Monday, September 28, 2009

The Heart of the Matter

Suddenly I was in the back of that rocking ambulance again. This time with Howard Thorpe. His pallor revealed what his silent lips did not. The wail of the siren bounced around us and the lights of the city streaked past.

He knew what was happening behind the layers of tissue, cartilage and bone. He knew what had occurred deep within his very core. The aorta is the body's largest vessel. A firefighter’s hose of blood which runs the length of the spine where it bifurcates into smaller but also high-pressured arteries at the neck and thighs. A tear in the aorta can cause a man to bleed to death in minutes.

Howard had come in with mild chest pain and leg pain while he was skiing. A neurosurgeon from Montana, he knew that chest pain wasn't to be trifled with, figuring it was nothing but wanting to be sure he came into the clinic to get checked out.

At that time the pain was in the middle of his chest, maybe a 5 or 6 out of 10. His initial exam rang no great alarms. The electrocardiogram was overtly normal, his blood pressure not too low or too high, heart rate was skipping along maybe a bit quickly, but nothing worrisome.

Howard was very personable, kind, unassuming. The clinic was busy that day but he was my primary concern. The broken wrists and dislocated shoulders could wait with ice packs and slings in various positions.

Howard’s family was still skiing on the mountain, unaware of his mid-morning check-in. I administered nitro spray under his tongue, feeling somewhat sheepish as I warned him about the possibility of a headache… like he didn't know! But then, one can’t be sure what medical people forget or fixate on when they are the patient. When suddenly they are on the them side of the ledger. Anonymous in their underwear and open backed gowns status…shuffling with their IV poles to the “patient" washrooms.

Howard said his pain had gone from a 4 to about a 1. I told Bob, the physician, and he advised me to keep his pain down with nitro and continue to monitor him. We nodded knowingly, the new onset of angina now under control. A cardiac foreshadowing. It was minor in the grand scheme of things. Thorpe was in good shape. He'd go home, and with his connections in Montana he would have the best cardiologist who would fast track him in to the cath lab where they would isolate those pesky narrowing arteries and do the things they do to them.

Howard would probably never even have to be an inpatient. He'd be tickety-boo and back operating himself in no time. All of this Bob and I were comfortable with. A nice guy with a not-too-bad diagnosis.

I went to get bed 3 ready for the next fractured wrist reduction. I heard my name from bed 1. "Erin? I just can't seem to get comfortable. Could you give me a hand?"

I walked quickly to his bedside. The head of the bed was raised and he was fidgeting in a strange way, fussing with the pillows. "I just can't seem to get comfortable. Can you lower the bed please?"

There was something about his movements that struck me as odd. Even bordering on alarming. "Where is the pain, Dr. Thorpe?"
"Right here, between my shoulder blades". He reached awkwardly around and pointed to that area on the back that immediately caused the hairs on my neck to stand. A classic sign of an aortic dissection. The tearing-of-the-lumen, pain referred to that area.

Trying to mask my reaction in my face or demeanor I helped him settle and quickly found Bob.
"His pain is mid-scapular,'ve got to get in there now".

Bob and I exchanged looks which confirmed that we shared the same thought. Our initial apple-pie assessment of his prognosis had just soured. This was not good.

We moved Howard to the trauma room. Bilateral blood pressures on his arms and legs showed a marked discrepancy in pressure. On top of that, the pulse in his left foot had disappeared. His major blood supply was compromised somehow… his circulation wasn't going where it was supposed to. Now the leg pain made sense. Clinically it was clear that he was dissecting. If he was lucky it would be contained, with the more delicate vessel tearing inside while the thick outer lumen remained intact.

We were arranging the med-evac to the tertiary center which housed the vascular surgeon. At this point it looked like ground transport would be faster than landing the chopper. Someone had to go with him, and that someone was going to be me. Bob explained to Howard what was happening. Strange… or was it… that Howard hadn't come up with that differential on his own. Emergency staff are so versed in the tell-tale red flags of triage that Howards’s textbook discomfort immediately drew the two of us to the same conclusion. Maybe it was Howards denial and his own rosy hope that it was angina that blocked out his objective analysis of the situation. Can a man indeed be objective when he’s subjected to such an experience. …

We loaded up in the ambulance. His son-in-law had arrived but was unable to locate Howard’s wife and daughter on the hill. They had planned to meet in about an hour. His son-in-law was planning to bring them to the hospital as soon as he could but now Howard would have to go without seeing his family.

