90 Seconds in Heaven?

Today was another eventful day in the Grady ER:

An elderly lady with a possible stroke, a middle-aged man who overdosed on tylenol in a suicide attempt, a young man in diabetic ketoacidosis because he can't afford his medicine for his diabetes, and lastly, the miracle patient who came back from the dead.

____

We got a call from EMS, "We're about 5 minutes away with a patient that is unresponsive and losing a lot of blood through the oropharynx(throat). We can't intubate him because he's clamped up." The physicians hurried into the CPR room to prepare the intubation equipment along with airway drugs (to paralyze and anesthetize the airway for intubation). As EMS wheels the patient into the room, the paramedic reports the patient lost about 2L of blood in the ambulance and went into ventricular fibrillation (vfibb) and they tried to shock him, but he was still in vfibb.

There about 10 people in the room at this time (interns, residents, attendings, nurses, medical students). Everyone got busy working on the patient. Someone cut off his shorts, the resident started a central line in his femoral vein, an intern started chest compressions, another resident worked on intubating him, another resident was getting an ultrasound of the heart, another resident was giving epinephrine injections, a nurse was standing by ready to shock when needed. People kept switching turns doing chest compressions. Every two minutes, they would stop compressions and check for a pulse. Every 6 or so minutes they would give a shock. After 20 minutes of working on the patient, the resident in charge of the code asked if anyone else thought that they could do anything to bring this patient back. No one said anything, and time of death was declared.

A chill ran down my spine. Through this whole process, I had been standing in the corner, trying to stay out of the way, watching everyone trying to desperately to bring this man back to life. I felt like crying (but I didn't). He was a stranger, yes, but the loss of another human life is hard.

As people were leaving the room, the resident I had been shadowing came over and asked me if I had any questions. As we were discussing the patient, we hear someone say, "He has a pulse!" With this, the activity in the room picked up again as the patient was ventilated and given more blood and fluids.

After having no pulse for about 20 minutes, the patient's heart had started to beat again on its own...a few minutes after he was declared dead.

12 Steps to Freedom

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

________

As part of the psychiatry/neuroscience II module, we are required to attend an Alcoholics Anonymous meeting. I went to one tonight about 10 minutes from where we live.

I was apprehensive about attending the meeting. I wasn't sure how to act and if I should introduce myself. "I'm Lindel and I'm not an alcoholic?" That didn't seem right. I didn't want to be perceived as judgmental. I didn't want them to think "Why is she here?."

As I walked into the building, I saw a room where a few people were gathering. Unsure if it was the right room, I stepped in and sat down. I then saw that everyone had the 12 Step Book with them and I was assured that I was in the right place. As I sat there waiting for the meeting to start, I was unsure of what to do. So, I started reading the 12 step book that was in the chair next to me, listening to the conversations around me, and contributing to them when I could (The extent of which was naming Simon as the third chipmunk of Alvin and the Chipmunks and remembering LaLa as one of the teletubbies.) Everyone was friendly and no one seemed upset that I was there. As I looked around, I was surprised at the amount and variety of people who were at the meeting. I had expected less than 10 people, and honestly, I had expected them to look...different. I'm not sure if I could have told you before this experience what I thought "an alcoholic" looked like, but I (ignorantly) expected them to be identifiable-- maybe a bit disheveled? looking like they've seen the harder side of life? I don't know. The people around me looked like people you would see in the grocery store, in church, at school. On other words...like ordinary people. I should have known better since I have a friend who is an alcoholic, but I guess I always thought that he/she wasn't your typical alcoholic. There were old, young, men, women, black, white, rich, poor....all different kinds of people.

The meeting started off with people around the room taking turns reading alternating paragraphs from chapter 11 of the 12 step book. This chapter/step is concerning prayer and meditation to gain the insight into God's will for you and how to accomplish His will. After the reading, people around the room would take turns giving their impression and thoughts of the 11th step. Some people spoke directly about how their thoughts on prayer and meditation. Others spoke about other issues tangentially related to Step 11. A lot of times, people spoke around their issue, never directly addressing it, which made it more difficult to understand.

Something that struck me was that no one directly spoke about their problems with alcoholism. Before anyone would make a statement, they would say "Hi, I'm ______ and I'm an alcoholic." However, none of them spoke directly about their problems with alcohol in the past, temptations they face in the present, or how they ended up in AA like I expected they would. It was a lot more focused on the individual step they were discussing for the night.

The meeting closed with recognizing people who's "anniversaries" of sobriety fell on today's date. There were two women -- one who had been sober for 1 year and one who had been sober for 5 years. The group then gathered in a circle, held hands, and recited the Lord's prayer.

This assignment really provided insight into who are alcoholics. By going to this meeting, I got the chance to see "the face" of alcoholism. It really can be anyone.

OPEX Reflections

Yesterday was my last day at OPEX (out patient clinical experience).

Yesterday I worked with Dr. X, a resident. We saw a wide variety of patients -- an 8yo boy with pink eye, a russian woman with migraines, a U.S. health service worker with an infected finger, and a mom wanting her 7 yo to be evaluated for ADD.

There were several things that struck me as we saw each patient--

1) It was so refreshing to see a child -- a talkative, friendly, outgoing 7yo boy at that. You don't realize you are missing anything working in a primary care adult clinic, but seeing that boy yesterday made the appeal of family practice care clear to me. You see a greater variety of patients. It was fun to take care of an enthusiastic little kid that talked about baseball, his best friend in school, and playing outside.

2) Cultural, communication, and social barriers. Our patient with migraines was an middle aged woman from Russia whose second language was English. My preceptor was also an immigrant whose second language was English. There were several times that I witnessed communication breakdown between them.

Dr. X -- "Was your head trrrobbing [throbbing]?"

Patient -- "What? No, I had a migraine."

Dr. X -- "you know? pulsating? what did it feel like?"

Patient -- "the pain was just on my right side"

Ai yi yi...and so it continued. The problem wasn't just the communication though. I really didn't like the way the interaction was going. Dr. X was acting very paternalistic and started lecturing her on how she shouldn't be taking ambien because it continues the insomnia cycle when she mentioned that she wasn't sure if she could take ambien and imitrex(migraine medication) together. Whenever she asked a question, he would continually interrupt her and say "now, listen to what I'm saying." Lastly, he kept touching her knee or her arm or hand when he was talking to her. Now...I like my personal space, and I know if I was that patient, I would have felt very uncomfortable about the doctor continually touching me while we are speaking. Ultimately, the doctor had the best intentions -- he wanted to educate the patient and help her get control of her migraines, but the approach was not for me.

3) The ADD epidemic. It is well known that ADD and ADHD are over diagnosed in children in the United States. It is no joke to put your kid on medication for life not to mention the psychological impact of "you have a disease that makes it harder for your to succeed" on the child. One of our patients was a mom bringing in her young daughter for ADD evaluation. She kept going on and on about how her kid refused to focus and how whenever she found something difficult she just quit or how she puts the wrong answers because she gets impatient with working out the problem. This child may very well have ADD, but I didn't like the way the mom was talking about her own child with the girl right there in the room. It just felt like she was being attacked and being told that something was wrong with her. It bothered me.

Looking back over the last year of OPEX experiences, I have learned so much. I can take a history and do a physical with ease now. I can come up with a differential diagnosis and a treatment plan for patients. I've seen the application of lecture material in real live patients over, and over, and over again. It has been a great experience and I am so glad that it is part of Emory's curriculum.