A Heart Full of Gratitude

     As crazy as it sounds to say, I'm already done with five rotations, and am approaching the end of the sixth. That being the case, and because today is a nationally recognized day of thanksgiving, I think some thanks are in order. Actually lots of thanks. I know I'm not done yet with this journey to become a PA, but even getting this far has certainly been a group effort, and so many people have contributed to getting me this far, and I'm sure I'll miss someone (apologies in advance). I'm not going to use names since this is a public post, but I think you all know who you are. I'm sure I'll miss someone, so I hope you'll forgive me if I do. And now, without further adieu, and in no particular order, I'd like to say 

Thank you so much...

• To the undergrad advisors who not only allowed me to study both German and Health Professions, but actually encouraged it, and then to ensure I fulfilled all the requirements for both my major and minor, and even found ways to make the two complement each other.
• To the people of Migori, particularly at St. Joseph's and in Medics to Africa, who were always eager to teach me in the hospital, and who helped opened my life to new experiences as they taught me to experience and appreciate their culture.
• To the friends who have been so patient and understanding about the fact that I am horrible at responding and having free time to hang out right now. 
• To my PA classmates and friends, I really would not have made it this far without you. The spirit of cooperation and encouragement, as well as the study parties and note sharing, allowed me to keep working a bit during didactic, and helped push me to push myself. You are all amazing. 
• To all the RNs, MAs, NPs, MDs, and other healthcare professionals who have always become so excited when they hear that I am studying to be a PA and who have cheered me on and told me I could do it or that they were excited for me, even if I'd never met them before. Many thanks to the ones who shared their wisdom and advice, encouraged me when things were hard, and were just as excited to teach me new things as I was to learn them. 
• To my PCP who wanted me to update her on all my progress, encouraged me when pharmacology was awful, and who even taught me how to do minor procedures.
• To the boss who let me take off almost an entire month for PA school interviews and then helped me transfer to a store in MA so I could continue earning some money during the didactic year. 
  
• To the coworkers who kept me sane, made me laugh, swapped shifts when school things came up, kept me humble by reminding me that I'm "not even that great," encouraged my deep appreciation of all things sarcastic and nerdy, greatly improved a sucky birthday, cared for me when I almost passed out after blood donation, and reassured me that they would, in fact, still hang out with me even after I quit to focus all my attention on clinicals (and who actually honored that promise).
• To the friends who helped me decide when it was time to quit my job at the coffee shop, and who even made me rehears with them how I would give my notice.  
  
• To my boss who not only worked with me to ensure that my work schedule didn't conflict with my ever-changing school schedule or tire me out too much, but who also accepted my two weeks notice when the time came to quit, helped me end on a good note, and even worked things out so I could still continue to get free coffee for a little while longer after my last shift. She also bought me wine to cheer me up when my birthday last year wasn't the greatest, and continues to plan events for all of us former coworkers to stay in touch, so extra points for her.
• To the customers who cheered me on and encouraged me to keep studying (even when they didn't know me that well or even know what a PA is), and who could brighten a bad morning simply by their presence or smile.
• To the bad customers, who gave me important experience with personality disorders and substance abuse, as well as many opportunities to practice being patient and keeping a straight face. 
  
• To kitties and animals of all kinds, for brightening my day and occasionally letting me snuggle you.
• To the medical students who helped me acclimate to my first rotation and were always ready to help, and really to all the medical students I've worked with since. Most have been genuinely pleasant and helpful, and any competition between the MD and PA students has been friendly.
• To all the people in the psych department, from doctors to social workers to mental health counselors to nurses who were so patient with me during my first rotation, and who were always willing to answer my questions and give me their insight, as well as tell me where I needed to improve. 
• To all my first patients, they'll probably never read this, but I so appreciate their willingness to be examined and interviewed by a student, and their patience with my clumsy efforts. 
  