Dusk and damp misty rain greeted us when we rolled Howard out of the clinic. The fresh evening air did nothing to untie the knot in my stomach as I carried the bulky cardiac monitor behind the stretcher, a cell phone and Doppler to amplify pulse sounds. Two large-bore IVs were running into his arms and I had a pocketful of morphine and Gravol to keep him comfortable during the ride. I had no other drugs or equipment to rely on.

Shaun pulled the ambulance out of the bay… the sirens came then. It’s an altogether different matter when you are riding inside their wail.
As we accelerated down the dewy road toward the highway Howard was asking me questions… almost talkative.
"What are my blood pressures?"
"They are dropping, Dr. Thorpe. The left side is only 70 now."
"Why are you using the Doppler?"
"I can't feel your femoral pulse on the left side. It’s gone." A place where normally the bounding heart rate kicks at your fingertips now gave me only a swoosh-swoosh-swoosh when I pressed the Doppler to his groin.
"These things are so sinister in my mind,” he said. “The only time I see them is when I am trying to repair spinal damage from them".
"I suppose it must be worse to have the medical knowledge, to know all the worst case scenarios. Worse than being blissfully unaware."
He nodded.

I have a strict pact with myself to never reassure patients when I don't know what an outcome might be. "It'll be okay" or "You'll be fine" are phrases that never escape my lips unless I am putting a bandage on a skinned knee.

Thorpe arched his back grimacing with pain, said, “It feels like it’s more in my throat now.”

I thought that he was going to bleed out right in front of me. Unsure as to the best thing to do as I watched his pressure plummet, I grabbed the EHS cell phone and called the clinic to update Bob and figure out what the hell I could do in the back of this ambulance if this man suddenly blew on me.

As Bob answered the ambulance lurched to the side, passing an unaccommodating commuter. The phone slipped from my hands and fell into several pieces on the metal floor.

I flipped open my own cell, so thankful that I had thought to bring it. Bob came on the phone again.

"His pressure is dropping. I've lost his femoral and he's getting pain higher up the sternum".
"Nothing you can do, Erin. Keep him comfortable, pain meds, fluids, that is all you can do in the back of an ambulance. It is out of your hands."

What I already knew but couldn't swallow.

Howard refused any morphine. Looking back I think he wanted to be as clear as possible for what could be his last moments. He knew he was a time bomb ticking.

He was silent and I forced myself to respect the desire he had to be alone in his thoughts.

Was he happy with the way his life had turned out? Satisfied? What haunting thoughts came to the surface now? Was it fear… resolve… peace?

His face revealed nothing.

He turned to me.

"Erin. My wife's name is Pauline. My daughter is Isabella. This is my wife's cell phone number. If I don't make it please call them for me. Promise me you'll call them and tell them I loved them." With a shaky hand he scrawled a number on a scrap of paper from his wallet.

I took the number and folded it into my scrubs.

"I promise". Was all I could say. My own heart was thumping in my throat.

He nodded, closed his eyes and seemed to go deep within himself. I bit hard at the inside of my cheeks. I felt myself go cold. I was going to watch this man die. The tinny interior of the ambulance his last vessel, a stranger at his side. My eyes remained locked on the cardiac monitor with its reassuring blips every second.

We arrived at the hospital in record time despite the rush hour traffic and the bridge. Shaun smoothly rounding corners, passing lanes and lanes of hassled motorists.

Howard is whisked into the ER, a trauma bay and team waiting for him. I pass on my report to a disinterested male nurse who is only half listening until I get to the part about the vanished femoral pulse. He glances up at Howard, several feet away being hooked up to monitors, oxygen, new IV bags.

I squeeze Howard’s hand as I leave.
"My name, Howard. Please remember my name, so you’ll know who to leave the message for at the clinic when you call to let us know how you are doing after surgery."

He repeated my name.

“I won't forget. You all did an amazing job. It may be a small clinic, but you all know what you are doing. Had me on my way as soon as possible. Other places might have missed the diagnosis. Shaun's driving was superb. I know how bad that bridge can be. Thank you for everything."

It was weeks before I heard the end of the story. A physician friend of his came to our ER department with gifts, wine, and a letter for the staff.

