Get Busy Living

I will never forget the elderly lady in room 9. At 90 years-old Mrs. S had been living 2 months from hell. She had come to the Emergency Department because she had fallen at home, and was unable to walk-her “hip was killing her.” The month prior she had lost her husband of 70 years-count them… 70 years. One week after that she was walking outside, had fallen, and landed on her face, rupturing her eye ball, losing her teeth, and breaking her nose. On the fourth of July an errant bottle rocket deployed on the roof of her house catching it on fire. Two days ago, her dog “Mr. Fluffs” had been stolen out of her car at the mall. And now this.

When I walked into the examination room I was surprised to find a spry, witty, energetic woman sitting on the bed reading a “People Magazine.” She had explained to me in great detail, the events of her life over the past 2 months, interjected with a magical spark of energy, and candor which could only be generated by a woman her age. She described the events of how she fell-quite simple compared to the last 5 tragedies- “You see, I was walking from the living room to the kitchen, and I tripped over one of Mr. Fluffs toys." Oh, the irony-my heart sank.

After examining her, I realized how serious her injury was: her hip was very deformed, her leg cocked outward, and rotated, which made me suspect immediately that she had fractured it. At the time I told her that we were going to get an X-Ray, the Emergency Room became tremendously busy-as can happen in a Trauma Center. There had been a car wreck and 4 critical patients were coming to Stanford. This can grind the busy pace of the Emergency Room to a halt-suddenly the name of the game becomes “triage”: helping those in need who might die…first.

Our help was summoned to the trauma bay. At this point as an Emergency Room Resident your job becomes something of a juggling act-you need to help the sickest of the sick first, but be mindful of the other 6 patients you are treating as well. After an hour of trying to stabilize the trauma patients, and running back and forth from my other patient’s rooms-looking up lab results, x-rays, and seeing if the treatments we had given them were working, some (with the exception of Mrs. S) had become understandably restless, hungry, tired, and irritable. Although most understood that we were very busy and that I was trying to treat them as quickly as possible, the 25 year-old College Student, who had an ear ache in the room next to Mrs. S, had started yelling and bemoaning that he “had to wait 30 minutes!!!” I had explained to him that this was an Emergency Room, and unfortunately when very sick patients need our help, we need to tend to them first-this was of no consolation, and only fanned the flames.

I left the room to get him his prescription for Motrin, and realized that Mrs. S’s X-Ray was back: she had a badly fractured left hip and was going to need surgery-if she wanted it. I walked in the room, she was reading her People, she looked up at me and I told her the news…. “Isn’t this the *@%&!!!” she replied, with a huge grin, missing one eye, 5 teeth, and let out a loud infectious cackle. I laughed with her. I could not believe her infallible spirit-after everything she had been through-after all of the loss.

Meanwhile, the 25 year-old next door continued to yell, this time threatening “to sue us all.” I was struck by the contrast of the situation-the impatience, the lack of putting others ahead of your own needs... for just 30 minutes, a woman with a possible life-ending injury laughing in the face of adversity. How did Mrs. S. display such grace under fire? How do people like her maintain that attitude and spark for life-the notion that “nothing is going to bring me down”, even when things are at there worst?

I asked her, the response was elegant: “You cannot change the past, so there ain’t no use complaining, and there ain’t nothing a smile or a good laugh won’t fix-call the surgeons, I have more life to live.”

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End of Life Choices

Every day in the emergency department I work hard to cure disease and save people's lives. When patients come through the emergency department we start with the assumption that they wish to have all appropriate interventions that could save their lives. Often we are faced with an unresponsive patient, either from illness or trauma, who is unable to convey these wishes, so we aggressively try to keep the patient alive as long as possible.

A couple of months ago I had the opportunity to see a patient who made a different choice. It was the mother of a dear friend of mine who was terminally ill with metastatic cancer. My friend knocked on my door at one a.m. and took me to see his mother, M. "She's not breathing" was all he said.

This was not an unexpected development. I had known that M. was close to death for a couple of days, from conversations with my friend. Her devoted husband had cared for her in their home for over a year, and just a few weeks prior she had made her wishes clear: no more hospitals. The whole family entered the foreign realm of a "hospice" family where they were provided with home nursing care, counseling for the immediate family members, and a variety of services to help them prepare for the inevitable passing of their beloved matriarch. She had been kept comfortable in her home up to this time, with medicine for her nausea, pain, and difficulty sleeping.

