Thursday, May 31, 2007

I feel like this story needs a visual demonstration.
Picture this: very small, very cute hippie lady sitting in a bed in the ICU. She's chugging down chocolate pudding, I'm standing next to her with the suction tube, pulling all of it out of her tracheostomy tube. Ok not such a pretty picture. But now you understand what aspiration is. Instead of going the right way, into the esophagus, it goes forward the wrong way, into the windpipe. And if they have a trach in, I end up pulling it all out of their windpipe before it falls into the lungs and rots.

Here's a prettier picture.
This is Gus. Gus has been living inside my/Sam's cupboard for the past few months. Sam, look how Gus has grown! I'm actually so busy gawking at your mutant onions that I've forgotten to water your real plant. Don't worry, it's not dead yet.

Tuesday, May 29, 2007

I was right. Unfortunately.
All hell broke loose in the ER; this week is going to be a busy one. We coded purple today: no new admittances to emergency because all beds were full and all staff, including on-call, were working. It was mayhem. There were codes called every other hour, either cardiac arrest or respiratory failure. The rotation through the rescue bays were brisk.
Sadly, it was the chaplain who was the most busy, praying over and comforting families who were shocked and in grief from sudden and unforseen tragedy. In ER, this is the reality. People do die and we need to be ready to move right on to the next patient.
I felt stuck at one point during this day. Stuck on a patient who seemed to be perfectly fine, who'd walked into the ER with his coat over one arm. A little apprehensive-looking but walking erect and hadn't come in on a stretcher. So given the present circumstances in Emergency, you can understand the slight frustration I had in encountering this patient. Frustration especially at attending physician who had written me the consult. His chief complaint was completely ridiculous: he complained of choking on milk in the middle of the night. No other complains. No pain, no trouble eating during the day, nothing. I almost left him right there in the examining room. I ran through my history-taking interview, did my routine checks, tried all food consistencies (even milk!) on him: no coughing, no choking, no voice change. By then I felt like I was wasting my time doing absolutely nothing with the perfectly healthy-looking man. Just for kicks I decided to do a test in radiology, a modified barium swallow, before I wrote up the paperwork to discharge him. I ran to the attending MD, did some mad venting, then got the requisition and ran the test.
And I found a hernia. A paraesophageal hernia of the stomach that his stomach acid was refluxing into. Apply some pressure, get a rupture and the gastic acid would have filled the abdominal cavity, leading to damage of major organs and even death.
He's going for surgery tomorrow.

Moral of the story: Patience, thorough clinical care, and go to ER when you're choking on milk in the middle of the night.

Wednesday, May 23, 2007

Things feel strange this week.
ER is eerily calm. The beds in the hallway are empty. The rescue bays are empty. Subacute is quiet. The only patients I had consults for today were a left leg hematoma and a chronic ALS (amyotropic lateral sclerosis) patient being transferred to MNI (Montreal Neurological Institute).
ICU is not much different. Quick in and out problems that resolve themselves. Beds are empty.
Two patients coded on the floor today. Crash carts came in and out. One lived, one didn't. Otherwise, the floor was silent.
I'm getting a feeling of "inquietitude", like this is the calm before the storm.
Something is about to happen.

Thursday, May 17, 2007

Often, things are not as they seem.
As an OT, one of my responsibilites is to make sure my patients can swallow their food and their meds and that all this goes down the right tube and into the stomach. We look for the telltale signs of aspiration, or food going into the lungs, such as coughing, voice change, and lack of a swallow reflex. We then proceed to make recommendations based on our observations. Too much food going down the wrong way, into the lungs, and that'll cause necrosis, granulation of lung tisse or infection (pneumonia).
However, people can be silent aspirators and this is where it gets complicated. Some people, because of decreased sensation or cognition, don't cough or choke on their food as it slides into their lungs and show no signs of aspiration. These are people who inhale their food, literally. As was the case with one of my patients this afternoon.
I don't know what tipped me off but for some reason, some suspicion, I requested a test in radiology for this patient. As I said, he ate well, but something rubbed me the wrong way. As soon as the test began, my eyes were glued to the screen in utter amazement as half of whatever he swallowed travelled into his windpipe and down to his lungs. Swallow after swallow, half into the stomach, half into the lungs; it was like he was drowning in his food. And of course, there he was, sitting amicably in the testing cubicle, happily eating away. It was the hardest thing to tell the patient and his family that his food was going into his lungs and not his stomach and that we'd have to put a tube in him to feed him.
So many times, things are not what they seem.

