Night Shift
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You can’t help but see the ED from a new angle when you enter as an anxious patient

It had been a long day when I sat down by the roaring fire to enjoy a glass of red wine. My father-in-law, who lives with us now, sat down nearby and began to describe his worsening, but stable angina. While attempting to pay close attention to his story I began to notice something strange that I initially mistook for the effects of the wine. I realized with some fascination that I could not feel my left arm. It was not numb. There was no tingling. No pins and needles, as I have so often asked my patients. No, it was as if the arm just didn’t exist. As Pop Pop’s voice faded into the distance I became fascinated with my surreal appendage. It moved normally. I could see it and feel it as I drummed my fingers on my thigh. I could feel it on my neck as I ran my hand through what’s left of the hair on my head. But if I closed my eyes, it just seemed to disappear. It was as if someone else was doing it.  ‘Isn’t that amazing?’ I thought somewhat leisurely.

“Oh crap!”  I thought,  finally awakening from my academic haze.  “ I’m having a frickin’ stroke! So this is what it feels like.” I got up and left Pop Pop in mid sentence and went upstairs to look in the mirror and take an aspirin. While I was concerned, I was still intrigued to be on this side of the equation.  As I stood in front of the mirror, I went over all the risk factors for stroke.  I had none.  Then I methodically started through the neurologic exam.  All the cranial nerves seemed to be working fine. There was one thing, though. My tongue. I had a patient recently who reported that his arm didn’t work quite right for an hour or so before coming to the ED.

Everything in his exam was normal except he had a slight tongue deviation. So I stuck out my tongue and examined it carefully. My tongue, however, seemed to have a mind of its own. It came out straight but would then seem to deviate. It was as though my close attention to look for deviation was making it deviate. It was acting under suggestion, which, if it hadn’t been so concerning, would have been comical.  In my growing exasperation, I actually found myself telling my tongue to behave and act naturally.

I did the motor exam: Squats, toe raises, bicep and tricep strength.  All normal.  I did finger-to-nose, rapid alternating movements, and even tried doing reflexes. They all seemed to be normal, but I still couldn’t feel my arm. “How weird,” I kept thinking to  myself. I chewed up an aspirin and sat down to think through my medical history once more. I wasn’t hypertensive, hypercholesterolemic, diabetic, and I didn’t smoke. I had no history of vascular or cardiac disease. “Heck,” I thought, “I’m the picture of health.  And a fool if I sit up here in my room all alone and have a stroke.”  

So I went back downstairs to break the news to my wife. But there was one slight complication. Just as I hit the bottom step, my wife opened the door to welcome four friends into the foyer. My sister and her husband from out of state, and a couple from the Midwest, had just arrived to celebrate the New Years with us.  We were all planning to start this off with a birthday party at a friend’s. “Hey, it’s so great to see all of you,” I said, giving hugs all around.” How have you all been doing?  How’re the kids? Oh, How am I? Uh? Well? Great! Except I have to go the ER . . . right now . . . because I might be having a stroke.”

“What?” my sister and brother-in-law laughed, expecting my usual wise-crack.

“What?” our friends said putting their bags down in confusion.

My wife said nothing but just stared in disbelief. “Uh, yeah,” I said, trying to break the ice. “It’s nothing big. I just can’t feel my arm. You guys go on to the party. We’ll catch up. Honey, do you mind driving me to the ER?” She still didn’t say anything, which, by the way, is unusual. I turned to go upstairs and change clothes. If my mother taught me nothing else, she taught me “You don’t go the ER with dirty underwear.”

When my wife arrived upstairs, I was attempting to remove my shirt. Despite the fact that my hands could move normally, the lack of tactile accuracy made it such that I was fumbling with the buttons. I tried to crack a joke, but the widely dilated eyes of my wife let me know that she was fighting back the terror. “Should we call an ambulance?” she finally said.

The thought of walking onto and out of an ambulance was just too humiliating for me to tolerate.

“I’m fine,” I told her. “Just drive to the ER normally. And don’t get us killed on the way.”

As a consultant to hospitals seeking to improve their EDs, I was fascinated to experience my local hospital as a patient. (By the way, I did not go to the facility where I work. That would have been just too weird.) As we pulled into the hospital complex I was acutely aware of the emergency signage and ease of finding and entering the ED. As an aside, if you haven’t done the same at your own hospital, you should. The experience can be enlightening.