• To all the friends, near and far who have listened to me and supported me emotionally and spiritually as I struggled with non-school related issues. 
• To all the nurses, especially in the ED, who were willing to teach and observe as I learned and performed necessary procedures.
• To the PAs who have continually offered encouragement and and much-needed guidance, and especially to the friend who has been working tirelessly to make it possible for me to do my next rotation with him.
• To the rotation coordinators who have allowed me to set up a rotation in Oregon, rather than returning to an unpleasant site. 
  
• To my sister and brother in-law for letting me crash at their apartment at least once or twice a week for my entire women's health rotation since that site was much closer to their home than mine.
• To the friends who taught me how to be a good listener, how to admit when I don't have answers, and encouraged me to find them.
• To my church family, both in Oregon and here, who have supported me through this entire time with notes of encouragement, prayers, meals, free furniture, listening ears, and much needed hugs. 
  
• To my long-suffering roommates who have put up with my crazy schedules, hermit-like ways when studying, times when I get behind on cleaning, stress-baking, emotional breakdowns, and everything in-between. You are saints. 
• To the friends, family and coworkers who check on me to make sure I'm sleeping and eating, which is not something I ever thought I would need reminding to do (PA school is nuts).
• To all the people who have sold their furniture cheaply or left good quality stuff out for anyone to take. 
• To all the cities around me who keep their parks, beaches, and other lovely areas of nature open to the public.
  
• To the girls in my small group, who really have blessed me in so many ways that I couldn't list them all, but in particular your love, your support, your care, your prayers, your laughter, and for giving me a family even as I'm miles away from the one I was born into.
• To the tech who brought me water after my first code and assured me that I did fine.
• To Groupon, Living Social and the like, for letting me occasionally afford to go out to eat or do something fun and feel like a normal person again.
• To anyone who's ever bought me coffee or a meal, you have no idea how much that means to me. 
  
• To the Ugly Mug and Red's Sandwich Shop for providing delicious food and excellent locations for Diner Dates with my Stabrucks ladies. 
• To the public safety people who let me in to my car after I locked my keys inside, saving me a call to AAA. 
• To Dibacco's, Hogan Tires, and AAA for taking care of my lovely, but rather old, car and for keeping it going so I can make it to rotations.
• To the tow truck driver who rescued me from a Boston highway on-ramp when my car broke down, and then gave me a free ride to my friend's house so I wouldn't have to walk there in the rain. 
  
• To all the friends and family who have invited me into their homes for Thanksgiving and given me a home for the holidays. 
• To the libraries of NOBLE, for letting me study in their quiet halls, and for letting me borrow so many wonderful books and movies for free.
• To all the podcasts that help me learn and study, or simply keep me entertained, during my long commutes. 
• To my family, there is so much I could thank them for, but for now I shall highlight their unflagging love and support, whether it be emotional, mental, physical, spiritual, or financial, and the fact that they have kept me going even though I do not thank them nearly enough. I love you all.

 

Happy Thanksgiving, everyone!

When It Doesn't Go As Expected: Guest Post

     Not long after I finished my rotation in women's health, my friend Mallorie posted to Facebook about some of the things she went through during and after the birth of her daughter, Quinn. I won't spoil the story now since you will read it below, but as I read her words I couldn't help but realize that she was shedding light on yet more aspects of pregnancy and womanhood that are rarely shared or discussed, and it was obvious how her words touched those who read them. My initial thought was to ask Mallorie if I could reprint her story on this blog as a guest post, an addendum to some of my thoughts from my women's health rotation. The more I thought about it though, the more I realized just how many women I know who could share their own tales of how pregnancies and entering motherhood didn't quite go as they'd planned. I started to ask myself, why stop with Mallorie's story? Why not share them all? The short answer to that question is that there are too many stories to share and not enough space or time, but I still wanted to do something. As I was pondering how I could bring my ideas to reality, October began, and I was reminded that it is not only Breast cancer Awareness Month, but also National Pregnancy and Infant Loss Month in the U.S. It seemed a fitting time for my idea, so I contacted a few friends, compiled their stories, and post is the result, even though taking the time to get everything together means that it's no longer October.