Monday, May 14, 2007

Work today was busy, and I was getting irritated because...well there's so much to do and not enough time. And people were not always the most polite but considering some of them work 18 hour shifts, I guess that could be excused. I also get very grumpy when I'm tired. My own temper was starting to rise around 3 pm when I still had 4 consults on my plate and the local attending physician was happily doling out more.
Then I met Mr. V.
He was on one of my consults and I went in reluctantly, silently urging him to swallow everything I give him so I can clear him for DAT (diet as tolerated). I'd hear rumours about him too, from the nurses and the physio...about him being agitated and aggressive, kind of confused. He had hx (history) of drug abuse and was homeless and suicidal, had tried to bite the nurses that attended to him and kept on spitting at people, which is never good when you're Hep C +ve. You can imagine my state of mind when I walked into that room.
But as I introduced myself as the occupational therapist and started talking to him, I realized that we clicked. It was so tangible that you could almost hear the audible snap. You know when you see something in someone, something special? I saw something in this man. Past the aggression and the anxiety there was a decent human being. Quirky personality for sure, but workable. My supervisor says this, "He's the one at the wheel and I don't want to be in that car". Well, I think I can take the wheel.
Do you ever experience that? Some people are hard to love. We all know people like that, I bet someone pops to mind right away. But if you get past the outer crust, you find something, be it a depth of personality, a character trait, a common interest, that piques your appreciation. Sometimes they turn out to be people you never expected them to be.
My next move with Mr. V is to find out how someone who is wheelchair-bound is able to throw himself in front of a car.

Friday, May 11, 2007

People tell you that life experiences will make lines blur.
This has never been truer for me than in the hospital setting. Sometimes the line is just a wide grey streak that runs down the middle of the page. Indiscernable.
Two of my patients died this week. Or call it what you like. Diseased. Passed away. Moved on. They no longer exist as people on this earth. As health professionals who are faced with this tragedy weekly or daily, we find ways to cope. Sometimes it's morbid jokes ("I have a lighter caseload today; more time for lunch"), sometimes it's reminiscing about their character ("Mrs. B was funny, and always stuck out her tongue when the nurses drew blood"). Most of the time though, we just quietly file the paperwork, send the chart off to Medical Records and forget about ever having seen the patient. And especially as therapists, we only track in our minds the ones that are candidates for evaluation and rehab. We work efficiently; no time to dwell on those we cannot help and heal.
How does the heart get so calloused? Since when have we regarded the loss of a human being as just another mundane occurance? We can call it a defense mechanism, or a coping strategy. But what does ethical compassion call for? Or even beyond the scope of ethics...in our ingrained concept of right and wrong, what feelings should this death evoke in us? And how do we deal with dying patients day in, day out without destroying out hearts with grief?

Mrs. B was funny. She always had a smile ready, even when her pleural effusion made it hard for her to breathe and gave her pain in her chest. She would always stick out her tongue in between her teeth when the nurses took blood because she hated the prick of the needle and the sight of her own blood draining into a vial. She never ate her mashed potatoes with gravy and defiantly tolerated solid foods, even when she had difficulty chewing and pushing down the food because of her decreased pharyngeal elevation. She never wanted us to NG tube her to help her eat. She was getting better. No one could have forseen the pulmonary embolism that killed her.
I wonder what happened to the heart-shaped pillow she always had on her bed.

Wednesday, May 9, 2007

What are the most important things in life?
More and more often I find myself questioning, examining and re-examining the activities, the committments and the ins and outs of daily life we take so for granted. Working in the ICU has doubled the frequency of my musings and has given me some startling reminders.
See, it's not the very sick ICU patients that are disturbing - one patient I saw today was on a respirator, had five EKG pads, one brachial arterial line, a few venous IV lines, a defibrillator, a foley catheter, NG feeding tube, and no less than four chest drains coming out of her. There isn't one more line we could have put into her to help her live. Yet she had family surrounding her bedside.
No, the most disturbing patients are those who are completely and utterly alone; sick and without family.
I wonder if they feel the loneliness and despair and hopelessness that I can imagine I would feel being in their place. I wonder if they ever long for visitors as they look on at their roomates' families and friends sitting at bedside. Sometimes I wonder if they are proud of their achievements and successes then. If they think back to the things they've done in life so far and smile fondly at their accomplishments. Do they feel that they've been a good person, that they've made a difference in the world or do they wish for a second chance at life?
Imagine being hooked up to tubes that breathe for you, eat for you, monitor your vitals and make your heart beat. What would life look like then?

Tuesday, May 8, 2007

Sometimes there is hope in madness.

Emergency has been crazy for most of the past week. Today was not an exception. It comes and goes in waves. A bit like the weather I guess; it's unpredictable. Sometimes it's so crazy that the doors close under the classification of a code purple, when even the rescue bays are full of sick and dying people. Usually someone is yelling. Or crying. There are anxious family members milling around, trying to figure out the CT scans and colonoscopies and workups and discharge for their loved ones. There are people sleeping, people arguing, curtains open and close, arguments escalade, tempers flare, nurses draw blood, orderlies wheel stretchers in and out, doctors with their stream of medical jargon - CVA, DM, SRCOA, CHF, NKDA, TKR...
I'm sitting in the middle of this, trying to shut out all the noise, to get my paperwork done, considering hiding in a linen closet to get some quiet when a lady starts to sing. She has this beautiful smooth voice. Calm, self-assured. And one by one, everyone falls silent. I think we were all shocked by this unfamiliar occurance. As health professionals, we like to think we know it all. And I think we're all struck by her courage. She's singing to her dying husband and it sings peace into our hearts.
We all turn back to our work, quietly, as she continues her song.
I sign my paperwork, grab my binder and head down to medical rounds and on my way, although I don't remember the words to the song, I'm glad that someone reminds us that even in the midst of the storm, a calm can be found.