It would seem we have survived another winter. Starting back in December I began crossing off each day as it schlepped by on my refrigerator calendar, aptly named "Countdown to the End of Winter." March 20 was happily circled and starred at the very bottom of the long and winding path: the first day of spring. Various other events were penciled in, like LAST WEEK OF FEBRUARY (pass go, collect $200) "45 degrees Fahrenheit!" (Boardwalk!) and BLIZZARD (Go To Jail). On March 20th, it was 27 degrees and blustery (Go BACK to Jail).
Moving forward, I look forward to sunshine, birdsong and daffodils blooming along the Charles. Perhaps I will gaze upon the multitude of rowers making their laborious way up and down the river whilst I try to concentrate on a gigantic volume of MCAT review lessons. Better yet, it is time I got back to people-watching, keeping a keen eye out for anything remotely curious and worth exaggerating when it comes time to retell. I've decided to avoid saturating my literary efforts with stories from my sinusoidally insane job. I call it this because of the daily fluctuation between heart-thumping terror and grinding monotony that it induces. The experience has been an amalgamation of overwhelming passion for learning, medicine, and life, as well as tear-producing boredom and belittlement. Nevertheless, having been the one pumping on a man's chest while his wife held his hand on the other side of the stretcher, among other happenings, has taught me something that I'm barely able to describe - something about the grave importance of effort and responsibility for others. More lessons in establishing Sincerity of Purpose, I suppose. Anyhow, I would hate to give anyone the false impression that I spend every day running around a earthly, halogen lit limbo, watching and engaging in the battle of human salvation that burns in every reach of the ER. In truth, I spend many hours traipsing around with urine cups and medical supplies to be stocked in the exam rooms. To be sure, the outside world is quite a bit more invigorating.* I have yet to see it though, recently, given my situation in trying to succeed in classes, getting my med school applications together, and fighting the eternal battle between life and death.**
In conclusion, I need to write, and I need to write about the subtle curiosities that everyone is able to understand and find in their own lives. Medical phenomena are inspiring, powerful and the love of my life, but not the best material for creativity. This is a right-brained exercise.
*Except for yesterday, when I irrigated a ball of wax the size of a large marble out of someone's ear all by myself. I FIXED A PERSON, and man was it a trip. Not kidding.
**HA.
Tuesday, March 24, 2009
Monday, February 9, 2009
Spitting the Same Color into the Snow
Today I brushed my teeth while walking down the sidewalk. I realized how much time had been wasted over the years, standing over the sink.
Saturday, January 24, 2009
Cancer Week
If ever you were to talk to someone who works in an ER, or say, ask about their day, they would first tell you either a) it was busy as hell or b) I finished three New York Times Thursday crossword puzzles! Second, they might follow with a comment likening to "it was cardiac day," "it was belly pain day," "infection day," "drunk-as-hell day," or "psycho day." The latter two actually tend to fall on nights, but prove that ailments in our city (and most others, from what I know), strike in eerily uniform waves. Sometimes this makes sense. New Year's Eve was the night of Drunks and Extreme Frostbite.* The day the stock market crashed with a magnitude not seen since October 29th, 1929 - that was White Guy with Heart Attack Day.
Today, friends, was busy as hell, a veritable zoo, and Cancer Day. More accurately, this week was Cancer Week.
To be honest, few things arouse genuine sadness for me in my job. This can be accounted for by the fact that most people who come to the ER are weenies. What's more, is that once they are in a stretcher, splayed out under the meager clothing-like offerings of the hospital gown, they become completely helpless. A person who may have ambled in because of a tummy ache one minute may be well on her way to landing a part in cable's next hot medical drama as soon as they realize there is someone being paid to take care of them. "Will you help me, please, to sip my water, nice lady? I am so weak, eeuuuggh!" The other day, a patient whom I had been translating for all day, after walking herself to the bathroom, stood up from the toilet and called out to me, demanding that I wipe her you-know-what.** This, my dear friends, is typical.
