn't talk to me that way..."

"So then I was the one that picked up in NSTEMI when everyone else missed it..."

"Oh my computer wallpaper? Yeah, that is my new (insert car, motorbike, horse, boyfriend)..."

"Well, you know I worked (insert ICU/CCU/ER at Huge Tertiary Hospital) for years where we did countless (insert impressive procedure here)'s."

Honestly. It is true. And I know I am not immune. I catch (or don't catch) myself mid-sentence falling into the "I am kinda a big deal" statements all the time now and it makes me cringe.

Is that all the majority of our discussions are about? Posturing? Ego primping? Ego pimping?

I know this is no new sociological discovery but still I have been finding it a fascinating exercise to be mindful of this pervasive theme and attempt to steer from it. The worst is it permeates every corner of our existence from the "I'm a big deal car" to "I'm a big deal handbag" to "I'm a big deal skis" to "I'm a big deal bookshelves" to "I'm a big deal snow pants".

Ack. Who am I kidding. Even my blogs are just one giant "I am kinda a big deal" exercise in internet pontification.

I hate that this is true and I loathe that I've been a sucker to it for so long. So now the question is how does one reprogram oneself? Or how long does it take to not notice again and keep playing along?

Sunday, March 22, 2009

This Is Why We Do It

She was a beautiful woman in her late 40's. I was a disheveled and sweaty triage nurse. Our waiting room was overrun with people holding their bellies, foreheads, children's hands, and cell phones. There were no beds in the department. There was a large stack of charts waiting to be brought in, and still another chart buzzed through the printer.

I looked at the chief complaint: "food poisoning".

I called her to the triage station from the waiting room but she simply lifted her head, brown hair covering most of her face.

"Do you need a wheelchair?"


I wheeled her in and looked at her flushed cheeks. She didn't look well, but then again, if she had food poisoning she probably had high velocity liquids coming out of her from all angles. I asked her what she had eaten, a hamburger and caesar salad. Ooooh. Hamburger. Not good. She had vomited once in the parking lot. No diarrhea. Her heart rate and oxygen were normal. Afebrile.

No meds, no allergies. She told me she had a history of hypertension but her doctor had recently taken her off her meds because she "needed to lose 10 lbs and then be reassessed". She only looked about 10 lbs overweight, if that. Her BP was 208/110. Umm...

"Do you have a headache?"

"Yeah a little bit."

"Visual disturbances? Double vision? Spots? Stars?"


"Chest pain?"


"Do you feel lightheaded? Dizzy?"


Ok. Symptomatic HTN. No beds. Except for trauma bay. I asked the acute side nurse if she'd mind me popping this food poisoned lady into the trauma bay, just for a few minutes so I could get her on a monitor, get an EKG, and do a more thorough assessment. Her pressure was high and I was just not sure what was going on with her. "Do what you have to do" was the reply from the harried nurse who already had her hands full with a query stroke and 2 cardiac patients.

I wheeled the patient into the trauma bay, her repeat pressure was 168/78, HR 97, O2 98%. Now I was feeling sheepish for using our hallowed trauma bay for yet another puker and pooper. I asked her to turn from her side onto her back so I could hook the oxygen tubing behind her ears. I pulled the dark hair from her face. Her head turned in my direction, clear blue eyes stared up at me as she murmured, "I need to lay on my side for a minute". Her eyes rolled back in her head and she began to seize. Her face began to turned blue, first just around the mouth, then spreading up her cheeks, an unnatural mauve. Her husband used his body to keep her from rolling off the other side of the bed.

"I need some help in here!" as I pulled up the side rails and grabbed the bag valve mask for oxygen.

Within minutes two other nurses were at the bedside with a doctor in tow. Instantly we set about our duties.

An I.V is placed in her arm, valium goes in. No pulse. The OPA is inserted and we are bagging her. Her rhythm shows v.fib. The skin of her arms begins to mottle, and as I cut off her shirt I see that her chest is also mottled, no demarcation line though. I stick the quick look pads to her chest and charge the defibrillator.

When was the last time I hit the shock button? Why is this lady dying on us?

I see her husband standing with his eyes fixed on the head of the bed, mouth slack but eyes attentive, seeking. Just then another nurse offers to walk him outside, he agrees.

"I'm clear, everyone is clear. Shocking!"

And thus began the long hour of CPR. 13 shock deliveries, 8 doses of epi, a dose of magnesium sulphate (during a brief Toursades episode) and one dose of atropine.

We would get a rhythm, then a pulse, then back into v.fib. It was a roller coaster. We had no idea why this was happening--she could be a bleed--but was it hemorrhagic or ischemic? Was she an acute M.I? We had no labs so couldn't determine if it was her electrolytes. Pulmonary embolus?

