It’s Not Easy Being Green
I wrote this piece in 2002, and it was published in the medical school literary magazine where I did my residency. As I mentioned in my last post, I have hundreds of journal entries and essays like this one. Geez, I used a lot of medical jargon! I’m experimenting with keeping the original writing relatively intact, and just footnoting the medical-ese (with a fair amount of snarky editorializing). Here we go:
The city hospital emergency room on a slamming Friday morning, my intern year:
I walked in with my coffee, and my “Good morning!” was immediately followed by “Good God!”
What with the light cold drizzle after days of subzero temps, people were slipping and falling all over the place, and there was a pileup on Route 95. The dry-erase patient assignment board was jammed with multiple cases of “s/p MVC1” and “s/p fall”. The noise level was more Saturday night than weekday morning. The stretchers extended far back into the dark recesses of the hallways. I sighed, hid my breakfast in a corner behind a computer monitor, downed my coffee, and got to work.
I wandered, trying to find the first patient on my list, who per the board was supposed to be on the ‘stretcher near Side B broom closet’:
“Are you Mr. Garcia.?… Are you Mr. Garcia? ”
Then, I learned that no curtained cubicles were even temporarily available. How the nurses rolled their eyes at me when I objected:
“What, I have to do a physical exam in the hallway?” How naïve of me to think that we could offer anyone some privacy or dignity. “Lo siento Señor Garcia, Hay que examinar el testículo doloroso aquí en el pasillo…”2
One could argue that the emergency room was not an environment conducive to practicing empathy or encountering kindness. But I found it there, even me, running breathless, green and inefficient.
I remember Mr. Murphy, 91 years old and lucid. To be honest, he was more alert and oriented than I was. But he was unable to see: both of his eyes were cherry-Jello-red, the lower lids hanging loose and spilling over wet green goop. Poor Mr. Murphy, living alone, valiantly and tentatively hanging on to his independence. There he was, on the busiest morning I could possibly imagine… and he was stuck with me for a doctor.
I didn’t get to him right away. At 7:30 am signout I inherited three other patients, all to be discharged, priorities priorities, rush rush them out. I made many phone calls, filled out and signed many many papers. Then I took a quick peek at the board: I needed to see all the patients whose names were written in purple, and there were three purple names I hadn’t seen yet, with chief complaints “s/p MVC”, “weakness“, and “hypoxia“3. Mr. Murphy was up there, under “hypoxia“.
Imagine my confusion at the sight of those Christmas eyes, cherry red and dripping green, and the chart declaring an oxygen saturation 89% on room air4. Mr. Murphy was a polite gentleman, and offered me his hand though he couldn’t see me at all. He told his story, using phrases like “Based on the evidence I can’t see, I suspect this is a rampant blepharitis”5 and “My cardiac history reads like a novel, dear, you’d best speak to the author, my cardiologist”. In between sentences he coughed up great green wads of smelly sputum that I caught in a specimen cup and sent off to the lab. The microbiology eventually came back: gram negative rods in abundance6. Ah! Obviously a bacterial pneumonia. I thought I had made the important diagnosis. Rampant bacteria, all right. Give the man some Zosyn7.
But no, no no. Woman makes plans, and God laughs.
While we were running around clearing c-spines8 and seeing not one, but two elderly ladies s/p fall with new and very painful osteoporotic vertebral compression fractures9, and then chasing and capturing the demented and delusional woman with BP 216/10610 who kept trying to escape- while we were doing all this, Mr. Murphy had a chest x-ray. It showed (in the words of the radiology resident) “flagrant and severe CHF11, maybe an opacity in the left lower lobe representing a superimposed pneumonia”. Now he had not two, but three major diagnoses. And I had missed it.
By now, it was 1 pm. There is a rule in the ER, I have found, that states: “Only when you are extremely busy and therefore behind with a certain patient will a family member show up asking detailed questions about that exact patient.” I had finished the painful task of booking my osteoporotic ladies– sweet dears, lots of hand-holding and morphine. Then I had to translate for the admitting team for Mrs. R. from Puerto Rico, thinking, Why doesn’t everyone speak Spanish?