     Before I get into my friends' stories, I'd like to take a brief moment to spotlight miscarriage, the most common form of pregnancy and infant loss, as it does not come up in the stories below. I have many friends I could've asked to to talk about their own experiences with miscarriages, but instead I'm going to simply link the stories of two women who have already written about their own experiences. One is from Jessica, a doula and friend of my family. She shares the story of the stillbirth of her daughter, Daphne Grace, at 34 weeks in The Beginning of a Life Long Journey. In her post, Hello, Goodbye, Jessica provides summaries of all four of her pregnancies (only two of which ended in live births), and explains what October means to her in light of her miscarriages. The other story is from Laura Benanti, an actress, who wrote about her own miscarriage, and the lack of public discussion about them, in her article My Experience With the Voldemort of Women's Health Issues. In the article, Benanti mentions the song Beyonce wrote after experiencing her own miscarriage, which you can listen to here: 

     And now, finally, the three stories that are the focus of this post. Each of these dear friends tells a true story from their lives that deals with a different difficulty of pregnancy and/or becoming a mother. I apologize that this post is a bit long, but I think these stories are too important not to share. I am so proud of these women and so grateful for their willingness to share some rather personal, and painful, experiences from their lives. I know that I have many more friends and relatives whose stories could have been included in this post (in fact, I came up with 15-20 names in just a few minutes of thinking), so if anyone reading this would like to share their own experiences of pregnancy and/or motherhood, let me know. I would certainly be interested in turning this into a recurring series. 

Mallorie & Davide

Photograph by: Helen Carmina Photography

      When I saw this photo to the right I couldn’t help but get teary eyed. This is my story. This sweet mama in this photo had a birth plan and it played out a different way. I had a home-birth planned….we bought all the supplies and even had the birthing pool at our house, but I also had a breech baby. After going to two separate chiropractors a couple days a week, for a couple months and going through an ECV (External Cephalic Version WITHOUT an epidural—never again) the baby still would not flip. After much prayer and discussion, Davide and I decided a cesarean was the best route for us, and one that brought us the most peace in all of what was going on. It was SO HARD to come to that conclusion because it was the last thing I wanted. I wanted so badly to labor for my baby and even just feel what a contraction felt like (call me crazy, I know), but God had different plans. Without the support of my midwife, doula, doctor, midwives, friends, and family, I would not be able to look back on this day and see it as a blessing. They supported me and gave me the best experience possible even though it was not on my birth plan.

     The interesting thing in all of this and that I find God teaching me as well… is to LOVE my body. I was so self-conscious of having a scar and what would my husband think of me after the scar, stretch marks, and saggy boobs. Society feeds us ALL DAY long with messages that suggest we are not worthy if we do not fit a certain mold, and I tell you what….there is something so empowering in getting caught up in what our bodies can actually do, rather than getting caught up in what the world tells us about our bodies. My body created a human being and is now also sustaining that little human being. ARE YOU KIDDING ME??? That. Is. INSANE. So many women would take all the scars, stretch marks, and saggy boobs in the world just to be able to carry a baby, and here we get caught up in the saddest body image struggles because society tells us otherwise. The human body is incredible and God does not make junk. He makes powerful beings and enables us to adapt and overcome the hardest struggles even when our body is physically failing and doing things we don’t want it to. He gives us the strength to see the bigger picture and to push forward in hope even when things don’t plan out as we think they should.

Photo Credit: Abigail Andrus

     And to continue in my soap box….I just want to say choose LIFE. There are so so so so many families who would LOVE to build their family through adoption. It is an incredible, selfless, and priceless gift that a mother goes through in choosing life and adoption. I’m also sharing a second photo just to show off how badass of a team I had supporting me the day of Quinn’s birth. They did every measure possible to help me in accepting what was happening while doing what was necessary. This is them putting her straight on my chest and leaving her there while I was getting stitched up. Also, I understand everyone has their own opinion, which they are entitled to; all I ask is that comments are not rude or hurtful and are kept respectful. Thank you!!