I still have a photocopy of it in my strong box at home. His handwriting is terrible so there are many words I cannot make out. He had dissected, from iliac crest to aortic arch. 7 hours of surgery and full recovery expected. In the letter he graciously thanked all of the staff. I smiled when I saw my name underlined—I am sure as a reference to my insistence that he remember my name and update me regarding his recovery.

But in it he says, “You all saved my life that day. You saved my life. There is no greater gift we can give each other. So I feel strange presenting you with these small gifts and a card. What can I say to the people who are responsible for me being alive today? Thank you really doesn’t cover it.”

In a strange way I am still haunted by that day. It simply comes at me from nowhere sometimes. As nurses we are placed in situations where a profound intimacy with strangers can be thrust upon us. We bear witness to the most pivotal times in our patients’ lives. In crisis we share moments with patients that is normally reserved for their most treasured loved ones.

“Promise me you’ll call them…”

I can hear his voice. I am in that ambulance. And I am scared. But more than that I am grateful for the precious burden of this work. Work that pains me, pushes me, frustrates me and scares me, but also honors me. Work that takes much from me, but gives moments in return that are profound in a life where superficiality often reigns.

I’m grateful just the same to come back to the present, to be running on the treadmill wondering what I need pick up from the grocery store for dinner.

(This is a re-post so my apologies for those who have already seen this. Working on a few posts right now but they are taking longer than usual as I feel guilty sitting in front of a computer when I should be memorizing the innervation of the pelvis...)

Monday, September 21, 2009

If I Had to Be A Cell...

Well, being a killer T would probably be more badass...but behold the beauty of the red blood cell...
© 2008 Kenneth Todar, PhD

Sunday, September 20, 2009


The #1 search term that has brought people to my blog in the past month?



Saturday, September 19, 2009

Why Medical School Equals Awesome

Two weeks ago I couldn't have described to you the structure of the inner ear, let alone the physics behind what happens when sound waves strike the tympanic membrane or how movement of the hair cells in the cochlea are translated into neurotransmitters. I didn't know that there are members in the Deaf community against the use of cochlear implants or that we have muscular mechanisms in place which dampen the sound of our own voices to ourselves.

Already I can look back over the past three weeks of school with some astonishment at the volume of information that has been thrown in our direction. The information we have gathered and disseminated amongst each other, the flash cards, the youtube videos, online dissections...I am sure part of this cooperative process has something to do with the fact that we only receive pass/fail grades for the first 2 years of our program, thus decreasing the competition factor by a notch or two.

Our program is structured using problem based learning. We are in groups of 8-10 and each week we are presented with a case study. We work through the various differentials as a group and come up with the likely diagnosis. Then we decide what learning objectives we need to tackle and are left to our own devices to gather that material, learn it, then return 4 days later to discuss it. Present in our groups is a physician who acts as a facilitator but not a resource, they are basically there to make sure we are meeting the curriculum goals and staying on track (and not teaching each other a bunch of misinformation). My group consists of 4 biochemists, one PhD microbiologist, a geologist, a biologist and a biomedical engineer.

2 weeks ago our case study was regarding a patient with sensorineural and conductive hearing loss. The case is revealed in stages during the two sessions on Tues/Fri...then the following Tuesday we have a 1 hr wrap-up and begin the next case. Since G.M had hearing difficulties our anatomy, physiology, histology, and clinical skills lectures were all based on the ear and examining it. Our guest lectures were from an ENT specialist, a patients rights advocate/medical legal advisor, a community physician, a speech/language pathologist, and a sociologist. All the discussions were focused mainly on the impact of hearing loss from the biochemical level to the community level. I found the amount of information that I retained MUCH greater than I would have anticipated. I am certain that the 'learning in context' aspect of the delivery had much to do with that.

What is astonishing to me is the truth behind, the more you know...the more you realise you don't know. This has been glaringly evident since day one of medical school. As an ER/community nurse I have to know a little about everything regarding primary care. Apparently--very little about everything.

How did I spend so many years in nursing school and 6 years as a nurse yet understand so little about the organism I was dealing with?

The other amazing thing is how each and every day I see a large gap in my knowledge filled-in ever so slightly. Something I've never understood before or always wondered about becomes crystal clear...from major to minor 'AHA!' moments. I am fascinated by the material we are learning, from the work of the smallest muscle in the body (the stapedius) to the social impact of 'fixing' an 'impairment' (cochlear implants).