We had intubated her successfully on 2nd attempt with a 6.5 after the 7.0 was a no go. With the intubation and bagging her sats remained 100% and we kept CPR going throughout. The numbers were running through my head...she'd been down now for over 60 minutes, she was getting 25% circulation of oxygenated blood thanks to the CPR, we'd given her enough joules of energy and epinephrine to power a leg of the Boston marathon and we still didn't know what was happening to her. What were we saving now? Would she be on a vent with severe brain damage the rest of her life? Would she even take to a vent? When do we call it? With enough epi on board I've seen PEA last for ages. After such a long time the heart is just twitching, it has no intention of ever beating again.

The lab attempted to do an EKG but due to mechanical interferance from the monitors and defib pads (which I was not about to remove any time soon) the print out was basically unreadable.

Her pupils were fixed and dilated. She is frighteningly cyanotic despite what our monitors were telling us.

She went into sinus rhythm. Tachycardic but sinus. We prayed that this time it would continue for longer than a few seconds.

It did.

The paramedics had arrived to take her to the Big Hospital. Her color began to improve, her cheeks no longer dusky. The mottling on her arms faded as they returned to a pale pink color. She was taking the odd breath against the tube.

We packed her into the ambulance, the doc and I at her side. We pulled out of the parking lot just as the respiratory tech pulled into the lot. Gotta love rural emerg. I attempted to fill in the gaping holes in the charting as the ambulance careened along the rainy streets. The paramedic student bagging her.

We arrived at Big Hospital and went through the usual song and dance with the dragon-lady triage nurse:

"Who is this patient? Where are you guys coming from?"

"We're from Small Hospital down the road, we talked to your ED doc who accepted her, this is the cardiac arrest we're bringing in..."

"I have never heard anything about this woman."

"Well, as you can see, she is intubated and unconscious. We've been working on her for over an hour. She needs a STAT CT among other things and time is of the essence, she could crash again at any moment before we know what is going on with her..."

*Large audible sigh from Dragon Lady.*

"Fine, roll her into trauma bay 1".


We get her into the trauma bay, give report to the nice accepting ER doc in shorts and the cranky ER nurse with green streaks in her hair. The RT saunters in in his scrubs and PUMA's, looks at the tube and remarks, "the tube is too small". I stifle a remark about his genitals and point out that it has provided her with adequate oxygenation thankyouverymuch pointing out her color and sats. Asshole. I am so not in the mood.

Doc and I walk down the hall where our paramedics are anxious to get us back to our hospital before they go on another call. We see her husband and young son walk into the waiting room. Both Doc and I say goodbye to him. I shake his hand and say something about hoping for the best outcome for his wife. He walks in a daze to the quiet room with the teary eyed boy trailing behind.

We return to the department.

I call the CV-ICU everyday.

Day 1: She had been to the cath lab, showed a 30% occlusion in her LAD artery. She had had two stents put in, and was still in an induced hypothermic coma so neurological status was unknown. Outcome did not look good.

Day 2: Still intubated and in coma. Body temp not rising despite cooling protocol cessation.

Day 3: Still intubated but some periods of wakefulness, responding to voice.

Day 4: The nurse comes on the phone and I ask again how Mrs. D is doing. I explain that I was one of the nurses involved with her code at Small Hospital.

"Oh I am looking at her right now, sitting up and having coffee with her husband."

A sputter from my end of the phone comes as the reply.

"Yeah, none of her doctors can believe her recovery. She has no neurological deficits at all. Well, she has some amnesia from the night of the arrest. She remembers going to the movie but nothing about the dinner or afterward. But that is probably a blessing, who would want to remember any of that? You guys did great work on her out there at Small Hospital!"

I tell her she has no idea how much I needed that news this week, thank her and hang up. My eyes are filling with tears of joy and relief.

I am still stunned and thrilled at this outcome. I cannot remember the last time I was part of a successful resuscitation. Scenes from that night keep replaying in my head and all I can do is shake my head with gratitude that she is alive today.

This is why I love my job.

Saturday, March 21, 2009

A Welcome Curveball

Some happy news this week...

I got an invitation to interview for an Irish medical school! April 10th to be exact.


This both pleases me and complicates my life greatly.

My life is nothing if not unpredictable.


I remember reading some Gary Zukav book years ago when I was in India. I was staying in this dingy 3$ per night hotel in Bangalore which had cockroaches crawling up through the sink and a single metal fan on the ceiling that rotated at a speed just fast enough to create noise but no breeze. I got to this section in the book where he said,

"If you had three minutes left to live who would you call? What would you say? And why aren't you on the phone right now?"