Lynnea & Donovan

     My whole life, well more like since I was 12, I couldn't wait to be a mother. I have always loved kids. I started babysitting since I was 14, and kids became a huge part of my life. Later my career path has led me to be a full time nanny for the past 6+ years, I have become accustomed to potty training, swift meal making, tooth pulling, bedtime telling, boo-boo kissing, and many more uncontainable joys of helping to raise children. Experiencing kids learning how to write their name, after countless hours of singing our ABCs, have brought much happiness! And there is nothing more enchanting then post-nap snuggles. It's safe to say, I love kids. Always have and always will.
     So my husband and I decided Christmas last year, we would officially "try" for a baby.  Figuring it would take a couple months to actually get pregnant, I was happy, I was finally ready to be a mother, and I dreamt about taking care of my own baby very soon, where I could be the one to kiss them goodnight AND goodmorning. Not to mention, I've had The Box, ever since I was 16. The Box, is a collection of baby possessions I have saved, found or have been passed along from other mothers, that I'd hoped would one day be a part of my baby's life. I have always expected I would have a baby.
     But, life almost never goes as we expect does it? After several months of trying to conceive. I knew something was wrong. And after countless doctor visits, tests, hormone therapies, and other expensive and uncomfortable procedures, I received the news that at this time it appears as if body won't be able to conceive. And they are not sure why. I have seen over three doctors, all coming to the same conclusion. My body appears as if everything should work fine, but it doesn't.     

     Pretty big news. And I could go on for pages and pages of what Donovan and I have talked/argued/prayed/cried about for the past month since we got that news. And how many hours I have wrestled with this news and how it honestly has shaken me to my core. But I won't. I will only say, that despite everything, I have felt an overwhelming sense of Gods peace throughout this entire journey. He has helped me realize, that often what we expect for our lives, is not what He has planned for us. But He promises that what He does have in store for us will be good. And I believe that with my whole heart. That no matter what I have always expected for my life, what God has prepared, is grander than anything we can comprehend. That's not saying there wont be heartache, for I have shed many tears these past weeks, but trusting God and His will, is beautiful. I also fully believe that I will be a parent someday, maybe not in the way I have always expected, but Donovan and I have always wanted to adopt. So we decided to forgo any expensive procedures of attempting to make my body try and conceive, and put that money into a adoption fund. I also believe God is a God of healing and miracles, and that maybe down the road, He could heal my body, and allow Donovan and I to get pregnant. But, I'm ok if that doesn't happen. Because I know that whatever happens in my life, if I remain trusting in Him and resting in His peace, my life will be filled with contentment. Because the one thing I know I can always expect is God is good. And He has an exquisite plan for my life.

Summary: Life doesn’t always go as we expect, but we can learn to ride the waves that come our way when we trust in God and take on this crazy and exhilarating life.

Margaret & Cesar

     My husband, Cesar, and I were married in November 2010. It wasn’t too long before we were expecting our first child, and on August 3, 2012 Noah Alexander came into the world. I had wanted to have a natural birth, but that plan went out the window when his heart rate started dropping. After the third drop, our doctor warned us that they’d need to perform an emergency C-section if his heart rate dropped again. I opted to have an epidural so I could be conscious for the birth, if it came to that, and it did. Despite the scare with his heart rate, he seemed fine, at least for the first 24 hours. By the next evening, while trying to do skin to skin, we could see that he was struggling to breathe. He had also developed a fever, and his platelets had dropped, so he was admitted to the NICU that night. Your hormones go crazy after a C-section, so I felt so sensitive, and I just kept crying. I felt like I was an electrical cord that had been severed and everything was out of whack. In short: I was a hot mess. It didn’t help that I was lacking sleep.

Noah's last feeding before being
discharged home.

     Eventually I was discharged from the hospital, but Noah had to stay. On the way home from the hospital my milk came in, so I had to figure out how to pump. A nurse friend had told me to pump as much as I could, but I wasn’t sure how long to pump for, and I didn’t have a feeding baby telling me when they were done. I just kept pumping because I didn’t know when to stop. In return, my body kept making milk. During those first days though, while I was busy figuring out pumping, my husband was at the hospital with Noah, keeping a close eye on our son and worried that there too many babies for each nurse in the NICU. Finally, after 4 days, Noah came home. 