It almost feels like a scam sometimes--I have the privilege of getting to learn full time about something that enthralls me--and at the end of it, I get to be a doctor!! What? How cool is that?!

And this weeks case has a blood disorder...I must return to the pages of my physiology text and attempt to wrap my head around the structure of the hemoglobin molecule.


Wednesday, September 9, 2009

Saturday, September 5, 2009

Curse of the Day

So today I picked up an amazing book called "Irish Blessings, Toasts, and Curses" from this cool little Celtic bookshop downtown.

It is going to be really hard not to turn this blog into a daily blessing/curse fest now...but I will try to control myself.

Except for from time to time...

Like today...

'May you marry in haste and repent at leisure.'

Thursday, September 3, 2009


Oh and last night at the pub a drunk Irishman spilled beer on me. I figure that's Gaelic for "Welcome to Ireland".

Wednesday, September 2, 2009

And So it Begins...

I can't believe I am actually here.

The goal of getting to this place seemed so very very far off that for a long time I hardly lifted my head to look up and see how many more stairs there were to the top. I would just focus on the two or three ones directly in my line of vision...keep my head down, and push on.

I remember very clearly talking to Vern about it one day on a walk in Revelstoke. It was the summer I first moved there and I could feel the contemplation stage of change slowly working it's way into action. I told her that at some time I'd have to give up work completely, move somewhere with a university, take 8 or so prerequisites, write the MCAT, apply to schools, then wait almost a year to find out if I was accepted or not.
She was also looking into a long application process at the same time, applying to school in Scotland to undertake her masters. We both sorta shook our heads at how daunting it all was.

Today I got to sit in a lecture room and look at my fellow classmates for the next 4 years. I've been so lucky since my arrival (save for the baggage incident) to have connected with some very amazing folks in my class. Musicians, chefs, dancers, researchers, engineers...we're all meshing into these interesting combinations. Our res unit of 4 has basically become the meeting point for our group of friends from res. We've already had late night jams, "Flight of the Conchords" showings, big group meals, and kitchen partying--and it's only been 5 days. My roommates are first years as well, and though they are a few years younger than me, it hasn't seemed weird. Just funny more than anything watching my one roommate figure out how to make a sandwich after coming home from the bar.

It was a long day of orientation today, and though I had ants in my pants after sitting for so many hours (8!) I must admit I was on the edge of my seat as they talked about clinical skills, labs, textbooks, the PBL groups, and our eventual hospital rotations. Next week we will be assigned our patients from the 'early patient contact program' which involves us following a prenatal woman from now through to 3rd year as she goes through the pregnancy and eventual birth/growth and development of the child. We're also being assigned a patient with a chronic disease who we will also be paired with until 3rd year. We'll be expected to attend hospital visits/doctor appointments/home visits with these patients...and be another resource for them as they work their way through the system. I am very excited to meet these people who will be a big part of my learning for the next 2 years.

After orientation we had a quick snack and headed out to the pub for a medical society social event. This was an event for 1-3rd years which included a life sized (timed) game of 'operation' as well as the normal mini version. I was terrible at the life sized one and wouldn't have come close to the top time even if I hadn't been buzzed out after 16 seconds. Instead of claiming fame and status with a win, I ate two free hotdogs (apparently my 'mystery meat' rule doesn't apply in Ireland) and drank some Guinness. The hot dog guy said that evidently I wasn't going to be a surgeon (I told him maybe I'd just be a slow one...) Came back to our place and had another jam session with my two new music-playing pals, drank some tea, and then called it a night.

It's strange to be in place finally. In the place that has been so far off on the horizon for so long. It is also lovely to be able to embrace the now--feel that my life has truly gone to the place it was meant to go, at the time it was meant to happen, and with the people I was meant to be surrounded by.


Tuesday, September 1, 2009

It's 0158h And I Have the First Day of Medical School Tomorrow

Yeah. The title kinda says it all. I will attempt a cogent post tomorrow (I promise). But for now let me say that I am so unbelievably happy I can hardly stand myself right now! My roommates are awesome...the friends I have already made are a talented bunch of uber quirky Canadians, and I love my life. We jammed until the wee hours yesterday then today explored, drank coffee, and bought school supplies.

Tomorrow is our first day as a whole group together. So far I've only met the Canucks...sorry for the rambly post but we hosted dinner, drinks, and an episode of "Flight of the Conchords" tonight and I may or may not have had a couple of stout.