Nonetheless, Cancer Week has put me in a state of gloom that I have only rarely fallen into since beginning work in the ER. Running the risk of generalizing, I notice that the composure, state of health, mental health, and fragility of many cancer patients (and importantly, cancer patients who are currently in the Emergency Room) are all very much the same. We all know someone who has cancer, and may think of them as the most courageous, strong, and illuminating human being we know. This may well be correct for the majority of cancer patients. But, if you have a long history with the disease, and you find yourself in the ER for something as minor as a cough or a headache, you are scared. This week I met a patient with a thirteen year history of breast cancer that later spread to her lungs, and just last week was found to have spread to her brain. She came into the ER rather than her regularly scheduled chemotherapy infusion because of a sudden, inexplicable pain in her back. She writhed in pain and fear as I probed her with questions about her cancer. As I helped her change into a hospital gown, and placed the leads to the cardiac monitor on her chest, I could see a new tumor ulcerating out of her breast; it had grown so quickly it actually broke through the skin. The resident meekly asked what the lesion on her chest was. "It's tumor," she replied, between sobs. "And they're not even doing anything about it. What are they doing?" To think that her disease was so far progressed removing the enormous, voracious tumor in her breast wasn't even on this week's agenda (having been filled with chemo and irradiation of her brain, if I had to guess), was deeply saddening. I asked who her oncologist was, and it turned out to be a doctor whom I worked with in my former job in the Cancer Center. We waxed warmhearted about a woman whom I have always regarded as a mentor and role model, and whom our patient had been coming to for treatment and support for thirteen years. As we spoke adoringly of our mutual friend, she softened and started to straighten herself out a bit. That, friends, is the kind of doctor I want to be. I want patients to feel less pain - and I say this with utter seriousness - just by thinking about me. Anyone in the medical field is in a position to make people better by fighting disease and reconstructing health, but so few, from what I see, can do this simply through their words and demeanor. It must have been horrible for both the patient and her oncologist to have to postpone treatment of a new breast tumor, to pass the baton onto the neuro-oncologists and neurosurgeons while everyone could see her body degrading in plain sight. But, that patient knew that after thirteen years, her doctor was still doing right by her, and she had every reason to believe that she was as important to her doctor as on that very first, horrible day.
That patient ended up having some fluid on her lung, which was causing the stabbing pain in her upper back. It was treated and she was feeling better within a day, but knowing the eventual end of this story yet to come, I am still emotionally tender. It didn't help that for the rest of the week, and especially today, the names of people I used to cycle through the Cancer Center's database kept popping up on the ER board, citing things like "fever," "general weakness," "nausea/vomiting/diarrhea," as chief complaints. I changed and dressed them, talked to them about the wonderful staff up in the cancer center, avoided bruising the leukemia patients while bathing them, and listened garbled monologues about pain and swelling in the upper right part of someone's arm, interrupted by a remembrance of Jane Fonda, whose acting career was a wreck but she had the most gorgeous boyfriend! (According to her son, the patient spoke with only about "50% accuracy, at this point." They had been through it all, were scared as hell, and asked for nothing. It presented quite the change from the normal routine of having to remind people that they are well enough to fetch their own glass of water from the counter, or go to the bathroom by themselves.
Cancer Week was hard because it is impossible not to compare the suffering of random patients to that of those we love. We all have personal stories and losses, and the sadness inside of the exam room with an acute patient and their family inside is coldly familiar, at least on some level.
That isn't something would feel right about avoiding, I suppose, but it isn't a feeling I'd strive to achieve daily in my career. Being the doctor that heals through both medicine and shared humanity, though, is definitely a goal to be sought.
*From what I hear, there were over 30 drunks in our 30 bed ER. Keep in mind some of those are in the pediatric department, some are designated for finger sprains and ear infections and thus ill-equipped for patients with life-threatening conditions. To make a long, dramatic story short, the smell of vomit lingered in our barracks-turned observation room for a couple of days.