I entered the bedroom of my friend's mother and found her lying peacefully with her husband sitting next to her bed, holding her head. According to her wishes, she had passed peacefully in the comfort of her own home. Her husband told me about the past couple of days, and how he had been in constant communication with hospice nurses about how to best care for her and keep her comfortable in her final days. I admired his bravery as he watched his wife of fifty-one years pass, and according to her wishes had not sought medical intervention. It was only now that he wanted my help, to confirm what he and his son knew, M. had died.

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Several days ago a seventy eight year old man came to the emergency department unresponsive after a seizure. A CT scan showed that his lung cancer had now spread to his brain. To keep him on the earth we would likely have to put a breathing tube down his airway and put him on a ventilator because he was not able to protect his own airway and therefore unable to exchange oxygen and carbon dioxide. His wife was unaware of his wishes - and it saddened me to see the position she was now in, being asked to decide if her husband would want to be placed on a ventilator knowing that his cancer had spread and he would likely die from his disease. He was unconscious and had not had the opportunity to learn that his cancer had spread, and to make plans for the future.

It is important for people to let a family member know under what circumstances they would not want further medical intervention. There are many important factors that go into this decision and it is different for every person. As a physician, while I am sometimes surprised at the choices people make, I need to know these choices so I can honor them. When people are unable to speak for themselves we turn to those who know them and love them to speak for them, and it is easier for these people when they don't have to guess what interventions their loved one would want.

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Breaking Falls

This month it is my job to cover orthopedic injuries at the San Francisco General Hospital. Some of the stories are extraordinary and interesting like the bullet lodged in a femur that required a 3 hour operation for extraction or a police chase where the suspect jumped two adjacent buildings and subsequently fell 30 feet to break several bones. Instead of focusing on these I will describe something more mundane but much more likely to happen to us: a simple fall from a standing position. It is worth mentioning because it happens often, it leads to fractures and disability, and most people can improve on their falls.

My first reaction when I lose my balance and head toward the ground is to extend my arms and stop the ground from hitting me. In emergency medicine we call this a FOOSH—fall on out stretched hand. According to Newton’s second law of motion the acceleration of gravity multiplied by my mass generates a force that is transmitted entirely through the area of my hand, to my wrist, which includes the metacarpal bones, and through my radius and ulna—the bones in my forearm. Because all the force is transmitted through a small area and a rigid arm, it stresses the bone beyond its tensile strength and leads to a fracture.

The experts in falling—sky divers and paratroopers—have developed a technique to minimize injury during falls called the parachute landing fall (PLF). The principle behind the PLF is to distribute the force over a greater area by creating more points of contact between the ground and the body than an out stretched hand. Also by staying less rigid and thereby reducing the force directed through any given bone, the tensile strength is less likely to be exceeded. And by translating some of the force into angular momentum through a roll, even more force can be dissipated.

After seeing so many people splinted this month for fractures, I suggest--instead of stopping the ground from hitting you by extending out your arms--tyring to slow down your fall and sharing the blow with other parts of your body besides just the palm of your hand (but maybe not including the head). To do this I would let my lower leg contact the ground first, followed by my thigh, and my torso while covering my head with my arms. With over 5 points of contact the force would be more evenly distributed and by rolling afterwards each point would feel less force.

Have any of you skydivers reading this changed their falling mechanics, and what was your experience? I just tried it and it wasn't so bad.

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Introduction to Sean Donahue, DO

I am a 33 year old Colorado Native currently pursuing my second Residency in Emergency Medicine at the Stanford/Kaiser Program in Palo Alto, California. My journey through medicine has been long, varied, and filled with fortuitous events which inevitably shaped my path.

I first experienced medicine when I was 6 years old and I visited patients with my father in the hospital. He was an Internist for 33 years and to this day remains my greatest inspiration. His dedication to his work and the quality relationships he forged with his patients was the impetus for pursuing my own medical career. I received my Undergraduate degree in Biology from the University of Colorado at Boulder. While traveling down the road to Medicine, I also worked as a landscaper, housepainter and biologist. Finally, I worked as an EMT for 4 years before hitting the books again in medical school.

In 1998, I met a wise, incredibly compassionate 80 year-old Physician mentor who opened my eyes to the world of Osteopathy. He told me about a school where “you learn how to treat people as humans not as subjects.” After seeing his enthusiasm and hearing about his philosophy regarding medicine, I was sold. Shortly thereafter I was accepted to Des Moines University in Des Moines, Iowa. As a testament to the strengths of DMU, 85% of my class chose careers in Primary Care (Family Medicine, Internal Medicine, Obstetrics, and Pediatrics), and nearly 30% went on to work in rural and underserved areas; an anomaly in today’s world of Medical education.