After this, I finally got a chance to catch up on Mr. Murphy’s admission paperwork, and there I was, standing up, on hold on the phone, about to spoon a mouthful of yogurt into my desperately hungry mouth- Only then did Mr. Murphy’s daughter show up. She was professionally dressed, cell phone in hand, and absolutely irate.
“Why hasn’t my father been seen by the ophthalmologists? Why hasn’t he been given any food? He’s been here since 7:30 this morning. What kind of institution is this, anyway?” etc. etc., and all directed at me.
Ophtho had been called hours earlier, there were no food trays to be had anywhere for anyone, and there were two new patients to see: a purple “N+V“12 and another “s/p MVC“. Plus more booking paperwork, plus I hadn’t eaten. I uttered a quiet *help* from me to no one.
I put another phone call through to ophtho- “Please speak to this patient’s daughter!” But no, they were “On the way, no worries”. A half hour later there they were, thank goodness, demanding “Get this gentleman into the eye room.” One less patient to watch over, at least for a while.
Running, running, 3 p.m. I was still trying to eat my breakfast yogurt when Mr. Murphy’s daughter appeared over the counter, demanding that someone help get her father from the ophtho chair to the stretcher: “Do you expect me to do it myself? God, this place,” she swore.
Thank God for Mike the nurse, my hero of the day, always on top of everything before I was. Between us we lifted a very tall and quite heavy Mr. Murphy to his feet, all of us attempting to keep his backside covered, but him ending up shuffling across the floor with the johnny open down the back anyway. I wanted to say, It’s OK, we’ve all seen naked patients before, but what does it matter? I’d be covering my backside too.
Then, as Mike the nurse went to magically find a tray for this famished man, I sat with Mr. Murphy and took a minute to talk with this gentleman. I asked him what he did before he retired. “I was a bookie, dear, and quite a good one.” Really? “No, actually I was in real estate, here in town.” Mr. Murphy made jokes, made me laugh, even as he hacked. I wiped his poor goopy face.
A couple of hours of paperwork and many phone calls later, Mr. Murphy was all set to go up to the floor. But the charge nurse came up to me, said: “Do you know Mr. Murphy needs to be booked to a telemetry13 bed?”
“No, he doesn’t”, I maintained.
“Yes, he does”, she asserted, and pointed to the computer: Troponin level: 0.314 .
The troponin level was elevated. Had we missed a heart attack? The result had come back five hours previously, and I hadn’t even thought to look it up. I panicked and started flipping through the chart for the ECG15 done at admission, and there it was: ST depressions in leads V4-V616.
I placed a shaky call to the cardiologist, who not only picked up the call quickly but also was thankfully matter-of-fact. He pointed out that the elevated troponin level was more likely just a “leak” from his stressed-out heart, rather than a full-blown MI17. Still, no way to be sure without careful monitoring going forward. So now Mr. Murphy was also “r/o MI”18. Major diagnosis #4. We lost the floor bed and he had to be re-booked, which would take hours. It was 6 p.m., this patient had been here for over twelve hours, and there were no monitor beds in-house. Standing up in clogs this whole time, dehydrated, starving, doing a bad job, my head hurt.
I went over to Mr. Murphy to tell him the news, dreading the phone call to his daughter. I took his hand, and told him the turn of events. He just smiled up at me blindly. “It’s alright, dear. I’ve waited all day, I can wait a bit more. It’s not your fault, certainly.” But it is, it is, I wanted to scream. As if he’d read my mind he grasped my hand tightly, and said: “It’s your job to care about people, and you’re doing your job. The rest will come with time.”
I thought I might cry. “Thank you for saying that, sir,” I said, and squeezed his hand back. And the whole hectic scene blurred, it was like the whole ER was quiet, I couldn’t hear anything, and Mr. Murphy still couldn’t see anything, we were in our own little world, for just a few seconds, both grateful for a warm hand and kind words.