** I did not.
Today, friends, was busy as hell, a veritable zoo, and Cancer Day. More accurately, this week was Cancer Week.
To be honest, few things arouse genuine sadness for me in my job. This can be accounted for by the fact that most people who come to the ER are weenies. What's more, is that once they are in a stretcher, splayed out under the meager clothing-like offerings of the hospital gown, they become completely helpless. A person who may have ambled in because of a tummy ache one minute may be well on her way to landing a part in cable's next hot medical drama as soon as they realize there is someone being paid to take care of them. "Will you help me, please, to sip my water, nice lady? I am so weak, eeuuuggh!" The other day, a patient whom I had been translating for all day, after walking herself to the bathroom, stood up from the toilet and called out to me, demanding that I wipe her you-know-what.** This, my dear friends, is typical.
Nonetheless, Cancer Week has put me in a state of gloom that I have only rarely fallen into since beginning work in the ER. Running the risk of generalizing, I notice that the composure, state of health, mental health, and fragility of many cancer patients (and importantly, cancer patients who are currently in the Emergency Room) are all very much the same. We all know someone who has cancer, and may think of them as the most courageous, strong, and illuminating human being we know. This may well be correct for the majority of cancer patients. But, if you have a long history with the disease, and you find yourself in the ER for something as minor as a cough or a headache, you are scared. This week I met a patient with a thirteen year history of breast cancer that later spread to her lungs, and just last week was found to have spread to her brain. She came into the ER rather than her regularly scheduled chemotherapy infusion because of a sudden, inexplicable pain in her back. She writhed in pain and fear as I probed her with questions about her cancer. As I helped her change into a hospital gown, and placed the leads to the cardiac monitor on her chest, I could see a new tumor ulcerating out of her breast; it had grown so quickly it actually broke through the skin. The resident meekly asked what the lesion on her chest was. "It's tumor," she replied, between sobs. "And they're not even doing anything about it. What are they doing?" To think that her disease was so far progressed removing the enormous, voracious tumor in her breast wasn't even on this week's agenda (having been filled with chemo and irradiation of her brain, if I had to guess), was deeply saddening. I asked who her oncologist was, and it turned out to be a doctor whom I worked with in my former job in the Cancer Center. We waxed warmhearted about a woman whom I have always regarded as a mentor and role model, and whom our patient had been coming to for treatment and support for thirteen years. As we spoke adoringly of our mutual friend, she softened and started to straighten herself out a bit. That, friends, is the kind of doctor I want to be. I want patients to feel less pain - and I say this with utter seriousness - just by thinking about me. Anyone in the medical field is in a position to make people better by fighting disease and reconstructing health, but so few, from what I see, can do this simply through their words and demeanor. It must have been horrible for both the patient and her oncologist to have to postpone treatment of a new breast tumor, to pass the baton onto the neuro-oncologists and neurosurgeons while everyone could see her body degrading in plain sight. But, that patient knew that after thirteen years, her doctor was still doing right by her, and she had every reason to believe that she was as important to her doctor as on that very first, horrible day.
That patient ended up having some fluid on her lung, which was causing the stabbing pain in her upper back. It was treated and she was feeling better within a day, but knowing the eventual end of this story yet to come, I am still emotionally tender. It didn't help that for the rest of the week, and especially today, the names of people I used to cycle through the Cancer Center's database kept popping up on the ER board, citing things like "fever," "general weakness," "nausea/vomiting/diarrhea," as chief complaints. I changed and dressed them, talked to them about the wonderful staff up in the cancer center, avoided bruising the leukemia patients while bathing them, and listened garbled monologues about pain and swelling in the upper right part of someone's arm, interrupted by a remembrance of Jane Fonda, whose acting career was a wreck but she had the most gorgeous boyfriend! (According to her son, the patient spoke with only about "50% accuracy, at this point." They had been through it all, were scared as hell, and asked for nothing. It presented quite the change from the normal routine of having to remind people that they are well enough to fetch their own glass of water from the counter, or go to the bathroom by themselves.