To my pleasant surprise, I was greeted by a friendly nurse who spoke to me face to face and not through a hole in a registration window. They didn’t ask for anything aside from inquiring about what was wrong. Since I introduced myself they didn’t even ask my name.  Despite the fact that this was a big, busy ED, within a few minutes they were walking me back to a room.  They offered a wheelchair, but I declined.  My wife snapped a look at me, then turned to the nurse. 

But I ignored them both. Before I could even lie down, a tech was there to do an EKG. A nurse came in and put a hospital gown down on the bed. As she began to explain what clothes to remove, my inner brat came out and I just shook my head and said “NO.” She smirked a little I-know-your-type smile and told my wife, “When the tech finishes with the EKG, YOU get to rip off the leads.” It was a woman-to-woman moment that was exactly what my wife needed.
“Get your shirt off . . . and BE GOOD,” she said. I remembered that last phrase as being her last words to our children as she dropped them off each day at school. It meant, “Don’t make me come down here to make you behave.” I obediently started stripping down.

“Thanks,” she said, starting to relax a little. Before long I was moved to a treatment room and greeted by the nurse, pharmacy tech, and the emergency physician, Ken Gummerson, a colleague I knew and trusted. It all felt like it was happening quickly, but then I looked at the clock and realized that almost an hour and a half had passed between the onset of symptoms and arriving in the ED treatment room. I’d had just about everything going for me – knowledgeable patient, reasonable transit time, quick door-to-doctor time, conscientious staff – and yet it had still taken an hour and a half. It made me rethink the whole idea of the stroke window. It’s really not that wide.

In any event, by the time I was examined, the symptoms were starting to resolve and it was clear that I had had a TIA. After a thorough history and physical, Dr. Gummerson offered to get an MRI.  Really? I thought. You can get an MRI on a Friday night before a holiday? “Sure, OK,” I responded.  “I’d like to know what caused this, if possible.”  

This time I let them wheel me over to the scanner.  The staff was incredibly considerate and accommodating.  Despite knowing that I was a physician who should know all about what happens in the scanner, they offered a warm blanket and words of reassurance.  The truth was that I was a patient now.  And I was trying my best to hide a dark anxiety.  Remembering that my father had died at about my age, while in a scanner, with my mother standing outside the room, I had to take a moment to run a quick checklist in my head. There was no panic. No life flashing before my eyes. Just a short prayer and a few deep breaths.

Have you ever had an MRI, or any of the myriad tests or procedures that we so blithely order on our patients?  You should try it.  They stuck ear plugs in my ears, clamped my head into a brace, and turned on a jack hammer that rattled my teeth.  I don’t know how anyone can relax in that environment.  

After being returned to my room I realized that my symptoms were completely gone. The nurses got me some coffee and a doughnut.   I was getting dressed and ready to go home when Gummerson returned to tell me that I did not have what I most irrationally feared: A brain tumor.

However, the MRI had demonstrated that the  ischemia was real. “Really?” I thought.  “That means that something potentially catastrophic did happen in my brain.”

“I have to offer you admission,” he said, already knowing the answer.  I already had my clothes on and was attaching my cell phone to my belt.

“No,” I blurted out before he could finish.

Then he said something  to  the effect that I should be careful that I wasn’t “denying.” I knew the statistics on how many TIAs go on to stroke.  But I just didn’t see myself in that group.

It was a long quiet ride home from the ED that night.  I felt fine.  The symptoms were completely resolved.  “It was probably nothing,” I thought.  Later, I discovered that a whole group of our friends had stopped to pray for my health and safety that night. Me. The healthy one who always takes care of everyone else. I was humbled, thankful, and a little embarrassed.

As the follow-up tests revealed, the whole event was probably due to a patent foramen ovale, present since birth, that had allowed a tiny clot to enter the cerebral circulation. An aspirin a day is probably the only treatment.

So, as my mother would ask every day after school, “What did I learn?” First, anyone can have real disease, even a knucklehead like me. So make every day count. Second, we need to take a serious look at the first impressions that our EDs give. I wouldn’t say I was desperate arriving at the ED, but it sure was good to see a friendly face who acknowledged the seriousness of my situation.  Despite all my jokes trying to act like this was nothing, the staff didn’t treat me like it was nothing.  They uniformly seemed to take the situation seriously and really care about my health and comfort. Finally, I have a little different perspective on “waste” in the American health care system. I got an MRI within 30 minutes of my arrival at the ED. That wouldn’t have happened in most places in Canada or the UK.

As a final note: My deepest thanks and congratulations to Dr. Ken Gummerson and all the staff at Anne Arundel Medical Center on a truly exemplary emergency department.