I know, it is nothing that profound at first glance perhaps. But I remember racing down the stairs and out into the dusty streets, finding an "STD" Booth (as they are called) and tracking my mother down for a strange, random, out-of-the-blue profession of admiration, love, and gratitude.

Working in the ED one gets reminded (too often sometimes) that many people never get to have those conversations before they unexpectedly leave this earth.

And so, that quote haunts me still from time to time. Who would I call today? And what would I say? What words are unspoken?

I am grateful for the phone calls and emails I've received lately regarding Jody, and grateful also for the conversations her death has inspired.

Today was Jody's funeral and thankfully the emotions and expressions were not too little, too late. Jody knew how much she was loved and respected, and in turn she made sure we knew the same.

It made today truly a celebration of her life, and not merely a declaration of our loss. I doesn't make her any less missed, but it does make all of this just slightly easier to bear.

Tuesday, March 17, 2009

Goodbye Beautiful Friend

Todd told me that Jody might not make it through the night. The indolent DIC had caused her to have multiple pulmonary emboli and her respirations had become labored, O2 sats dropping to the 40-60% range. I found this out in the back of an ambulance as I was returning from a spiral femur fracture transfer.

Earlier, I had received a message from my ED asking me to go on the transfer. I had no time to listen to the other 2 voicemails as I raced home from hot yoga, showered, changed, and headed back to the ED for the trip. It wasn’t until 4h later that I finally listened to the remaining messages and heard the one from Todd.

Too late to catch the last ferry to the island I went home and packed. I caught a few fitful hours of sleep, got up at 4am and drove to catch the first ferry of the morning. The whole time I prayed my phone wouldn’t ring with another call from Todd.

Jody was diagnosed in October 2007 with breast, lung, brain, and retinal cancer. She had just turned 39. In the ensuing months it spread throughout her bones and internal organs but she kept her sharp wit and smile. She somehow continued to glow even as the cancer raged inside her. She’d turn to you and say, “Look at me! Look at my skin! Does this look like the skin of someone who has the cancer?” And you couldn’t deny it--she was gorgeous.

When she was raising money for lung cancer research she told me—“lung cancer is the dirty cancer. There is much less funding and fund raising for lung cancer because society thinks it is only deserving smokers that get it. Well, it isn’t.” It made me take a look at my own buried biases about obesity and heart disease, diabetes, and yeah…cancer. She never smoked a day in her life, was athletic, and a veritable fireball of positive energy. She didn’t do anything to deserve this, but really—does anyone? I am still unable to stifle a bolt of anger when I see a 60 year old obese chain smoker and think—Jody will never get to that age.

In this world you will come upon a select few people who have a spark, a light in their eyes. People who draw you into their orbit simply because they take such joy in the dance of life. Jody was one of those people. I have always been in awe of her ability to act on, seek out, and attain all of the experiences she wanted to have in this life.

Our first night shift together in the ED I knew she was my kind of woman when she told me she was learning to grapple—and was the only female in her class. Soon there were two females and our friendship grew from there.

I was able to make it back to the island on time and even had one last visit with Jody before she slipped into unconsciousness. Her breathing became wet and ragged. Several of us gathered around her with Champagne and cake, telling stories and laughing about our many adventures in Jody-land. We took turns holding her hand and rubbing her back as she continued to work to breathe.

One of the hospice nurses, Christina, set up a bed for me on a fold down chair in a common room and I curled up for some sleep after we had arranged Jody so that she and Todd could fit in the bed together. I dreamed of Madeline, my mentor and beloved nursing instructor who taught me so much about grieving and death.

Around 7 am this morning Jody took her last breath in Todd's arms as he wished her peace and love. Her nurse came and introduced herself to me as Madeline. I shook my head at the coincidence.

Jody's wedding ring from Todd depicted the symbol of the Hummingbird totem, a Haida symbol often associated with marriage. I found this excellent summary of Hummingbird symbolism, the words describe Jody with shiver-inspiring accuracy...

When we assume hummingbird consciousness, our life becomes a wonderland of sensuous delights. We live for beauty, delighting in flowers, aromas, fine mist, and delicate tastes.
When it becomes our totem, the hummingbird teaches us to laugh and enjoy the creation, to appreciate the magic of being alive, and the truth of beauty.
Hummingbirds awaken us to the beauty of the present moment. As they dance the four quarters of embodied existence, they bring us medicine to solve the riddle of duality....
Hummingbirds teach us fierce independence. They teach us to fight in a way where no one really gets hurt. They teach us simple courage....

In hospice, the tradition is to open the window when someone dies--this allows the spirit to fly free. Then someone will travel upstairs to the garden on the roof and ring the bell to notify the spirit world that a new arrival is on the way.