In 2003, I started my first Residency in Family Medicine at the Mayo Clinic in Arizona. After completing this program I was Board Certified in Family Medicine. Most Physicians find one Residency to be more than sufficient (not to mention arduous and costly.) For me, the additional education of a second Residency was the next logical step (or a totally masochistic move depending on who you talk to) towards becoming the type of well-rounded doctor I have always hoped to be.

To me, Emergency Medicine is a natural extension of Family Medicine: in both fields you treat individuals of all ages with a variety of medical problems. My interest in pursuing additional training in Emergency Medicine was sparked after taking several International Medical trips to Eastern and Sub-Saharan Africa. There I was able to put my training in Family Medicine to excellent use, but I wanted more experience in caring for trauma victims and other medical emergencies.

As an Emergency Medicine Physician, you play an integral part in your community: you are always there for those in need, and at times are the last bastion of hope for those seeking medical care. Being an Emergency Medicine Resident is truly the “toughest job you will ever love.” You are often pushed to the brink of mental, physical, and spiritual limits. Every shift is different, and you never know what is going to come through the door.

Happily I have the support of my wife, Megan, of 7 years who stays at home with our 5 month old son, Sean Lawrence. In our free time we love to camp, hike, ski/snowboard and travel!! We hope to continue to combine our love of travel and service by completing at least one International Medical trip a year.

Through these writings, I hope to convey to you as honestly as possible real life experiences from inside a busy Emergency Department. I welcome your comments and questions and look forward to sharing this journey with you.

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Introducing Claire

Hi, my name is Claire and I am finishing my first year as a resident in Emergency Medicine at Stanford. I am excited about this opportunity to share my experiences as a physician, and to share my experiences with my patients.

It was after graduating from college that I first entertained the idea of a career in medicine. None of my post-college positions had been quite right for me and after dissecting out what I liked about each job I realized I was looking for a career which provided intellectual challenge, the opportunity to directly impact the lives of individuals, and work that made a difference.

I took my premedical classes at Goucher College in Towson, Maryland, a fantastic one-year program for people with at least a bachelor's degree who want to pursue a career in medicine. Upon completion of my premedical requirements I was off to Vanderbilt University for medical school. I enjoyed my clinical experiences tremendously and as graduation grew near I made the decision to pursue a career in Emergency Medicine.

My favorite part of this job is mystery and intrigue of being the first person to encounter a patient with a new medical problem or complaint that they have decided is too emergent to wait for routing medical care. It has provided me with great challenges and has humbled me on more than one occasion. It is a privilege to be the first physician to evaluate a new complaint, and in the emergency department I do this many times every day.

The team environment in the emergency department is a valued component of this career. I have always been drawn to team activities, from team tennis to ultimate Frisbee. The team environment that I found in the emergency department fulfilled my desire to continue to work with others in pursuit of a common goal.

The field of emergency medicine will require me to be a lifelong student of medicine. I have found that in addition to the intellectual challenges of diagnosis and treatment, I have also enjoyed learning a variety of diagnostic and therapeutic procedural skills. I enjoy the patient population that frequents the emergency department. I am excited to be surrounded by colleagues who are excited by the same clinical challenges and curiosities. I am excited to be continuing my training at Stanford, and I look forward to building a career in emergency medicine.

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Stepping Back

Since I will be contributing to this blog in the future I thought it might be useful to provide more of an introduction. I suspect my colleagues and fellow bloggers will do so shortly. As I mentioned in my previous post, I am a first year resident at the Stanford-Kaiser Emergency Medicine program. This means that I am still uncomfortable with being called Dr. Menon. I am still unsure if that will change in two months when I become a second year resident this June. Our program is a 3 year program, providing a short but intense immersion into emergency medicine.

My first introduction to emergency medicine came by way of a procedures course in medical school. After practicing intubation and drawing arterial blood gases (ABG) my curiosity was more than piqued. That interest quickly solidified into a passion after a spending a month in the ED as a medical student and working as the hour flew by unnoticed. It was the broad base of clinical problems, the added mixture of procedures, the general applicability of emergency medicine, and of course the excitement and chaos that attracted me to this field. It seemed like the easiest way I could help people and something I could do anytime and anywhere. So far, I'm happy with that decision.

When I am not in the ER I spend my time with the people around me, or flight instructing in the bay area, or playing basketball versus 20 year-old students at the Stanford gym (while trying to preserve my meniscus). I've never had much money but what little I have had I spent on traveling. I'm not sure if that qualifies as an addiction.

I hope to combine my interests in the future and practice emergency medicine oversees or in the vein of aerospace medicine by working with NASA.

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