     Noah had been home for 11 days when he started to become yellow and lethargic, and we noticed bruising between his belly button and scrotum. When we brought him to the ER, the doctors thought the bruising was just from a bump that we hadn’t noticed, and we returned home. The next day though, he started crying more. That night we started co-sleeping, which was amazing, but we realized in the morning that Noah hadn’t woken up during the night to feed. The urine in his diaper seemed concentrated and unusual, so we returned to the ER. He was hooked up to IVs and placed in a radiant warmer, before eventually returning to the NICU. This time though, Noah was given his own room with his own nurse because he was so sick. Cesar and I were given a private room so we could stay with him. Noah spent 2 weeks there. During that time, Noah had to be NPO and he couldn’t drink any of the milk I pumped, so soon we had quite the collection. We had milk at home, milk at the hospital, and then we had to borrow a friend’s refrigerator space for even more milk. It made me feel like a cow. We ended up donating much of it to the Mother’s Milk Bank in Colorado because I pumped more than 300 oz.

The only family photo of Cesar, Noah, and Margie

     Initially Noah was diagnosed with an infection contracted in the hospital during his first days, but despite treatment he wasn’t getting better. One doctor finally raised the possibility of Neonatal Hemochromatosis (NH), and wanted to investigate the possibility, but warned me not to look it up, because “it was kind of a sad diagnosis.” They’d already looked at Noah’s belly with an ultrasound, but it hadn’t been enough, so they did an MRI. Noah couldn’t hold his breath like you’re supposed to for the MRI, but despite the blurry images, iron deposits were clear all throughout his liver and into his pancreas. It was NH, a very rare condition that is basically liver failure in the womb, which causes iron deposits throughout the liver and sometimes other organs. Most babies with this condition don’t make it to birth, and those that do rarely live long afterward. The only known successful treatment is a liver transplant.

     Cesar wasn’t there when we got the MRI results so I called him, explained that it didn’t look good, and said I needed him there asap. That was Thursday. On Saturday Noah was flight-lifted to Seattle. Cesar flew in the propel airplane with Noah, and I arrived on Sunday with my mother in-law. We had the option to stay at the Ronald McDonald house, but we weren’t approved at first, so we stayed with friends until we could move in on Tuesday. Being there allowed us to be closer to the hospital and surrounded us with other families who were going through similar, and even harder, things with their children. Being there made it all a better experience. It wasn’t as scary as it could’ve been, and we had something to come home to. The volunteers put so much time and effort into caring for everyone. We didn’t even have to pay because the house only asked for a suggested donation of $30/night and our insurance covered it all. Despite the house and other families, it was a crazy time. I’m glad I got rid of the pictures from this time in Seattle because one of the hardest things was seeing how much Noah was hooked up. I have never seen so many lines of support as all the lines going into my son. I wish I could forget that image. We had brought lots of luggage with us and prepared for a long stay because we’d been told that it could take months to get Noah better, but in the end he was only there for 5 days. Noah passed away on September 7, just five weeks after he was born. 

Cesar and Margie in 2013

     When you lose a child, it haunts you for the rest of your life. I thought that the way I carried myself after he passed was it. But it wasn’t. The grief comes in waves. It comes and goes. Cesar and I briefly moved from Oregon to Hawaii to grieve. Noah had been conceived in Hawaii when we visited after our first anniversary, and it was almost like we had the chance at a fresh start. During our three months there, I became pregnant with another son. This time I went through 22 IVIG treatments starting at the 18th week of pregnancy to prevent NH, and just one year and eight days after Noah’s birth, his brother Micah Leonel was born via VBAC, healthy and whole. There were a lot of triggers about Noah at that time, and more in the months to follow. I am so glad that my mother was with me when another wave came when I was 6 months post-partum from Micah. For anyone else who goes through grief, know that you need to surround yourself with those who love you. It’s a big part of your healing. Reach out to the people who know you and love you well. You should know too, that moments of “set backs” are not bad things. They’re a part of the grieving process.