Cancer Week was hard because it is impossible not to compare the suffering of random patients to that of those we love. We all have personal stories and losses, and the sadness inside of the exam room with an acute patient and their family inside is coldly familiar, at least on some level.
That isn't something would feel right about avoiding, I suppose, but it isn't a feeling I'd strive to achieve daily in my career. Being the doctor that heals through both medicine and shared humanity, though, is definitely a goal to be sought.
*From what I hear, there were over 30 drunks in our 30 bed ER. Keep in mind some of those are in the pediatric department, some are designated for finger sprains and ear infections and thus ill-equipped for patients with life-threatening conditions. To make a long, dramatic story short, the smell of vomit lingered in our barracks-turned observation room for a couple of days.
** I did not.
Saturday, January 10, 2009
17 degrees - not too shabby!
It's the time of year when I kick myself every morning for not having moved to southern California yet. Oh the times that would be had! Running dozens of miles every morning along the beach, feeling the sun throughout the day while walking from work to class to my beachfront cabin which I would be renting for pennies, walking my dog through the canyons, being watchful for rattlers and cacti, dodging Mexican gangsters with guns and cocaine in Tiujuana (oh wait they only kill cops), hanging Christmas lights on a palm tree...it all brings me back to my childhood, spent tricycling the walkways of married-student-housing at UCSD in La Jolla, smelling eucalyptus trees, avoiding the scary bird that the people downstairs kept as a pet.
I'm going to stop there, I'm afraid I'll just be headed more towards the deep end of the seasonal-depressive pool if I let my imagination roam much further.
I'm going to stop there, I'm afraid I'll just be headed more towards the deep end of the seasonal-depressive pool if I let my imagination roam much further.
Wednesday, December 31, 2008
New Year
Greetings, everyone, and happy New Year. We in Boston have the pleasure of starting 2009 with a raging blizzard, bound to be as dramatic as last week's blizzard, if not more. The ER was a zoo today, New Year's Eve, and tomorrow will likely be the same...a lot of shaking the sleeping drunks in the hallway beds awake, shouting "Despiertate! Ahorita, respira! Mas profundo!"*
Here is some news: I started doing "hot yoga" (formally, Bikram Yoga) in an effort to a) regain circulation to my extremities at least a few times a week b) become very stretchy and be able to balance on one foot, limbs flying in all directions for prolonged periods of time and c) force myself to drink more than a few ounces of water every four days (drinking water makes me cold). It has worked! I stay warm for at least three hours after each class, and get the added benefit of having sweated out about a gallon of fluid every time (the room is usually ~110 degrees). Goodbye evil toxins! You should try it.
Admittedly, life seems pretty dull outside of the ER. My job used to be so boring I was forced to see the time in between work hours as material for creativity - the weirdos on the train, the funny hallucinations that struck me while walking around downtown, the daily habits of my pet rabbits (now pet rabbit, singular...his brother was adopted). I've been listening to Brahms string quartets whenever I am walking somewhere lately, so rather than thinking the profound thoughts that so easily come while walking alone, I am swept up in the etherial richness of one of his developments, sometimes waving my arms around as if I were playing. I doubtlessly look like a lunatic, which is fine, because there is a home for lunatics just down the street from me, the residents of which can often be found pacing up and down Fayette Street. No one would ever know I was not, in fact, mentally incapacitated. Am I not supposed to call them lunatics? Sorry, everyone.
*"Wake up! Now, breathe! Deeper!"
Here is some news: I started doing "hot yoga" (formally, Bikram Yoga) in an effort to a) regain circulation to my extremities at least a few times a week b) become very stretchy and be able to balance on one foot, limbs flying in all directions for prolonged periods of time and c) force myself to drink more than a few ounces of water every four days (drinking water makes me cold). It has worked! I stay warm for at least three hours after each class, and get the added benefit of having sweated out about a gallon of fluid every time (the room is usually ~110 degrees). Goodbye evil toxins! You should try it.