 

 

Comments   

# Thank God you are fine and for the fine group of ED staffAdan 2013-02-06 06:29
What a story Mark! You are absolutely right, being a patient and not the doctor in the ED is quite an experience. I think we all should be a patient at some point in our training, just to give us a reality check of what our patients go through. Thanks for sharing your experience.
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# TXMD 2013-02-06 09:51
Very much enjoyed the article, but I wanted to comment on one point:

"Finally, I have a little different perspective on “waste” in the American health care system. I got an MRI within 30 minutes of my arrival at the ED. That wouldn’t have happened in most places in Canada or the UK."

First, the ED experience is incredibly different for an MD-patient (VIP) than your regular Joe. It's true that we can get emergent MRIs faster in the states, but your 30 minute MRI certainly had something to do with your VIP status.

Second, did you really need a 30 minute MRI? Did it change your outcome? Did you even really need an MRI in the ED?
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# Lead Paramedic and EMS coordinatorKerry Hershberger 2013-02-06 20:44
First I'm glad that you had such a good outcome on such a potentially life changing episode. The purpose of this article was very good as everyone involved in heathcare of the ED patient including EMS should see how their roles and actions are perceived by the patient and until you are that patient it is hard to comprehend. Thank you for this great perspective however I do have problem with this part of the article.

“Should we call an ambulance?” she finally said. The thought of walking onto and out of an ambulance was just too humiliating for me to tolerate. “I’m fine,” I told her. “Just drive to the ER normally. And don’t get us killed on the way.”

As a paramedic and EMS education coordinator I have witnessed too many patients that find it humilating or feel it isn't important enough to call 911. Unfortunatly this widens that narrow stroke window you described. I have also been to accidents of patients racing to the ED trying to save their family or friend only to delay care or cause the death of that individual. Our EMS system does public education on stroke and chest pain awarness to call 911. Our hospital is a JACHO certified stroke center and very aggressive program that starts with 911 dispatcher to the Stroke unit. EMS has a seat on the stroke committee to keep that stroke window as short a possible. I would hope that everyone in healthcare use the 911 system when they have such symptoms, even as humiliating as it may be, your ED care should be faster with early EMS assessment, rapid transport, prearrival notification so the CT scanner is open for the patient to be in less than 10 minutes like our stroke protocol. So hopefully there will not be a next time but I would hope you would call 911 instead of putting your wife in that position.
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# ED physicianRon Morford 2013-02-07 07:43
I feel great today but I have been significantly ill and hospitalized several times. Two years ago a had a 5 vessel CABG and coded 4 times post op. Being a patient does give any of us a more complete perspective of how patients feel and what it is like to be on the receiving end of medical care. I too was thankful for good medical care and caring. Mark, I'm so glad you are doing well! Thanks for sharing your experience.
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# JAMES W MEADE MD FACEP 2013-02-27 09:19
"Think Stroke?"
"Think FAST"*
F facial asymetry
A arm drift of numbness
S Speech slurred
T Time to call 911 (Do not have your significant other drive you to the ED, I have seen too many people arrive dead that way.)
*smh.com
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# PFOWilliam Warren Bradford MD 2013-03-06 11:28
I had 2 strokes from unknown PFO in 3 months. Both occurred while working in the ER. I had to retired due to expressive aphasia after 41 years in EM. Peace, Bill Bradford Had Gore helical septal occluded placed - studies inconclusion as to close or leave open PFO.
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# Camp Coyote, Capt Vance You sort of medivac'd out.Don Vance, M.D. 2013-07-17 08:58
Medical Adventure with different source, cardiac event. At work, heart rate went to 150+. I told the nurse I needed an EKG, she said which bed and I said, no "I" need an EKG. Atrial flutter/fib. My partners gave Adenosine, 6,12 and 12 then Diltiazem and after a telephone consult with a cardiologist Metoprolol. By this time, my wife had arrived and with two of my partners was standing at the foot of my ED bed glancing up at the monitor and down at me asking repeatedly if I felt "OK"? I craned my neck back to see the monitor and noted a straight line and immediately confirming my optimistic nature assumed a lead had fallen off... then saw one complex and "uh Oh", wondered if I was supposed to cough! Ten second asystole, one complex and then 6 second asystole then back to sinus. Glad to know I am a committed optimist and glad we are both OK. Stay well my friend. It was good to have known you "Uncle Mark" ( the flight nurse friend of your niece at the Army mess hall). Don Vance
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