Cesar, Micah, and Margie in 2013
A daughter will be joining them in January 2016

     If you ask what I learned from everything that happened with Noah, I’d say that it didn’t feel like a lesson; it was more an experience we have had to grow from and share with others. We saw how much God was with us in it all, good and bad. Looking back now I wonder too why on earth I worried about the little things. Those were the least of my worries! As a new mother I was so worried about the little things, like if I’d have enough diapers and wipes. Little did I expect for my son to go. Cesar and I ended up having so much left over, and we just gave everything away to other expectant mothers. There were more important things to be concerned about. With that I’d like to advise new parents out there to do what you feel inclined to do. If it’s not to write the baby showers thank yous in the first few weeks, don’t do it. If it’s to just enjoy nap times, do that rather than worry about getting everything clean. Let your baby sleep with you, enjoy everything, rather than get caught up in little details. 

     To close I’d like to say that Noah lives on. I see him in his brother Micah, and I continue to tell his story. I hope that through it others can find healing for their own tragedies, remember to treasure their own loved ones, and see God’s work in us, even in times of grieving. 

     
Further Resources
     If you'd like to support or learn more about some groups mentioned in this post or who seek to help women and families all over the world, here are some links to get you started: 

Ronald McDonald House
Mother's Milk Bank
Hope Through Healing Hands
For further discussion of some of the body issues Mallorie raised at the end of her section, I recommend this post on We Seek Joy: Babies Ruin Bodies. To learn more about neonatal hemochromatosis, this article by Medscape is a pretty good summary. To learn more about what childbirth used to look like in the 1950s in the UK, and to hear how the medical world finally started giving attention to maternal health, I recommend the book Call the Midwife by Jennifer Worth. To learn more about how women around the world experience pregnancy, and how much more work still needs to be done in the area of maternal health and prenatal care, I recommend Half the Sky by Nicholas D. Kristof and Sheryl WuDunn. Just know that you might need tissues while you read. 

Don't Believe What You See On TV (24/30)

     Last Tuesday was the last day of my rotation in emergency medicine. Looking back it's hard to come up with a summary of this rotation. I worked 17 shifts, saw 100+ patients, had only a few repeat diagnoses, and performed quite a few procedures. I suppose the only general statement I think I could make is to say that the ED does not lack in variety. Sure, there are particular conditions that are seen commonly, but you show up each day for your shift not knowing what you will see. Even the "common" conditions aren't always that common, or don't present in the same manner each time. Take appendicitis for example. During my surgical rotation I saw a woman with appendicitis who presented with left-sided, rather than right-sided, lower abdominal pain. It turned out that she had a long, midline appendix that extended into the left abdomen. Then on this ED rotation there was a man with right-sided diverticulitis and a boy with a right-sided abdominal abscess who both presented similar to acute appendicitis. It wasn't until my last day in the pediatric ED that I actually saw a case of appendicitis that fit the "classic" presentation, and even then the patient had not yet developed a fever, as is common. 

Being woken up by solicitors
after my last overnight shift.

     The variety of the ED was also aided by the fact that, for this rotation, I didn't stay in the same area of the ED for all shifts. My schedule was 3 days on/3 days off, and for each group of 3 days I was in a different location. I had six 12-hour shifts in the main ED (3 overnight, 3 during the day), three 9-hour shifts in the more psych side of the main ED, four 8-hour shifts in the pediatric side (I covered one shift for another student), three 10-hour shifts in the fast track, and one 8-hour shift on an ambulance. It's really no wonder that this rotation seems to have flown by. I actually enjoyed all areas of the ED, but it was nice that if a student really didn't like one area, they only had to do three shifts there. That was definitely nice in regard to the overnight shifts. I actually saw a lot of interesting things on those shifts, but man did they mess with your sleeping and eating schedules. I spent the next 1-2 days after those just recovering and trying to remember what day it was. It didn't help that there were mandatory lectures two days each week, so for two of my overnight shifts I couldn't even go home when I got off at 7 AM, but had to go to lecture and finally leave around 9 AM and 11 AM. That was painful. At least when it was quiet I had the opportunity twice to head over to the fast track side and nap in a bed for a bit. It was actually quiet enough that I got about 2 hours of sleep/nap one day.