Admittedly, life seems pretty dull outside of the ER. My job used to be so boring I was forced to see the time in between work hours as material for creativity - the weirdos on the train, the funny hallucinations that struck me while walking around downtown, the daily habits of my pet rabbits (now pet rabbit, singular...his brother was adopted). I've been listening to Brahms string quartets whenever I am walking somewhere lately, so rather than thinking the profound thoughts that so easily come while walking alone, I am swept up in the etherial richness of one of his developments, sometimes waving my arms around as if I were playing. I doubtlessly look like a lunatic, which is fine, because there is a home for lunatics just down the street from me, the residents of which can often be found pacing up and down Fayette Street. No one would ever know I was not, in fact, mentally incapacitated. Am I not supposed to call them lunatics? Sorry, everyone.
*"Wake up! Now, breathe! Deeper!"
Tuesday, December 30, 2008
prologue
The post following this one is a huge story about my being a hero yesterday in the ER. Truth be told, the guy is probably gonna die anyway, but I felt like I did something right. The opportunity to write about such a thing will probably never rise again, so, below you will find a big, ego-stroking, shameless attestation to my greatness. While reading, please keep in mind that I drop things, have a problem with blushing,am no good at math, and mumble a lot.
affirmation
Yesterday at work an ambulance called in a radio report stating they were en route to our hospital with a 52 year old male with symptoms of a major stroke. He was seemingly paralyzed up and down the left side, unable to speak, and had left facial droop. When he and the paramedics rolled in the ambulance bay, the patient looked exactly as they had described. He was a thin Asian man who looked about 35, his eyes cast aimlessly in front of him, arm hanging off the stretcher, head lilting wherever gravity took him. Neurology was already down the in ER, and the residents began their assessments even while the medics were still lifting him onto the hospital bed. They called his name, shined light his eyes, tapped, lifted, and bent his arms and legs, then finally tried to instigate a response by digging the handle of a reflex hammer into the nail beds of his big toe and index fingers. Finally, the patient withdrew his left leg from the excruciating pain. The whole time, especially after the pain response tests, he had a serious frown on his face - the charge nurse, shuffling through the patient's wallet looking for ID said "don't worry everyone, I think that's his baseline." Looking at his driver's license, the frown was the same, almost hateful.
Now, the apex of a stroke protocol is to get the patient to CAT scan, scan his head looking for a bleed of any kind, indicating a hemorrhagic, rather than ischemic stroke. If the brain is bleeding, and thrombolitics, or clot busters, were to be administered, the patient would bleed out into his brain and die. However, since most strokes are ischemic, caused by a blockage brought on by a blood clot in the brain, the faster you can get through CT and administer thrombolitics, the better. In fact, thrombolitics only work within two hours of the stroke's onset - if no one catches a stroke within that window, there's nothing to be done, really. Whatever damage occurs - and in this guy's case, enough to cause paralysis and loss of speech - will likely remain largely permanent.
Having decided that the patient was, indeed, having a major stroke, and readied him to be swept off to CT, the neuro resident and fellow indicated that he should be taken up as soon as possible, and that other routine tests, like his EKG, blood sugar test, and a few others should be held until he got back. The CT was the number one priority. But alas, as happens with almost every patient in every hospital, there was a delay in our doing anything because he had yet to be registered in the hospitals administrative system. We bade our time, waiting for a medical record number to pop up under his name on the computer screen. Meanwhile, I fastened him in for liftoff, arranged the portable heart monitor, which I had been eying for a few minutes, at the end of the bed.