7:30 p.m., end of shift, but I had piles of charting to do, labs to follow up, calls to make. The admitting team came down to see Mr. Murphy. I knew the intern: “Thank Goodness you’re here, Please take care of this man!” I joked with my colleague, thinking to myself, Please do a better job than I did.
But at almost 10 p.m., as I fairly ran through the parking garage and then drove madly through the rain, I felt alright. Not light and happy, but just absolutely full. Satisfied, in a strange way. I’m learning. I’m green but I’m learning. And I’m often lost and overwhelmed, but at least I can try to be a friend to these people; and sometimes they can be a friend to me.
- s/p MVC = status post motor vehicle crash. “Status post” is used a whole lot in medicine-speak, especially referring to surgery, like “s/p appendectomy”.
- “I’m sorry Mr. Garcia, We’re going to have to examine that painful testicle here in the hallway…”
- Hypoxia = low oxygen level
- Oxygen saturation 89% on room air = basically he was getting a B+ on oxygenating himself, when normal is an A+. Humans really should be getting all A+ grades when it comes to oxygenation. This guy must have had supplemental oxygen running in by nasal cannula but I never mention it.
- Blepharitis = Inflammation along the eyelid, and most definitely not what this guy had. He more likely had a bacterial conjunctivitis, probably with the same organisms that were invading his lungs.
- Gram negative rods = bacteria that should never be hanging out in someone’s lungs. In his case he probably had a history of smoking and emphysema which made him susceptible, and the bacteria was probably something like haemophilus influenza or klebsiella pneumoniae.
- Zosyn was the brand name for the combination super-penicillin piperacillin-tazobactam, which is what one might have used for the bacteria mentioned above, if you could convince the infectious disease consult fellow in charge of the antibiotic formulary that the patient was worthy enough to receive it. The use of superdrugs like these was pretty closely monitored so as to prevent wanton overuse and subsequent antibiotic resistance. Didn’t work, though.
- Clearing c-spines = Making sure someone doesn’t have a cervical spinal fracture. When someone is in a bad car accident, the ambulance guys place a stiff c-spine collar around their neck to stabilize them until it’s clear that they don’t have a fracture. Because if there was and they were allowed to flop their heads around they’d end up paralyzed. We “cleared” them by removing the collar and most times just asking questions while pressing around on the backs of their necks. If it was iffy, off they went to CT scan.
- osteoporotic vertebral compression fractures = what it sounds like, really. Older folks with brittle bones from osteoporosis who slip and fall can end up with cracked vertebrae (bones of the spine). It’s really painful and there’s not much you can do for them apart from pain medication and physical therapy. This is why good nutrition and loads of walking and running all throughout life is really really important.
- BP 216/106 = Really really high blood pressure.
- CHF = Congestive heart failure. His heart wasn’t pumping strong enough to push the blood through his body and fluid was therefore backing up into his lungs.
- N+V = nausea and vomiting
- Telemetry bed = A special situation where the patient can be hooked up to a continual electrocardiogram, and the readout monitored at the nurses’ station. An arrhythmia automatically triggers an alarm. Which seems like a great idea, until you realize that every time the patient sneezes or rolls over or tries to use the bedside commode the readout jumps around and the alarms go off. This happens so often that no one really listens to the alarms anymore. (This is real, it’s called “alarm fatigue”.)
- Troponin level of 0.3 = Elevated enough to worry about but not a slam-dunk high enough to make a diagnosis.
- Electrocardiogram, duh.
- ST depression in leads V4-V6 = a pattern on the ECG that can mean a lot of things, including perhaps a heart attack, but in this guy it more likely meant his heart was stressed by everything going on in his body. (A real internist would go on and on about it but I’m going to leave it at that.)
- MI = myocardial infarction, the medically correct term for a heart attack. There’s a whole big pathophysiological explanation for the words that gets down to what’s happening at the cellular level but whatever.
- r/o MI = rule out myocardial infarction. “r/o MI” is a very popular diagnosis for admission to an ER or hospital, mostly because “missed MI” is a very popular reason for malpractice lawsuits.