How I got a few winks during overnights

     If you're surprised that I got any sleep while working in an ED, I should mention that E.R. and other medical dramas on TV can be a bit misleading about the day-to-day life in emergency medicine. There are quiet times when the only patients in the ED are ones waiting to be admitted. There's also just a lot of waiting. One of the attendings with whom I worked quipped that a more accurate TV show about the ED would just be a lot of people sitting around typing on their computers and waiting for lab results to come back. That's often a fairly accurate description. The waiting can be very frustrating for both providers and patients (and certainly the patient's family members), but it is a regular part of ED life. Later at night in particular it can take longer because there are fewer staff in the lab or imaging. Particular days, like Mondays (apparently everyone waits out their illness on the weekend and then comes in), will have longer wait times because there are simply more patients waiting to be seen. On that note, many patients who come to the ED, would be much better suited for an urgent care, or even their primary care. Now sometimes it's hard to tell who is truly an emergent case, but I will warn future ED patients that if they come in for a neck strain and other patients are there for potentially life-threatening illnesses, the neck strain will be waiting. Complaining will not get you seen faster if other people are in worse shape, and being disruptive might actually hurt your case because no one likes to deal with unpleasant people. So, when you're in the ED, be patient, and be observant. If there are patients being seen in hallway beds, or you hear a provider mention they haven't eaten or used the bathroom since their shift started, it's probably a busy time and you might be waiting longer. Sorry. Enjoy the free TV and snacks (if you're not NPO, that is). 

     Of course, there are moments in the ER when there's not enough time, moments when you are running because even the seconds count. These moments might not be as frequent as TV would make you believe, but they happen, and they can be terrifying. There were four times on this rotation when I thought a patient's life was in immediate danger. The first time was a young man, a healthy-looking fellow with nothing but a right-sided chest pain that he said he almost didn't come in for because it didn't seem so bad. In fact, his pain didn't seem so bad to us at first either. If you looked through the notes written about him that morning, you would see the same phrase over and over: "no acute distress." This is essentially a description saying that this man did not look sick, and gave no indication that, less than an hour after being brought to his room in the ED, he would need an emergency procedure to save his life. Physical exam however, revealed that the patient had a pneumothorax, also known as a collapsed lung. It can happen for numerous reasons, but in young, tall, thin males, like this patient, it's often a spontaneous occurrence and is not necessarily life-threatening. In fact, some studies recommend that if that the lung is not too collapsed, the patient can be managed conservatively* (i.e. they're allowed to go home and told to return if things become worse, rather than having a chest tube put in to let out the air that has escaped from their lung into their chest) because they'll likely heal on their own. In 1-2% of cases however, spontaneous pneumothoraces can become tension pneumothoraces,** meaning that the air flowing from their lungs into their chest cannot escape and begins putting pressure on the heart and other lung. This is an emergency. In the case of my patient, less than 15 minutes after getting the x-rays back that confirmed his diagnosis, and while thoracic surgery was on the way to the ER to put in a chest tube, his heart rate and blood pressure suddenly plummeted. While the nurse and doctor quickly sterilized and numbed the patient's chest, the PA and I tried to keep him talking so we could gauge his mental status and whether or not we actually had time to hit all the proper steps. I wasn't sure that we did because, as a witness later said, the patient "looked like death" and was struggling to focus and respond. Even as my worry and fear grew, the other providers remained calm, and in what seemed like eternity but was really 2-3 minutes or less, the patient's chest was cleaned, numbed, a needle was inserted between his ribs, and a rush of air came out. His vitals began to stabilize immediately, and he began to talk normally again, telling us that his pain was gone. Shortly afterward the thoracic surgery resident arrived, a chest tube was placed, and x-rays showed that the patient's lung had reinflated. He had to stay at the hospital for a couple days, but he was just fine. Unfortunately, not all my patients had happy endings.