For the past few months, following the example of a fellow ER tech at another hospital and dear friend, I have been teaching myself how to read heart rhythm strips and interpret EKG's. I'm usually wrong when I bring an EKG to the attending and tell him what I see, what I think is going on with someone's heart, and what irregularities I see in the various peaks and segments. Often, I get laughed at for carrying around Dale Dubin's Rapid Interpretation of EKG's, aka "the bible," of the ER. For some reason, my littleness, my perkiness, and occasional featherbrained-ness, makes me the least likely person to be of actual value in an emergency. Apparently, my enthusiasm is humorous, to some. Nonetheless, I now know the difference between a regular and irregular heart rhythm. And evidently, I am fresh and naive enough in the ER as to make sure everything else is going right, even when clearly, there is something terribly wrong in this man's brain. Well, I'm looking at the heart monitor, which by no means gives the same picture or even a very reliable picture of the heart in comparison to an actual EKG, and I'm pretty sure I'm looking at flipped T-waves in lead III and about a millimeter of ST elevation in V5.* I wasn't sure if lead III was supposed to be flipped, as some other leads are naturally, but was mostly concerned about the possibility that the elevation visible in V5 on this puny little heart monitor was really something hugely ugly, in reality. "Hey, um, sorry, I don't know how reliable this is," I told the neuro resident, "but I'm looking at his rhythm here and he's got a bit of ST elevation in V5 and I think maybe I should do the EKG now rather than after the CT, you know, while we're just waiting around."** He bent down to look at the monitor, and somewhat bewildered, agreed with me. "Yeah. Do it now."
Having done about ten million EKG's in the short history of my career as an ER tech, I had it done in about a minute and a half. While I waited for the image to flash up on the screen, I thought about what a nut I would look like if there was nothing wrong with his heart. Silly Morgan and her EKG's...we're in the middle of a stroke protocol, here! But, to my surprise and (I now feel guilty for this) outright glee, the man was having a major heart attack. I may not know all the intricacies of EKG tracings for hyperkalemia or digitalis toxicity, escape patterns or what have you, but I do know what a myocardial infarct looks like, and it was staring me right in the face. I showed my attending, who was with another patient, and he said nothing, except "Who is this?" "The stroke patient in Trauma 4." He rushed past me into the mob of doctors...neurologists, mostly, that were milling anxiously around the nurses' station.
Katy, the primary nurse and I ran - literally- the patient up to CT, where we were met by the cardiology fellow. She was my height, had a brown ponytail and glasses. Her scrubs were too big. "We need to get him back downstairs," she said, "he's having a major MI, he's our patient now." We know, Katy said. "Morgan saw it on the monitor." I was blushing furiously.
The rest of my afternoon I spent doing whatever I could to help the cardiologists and neurologists care for the patient, stood in on their conversations about where he would go...cath lab versus neuro, etc. I watched them do an echocardiogram, basically an ultrasound of the heart, and it was the most amazing diagnostic
procedure I had ever seen. Usually, when watching an ultrasound, everything on the screen looks like grey and white fuzz, completely indiscernible. But, in an ECHO, I could see all four chambers of the heart, contracting and relaxing, mitral and tricupsid and atrial valves aflutter, pumping blood to the various regions of the body. The tech could record the sound of the blood gushing through each of the chambers, squish-chunk, squish-chunk.
Sadly, the patient was outside the window for effective intervention for both of his major medical disasters. The CT was inconclusive, no hemorrhagic bleed but no sign of a clot, and the three hour time span in which a trip to the cath lab would have saved his heard had come and gone the night before, some time between when his family had talked to him around midnight and when they found him on the ground the next morning. Nevertheless, I beamed with pride for having been the first to pick up on his MAJOR HEART ATTACK, which may well have gone unnoticed until he had gotten back from CT and either I (if I hadn't been pulled away by some other task) or another tech got around to doing a routine, non-emergent EKG. I've seen stroke patients go hours without one, which is frightening. Needless to say, that will not ever happen while I'm in the pit.