When Todd went upstairs to ring the bell a hummingbird appeared on the roof. He marveled at the birds proximity. As Randi and I joined him on the roof we hugged and cried for a few moments before we noticed the bird had returned and hovered close by, it's tiny wings a blur. The delicate creature stayed near and we couldn't help but feel a sense of wonder and reassurance.

Jody is free now, and though we are sad she only was a part of this earth for a short time, we rejoice that we were among the lucky ones who got to share it with her.

...Only when you drink from the river of silence shall you indeed sing.
And when you have reached the mountain top, then you shall begin to climb.
And when the earth shall claim your limbs, then shall you truly dance...
Kahlil Gibran

Monday, March 16, 2009

Props to Pops

This Friday marks the anniversary of my dad's death in 2002. For me this year will be a bit sadder than most. My dad would have been over the moon had he been alive to see me start medical school. Many of the folks on his side of the family never even completed high school let alone university.

I had a few random things in a bag I brought with me from storage when I last moved. And I mean random...plunger for French press, old camera, greeting cards, mesh bag, mail, incense... and as I sorted though--a photo of my dad and I on his ride-a-mower when I was about 4 emerged. This photo floated out of my stack of paperwork and landed on the table. I had completely forgotten about it-- most of my photos are in storage about 900kms away.

I stared at it for a while then tacked it up on my fridge. I realised that his death day is tomorrow and that he died not knowing I'd reach my goal of medical school. Hadn't pieced that reality together yet. After losing a parent it seems all victories become somewhat bittersweet because that tender spot inevitably gets reactivated with each triumph. Our parents are the only people in the world that genuinely care when we succeed or when we fail. Our accomplishments to them are uncomplicated in ways that cannot be with a spouse or friends.

Many people say to me "oh, your father knows what you are up to" but honestly, I don't know if I believe that. I think (if there is an afterlife) it will be so unimaginably wonderful that our souls will be preoccupied with much more important things than hanging around earth to see if our living offspring become doctors or not. I know my father was very proud of who I was even when I was just a punk-assed 22 year old. I think a part of my wishing he were around to see me off in May stems from my desire to show him "See dad! You and mom done good!" Giving me the chance to say thank you for eating my watery scrambled eggs, letting me put rollers in your hair, and tolerating the boyfriends who wore trench coats.

It all worked out in the end Dad.

Thank you.

I hope you're riding some cosmic wave or fishing off a plentiful dock with Cubby right now.

Wednesday, March 11, 2009

For Keith

Ok. I know I promised that I was going to let go of all the rejection letter baggage...BUT my dear friend Anna B sent me this email, which reminded me of my friend Keith's comment a few weeks ago.

I had to post it. It amused me greatly. Hee hee.


Herbert A. Millington
Chair - Search Committee
412A Clarkson Hall, Whitson University
College Hill, MA 34109

Dear Professor Millington,

Thank you for your letter of March 16. After careful consideration, I regret to inform you that I am unable to accept your refusal to offer me an assistant professor position in your department.

This year I have been particularly fortunate in receiving an unusually large number of rejection letters. With such a varied and promising field of candidates, it is impossible for me to accept all refusals.

Despite Whitson's outstanding qualifications and previous experience in rejecting applicants, I find that your rejection does not meet my needs at this time. Therefore, I will assume the position of assistant professor in your department this August. I look forward to seeing you then.

Best of luck in rejecting future applicants.

Chris L. Jensen

Monday, March 9, 2009

Not Dead Yet

Sorry about the recent dry spell in blog-land. I moved last month and was poaching internet off some kind soul--but alas--the free internet gravy train pulled away about 10 days ago and left me to search out Caribbean housing and u-haul rentals via my CrackBerry.

I have been busily getting ready for the move and enjoying working in the mountains again. The lack of snow and icy conditions at the resort made for the busiest Presidents week in many years. No sprains or strains in ER that week...just lots of nasty fractures, crazy puncture wounds, facial/ chest traumas, and some living-anatomy-lesson-lacerations. But more on some of those later.

I was quite flattered and surprised by the number of comments of late on the blogs. It's nice to think that people actually read them! I am hoping that the internet situation will sort itself out soon (apparently I can tether the computer to my phone and work it that way--what WILL they think of next???)

In the meantime...I must sleep now but more posts to follow.

Subject Heading: Regrets

Ok. Not to belabor the point...but the final nail in the coffin of medical school rejection's from Canada arrived last Friday.

I must commend the University of Toronto for having the email subject heading, "Regrets".



No, not the rejection part, but the clear, concise let down. I hadn't even thought of "regrets" for a subject heading as the quickest-band-aid-removal for "what is the email from admissions going to say?"

Sigh. U of T, you complete me.

Well you don't. But your PFO email style does.