The view on my ride along

     I worked three codes during my overnight shifts. Two were only an hour or so apart. None of them survived. It was the first time I had actually watched a patient die. I'd come close during my last day of my surgery rotation when one of my patients requested to be put on care measures only after contracting an infection, but if she did pass, she did so after I was gone. This was different. The first patient had arrived in the ED in bad shape after an overdose, but still very much alive. Once his lab work came back though, it was clear that he was not a simple case of administering naloxone and observing until better. A lactate level of 4 mmol/L (typically the highest level mentioned in most studies of lactate levels) is 55% sensitive and 91% specific for death in the next 3 days. This patient's level was 15 mmol/L. Within a few hours of arriving, he went into cardiac arrest. I ran into the room, joined the rotation for chest compression, and was shocked at how pale, blue, and still he looked. Minute after minute everyone worked, administering medications, performing compressions, and delivering shocks. Nothing helped. An ultrasound machine was brought in and we paused long enough to stare at his heart as it appeared on the monitor. Nothing moved. We tried a bit longer, but eventually the doctor told me to stop compressions, felt for a pulse, and declared the time of death. The patient's family, who had chosen to stay in the room and watch, were composed and graceful as they thanked us all for doing everything we could and then said their goodbyes. I went back to my desk and stood there, my hands shaking, as I tried to compose myself and process what had just happened. A friendly tech brought me a cup of water and told me I'd done well. When, after a few minutes, I was ready to face other people again, the doctor who'd run the code asked me if I had any questions and kindly walked me through the events of the night. I am so grateful to that tech and that doctor. I needed a bit of kindness and gentleness to get me through the shocks and experiences of that first code, and less than 5-10 minutes was enough time to get me functioning like normal again. It had to be. The ED was packed that night, so there were still more patients to see, and, though I didn't know it at the time, in less than 2 hours I would once again find myself performing CPR. That time it was an elderly woman who'd fallen and hit her head. Though her heart seemed healthy, we lost her as well because we could not fix the damage to her brain. The next night I was part of another code, and, once again, was asked to stop compressions and step back so that a time of death could be called. 
     It sounds sort of horrible to say it, but the codes became easier. Already by the second one I was used to the routine and rhythm and could perform my role without having to continually remind myself to focus on my compressions rather than being distracted by my patient's face. I also learned how to recover. You had to. One can't have a mini-breakdown after each rough case because there's always another patient counting on you. So I learned to get some water and take some deep breaths, as well as pick an easy or pleasant patient to see next, if I had a choice. Letting a 3-year-old with pneumonia play with my stethoscope was a welcome change after hearing agonal breaths, and an injured toe seemed an easy fix after watching a heart monitor show asystole. 
     I don't wish to leave this post on a low note. The truth is that the vast majority of the patients I saw did just fine, and these codes only occurred on my overnight shifts. My fast track shifts were full of sprains, lacerations, and fractures, so I had plenty of practice suturing, stapling, splinting, and performing orthopedic exams. Patients in the pediatric department could pull at your heartstrings, but the good news was that pediatric patients tend to bounce back quickly, and once their diagnosis was determined and treatment was started, the parents often needed more care and reassurance than the patients. Yes, the patients in the main ED on my day time shifts could be serious, and I still wish that I had been wrong the first time I correctly made a complicated diagnosis (a small bowel obstruction caused by an incarcerated hernia in a patient with a massive ovarian tumor), but, for the most part, my patients were treated and returned home to their normal lives. In the end, the lives of me and my patients only intersected briefly, and these encounters could be terrifying or frustrating, but for those hours I had the chance to meet an immediate problem and do something to fix it, and that is a wonderful thing. 

*Light, Richard W. Primary Spontaneous Pneumothorax. In: UpToDate, Polly E Parsons (Ed), UpToDate, Waltham, MA. (Accessed on October 22, 2015.

**Noppen M, De Keukeleire T, Pneumothorax. Respiration 2008;76:121-127