I've been feeling down right proud of myself since yesterday. For a moment, I thought - "maybe this is the thing that will get me into med school." This was the first, and probably the last time in this job that I will have made a pickup of such magnitude, and before anyone else, that completely changed the course of someone's acute care. Maybe I will make a good doctor. That said, the day was not without its failures - I got a phone call from the charge nurse as I was walking home and got chewed out for having a) neglected to properly label a tube of blood I sent to the blood bank (for a different, relatively healthy patient) and b) having drawn said tube without verbal orders from a nurse...apparently, this is the most egregious error a person can make in the jungle of the ER. Guess I better not count on sticking in this job very long.***
*These things are bad. I'm not about to go into a big thing detailing how the EKG works, what it measures and what is considered normal or abnormal. I will say that it measures the strength and duration of the electrical signals that control the heart, and that any kind of blockage and/or slowing of a signal will be indicated by a widening, heightening, or altogether flipping of one or more waves. The four waves are named Q, R, S, T; thus, the ST segment is the segment between the S wave and the T wave. A millimeter is not very much, at all, and would otherwise be insignificant on a regular EKG if it wasn't seen in contiguous leads.
**That's right, I speak in awkward run-on sentences, especially when talking to doctors.
***That's right, in ten years, I'll be running the whole damn place.
Now, the apex of a stroke protocol is to get the patient to CAT scan, scan his head looking for a bleed of any kind, indicating a hemorrhagic, rather than ischemic stroke. If the brain is bleeding, and thrombolitics, or clot busters, were to be administered, the patient would bleed out into his brain and die. However, since most strokes are ischemic, caused by a blockage brought on by a blood clot in the brain, the faster you can get through CT and administer thrombolitics, the better. In fact, thrombolitics only work within two hours of the stroke's onset - if no one catches a stroke within that window, there's nothing to be done, really. Whatever damage occurs - and in this guy's case, enough to cause paralysis and loss of speech - will likely remain largely permanent.
Having decided that the patient was, indeed, having a major stroke, and readied him to be swept off to CT, the neuro resident and fellow indicated that he should be taken up as soon as possible, and that other routine tests, like his EKG, blood sugar test, and a few others should be held until he got back. The CT was the number one priority. But alas, as happens with almost every patient in every hospital, there was a delay in our doing anything because he had yet to be registered in the hospitals administrative system. We bade our time, waiting for a medical record number to pop up under his name on the computer screen. Meanwhile, I fastened him in for liftoff, arranged the portable heart monitor, which I had been eying for a few minutes, at the end of the bed.
For the past few months, following the example of a fellow ER tech at another hospital and dear friend, I have been teaching myself how to read heart rhythm strips and interpret EKG's. I'm usually wrong when I bring an EKG to the attending and tell him what I see, what I think is going on with someone's heart, and what irregularities I see in the various peaks and segments. Often, I get laughed at for carrying around Dale Dubin's Rapid Interpretation of EKG's, aka "the bible," of the ER. For some reason, my littleness, my perkiness, and occasional featherbrained-ness, makes me the least likely person to be of actual value in an emergency. Apparently, my enthusiasm is humorous, to some. Nonetheless, I now know the difference between a regular and irregular heart rhythm. And evidently, I am fresh and naive enough in the ER as to make sure everything else is going right, even when clearly, there is something terribly wrong in this man's brain. Well, I'm looking at the heart monitor, which by no means gives the same picture or even a very reliable picture of the heart in comparison to an actual EKG, and I'm pretty sure I'm looking at flipped T-waves in lead III and about a millimeter of ST elevation in V5.* I wasn't sure if lead III was supposed to be flipped, as some other leads are naturally, but was mostly concerned about the possibility that the elevation visible in V5 on this puny little heart monitor was really something hugely ugly, in reality. "Hey, um, sorry, I don't know how reliable this is," I told the neuro resident, "but I'm looking at his rhythm here and he's got a bit of ST elevation in V5 and I think maybe I should do the EKG now rather than after the CT, you know, while we're just waiting around."** He bent down to look at the monitor, and somewhat bewildered, agreed with me. "Yeah. Do it now."
Having done about ten million EKG's in the short history of my career as an ER tech, I had it done in about a minute and a half. While I waited for the image to flash up on the screen, I thought about what a nut I would look like if there was nothing wrong with his heart. Silly Morgan and her EKG's...we're in the middle of a stroke protocol, here! But, to my surprise and (I now feel guilty for this) outright glee, the man was having a major heart attack. I may not know all the intricacies of EKG tracings for hyperkalemia or digitalis toxicity, escape patterns or what have you, but I do know what a myocardial infarct looks like, and it was staring me right in the face. I showed my attending, who was with another patient, and he said nothing, except "Who is this?" "The stroke patient in Trauma 4." He rushed past me into the mob of doctors...neurologists, mostly, that were milling anxiously around the nurses' station.
Katy, the primary nurse and I ran - literally- the patient up to CT, where we were met by the cardiology fellow. She was my height, had a brown ponytail and glasses. Her scrubs were too big. "We need to get him back downstairs," she said, "he's having a major MI, he's our patient now." We know, Katy said. "Morgan saw it on the monitor." I was blushing furiously.
The rest of my afternoon I spent doing whatever I could to help the cardiologists and neurologists care for the patient, stood in on their conversations about where he would go...cath lab versus neuro, etc. I watched them do an echocardiogram, basically an ultrasound of the heart, and it was the most amazing diagnostic
procedure I had ever seen. Usually, when watching an ultrasound, everything on the screen looks like grey and white fuzz, completely indiscernible. But, in an ECHO, I could see all four chambers of the heart, contracting and relaxing, mitral and tricupsid and atrial valves aflutter, pumping blood to the various regions of the body. The tech could record the sound of the blood gushing through each of the chambers, squish-chunk, squish-chunk.Sadly, the patient was outside the window for effective intervention for both of his major medical disasters. The CT was inconclusive, no hemorrhagic bleed but no sign of a clot, and the three hour time span in which a trip to the cath lab would have saved his heard had come and gone the night before, some time between when his family had talked to him around midnight and when they found him on the ground the next morning. Nevertheless, I beamed with pride for having been the first to pick up on his MAJOR HEART ATTACK, which may well have gone unnoticed until he had gotten back from CT and either I (if I hadn't been pulled away by some other task) or another tech got around to doing a routine, non-emergent EKG. I've seen stroke patients go hours without one, which is frightening. Needless to say, that will not ever happen while I'm in the pit.
I've been feeling down right proud of myself since yesterday. For a moment, I thought - "maybe this is the thing that will get me into med school." This was the first, and probably the last time in this job that I will have made a pickup of such magnitude, and before anyone else, that completely changed the course of someone's acute care. Maybe I will make a good doctor. That said, the day was not without its failures - I got a phone call from the charge nurse as I was walking home and got chewed out for having a) neglected to properly label a tube of blood I sent to the blood bank (for a different, relatively healthy patient) and b) having drawn said tube without verbal orders from a nurse...apparently, this is the most egregious error a person can make in the jungle of the ER. Guess I better not count on sticking in this job very long.***
*These things are bad. I'm not about to go into a big thing detailing how the EKG works, what it measures and what is considered normal or abnormal. I will say that it measures the strength and duration of the electrical signals that control the heart, and that any kind of blockage and/or slowing of a signal will be indicated by a widening, heightening, or altogether flipping of one or more waves. The four waves are named Q, R, S, T; thus, the ST segment is the segment between the S wave and the T wave. A millimeter is not very much, at all, and would otherwise be insignificant on a regular EKG if it wasn't seen in contiguous leads.
**That's right, I speak in awkward run-on sentences, especially when talking to doctors.
***That's right, in ten years, I'll be running the whole damn place.
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