The ER: One Good Thing A Day

By Rade B Vukmir

The ER is a tough one for all involved- patients, families, nurses and doctors. There are both tragedies and victories found in the most major and minor of life's events. We would hope to bring a moment of clarity into this account of the day-to-day operations, striving to find "One Good Thing A Day." This work would be best explor

• Language: English
• Publisher: Dichotomy Press
• Release date: Jan 14, 2016
• ISBN: 9781944351113

Rade B Vukmir

Rade B Vukmir MD, JD is an American Physician, who has contributed extensively to emergency medicine and critical care medicine practice in clinical, academic and innovation arenas. Likewise, a dual professional degree involving both medicine and law has allowed impact in medical professional liability, risk management and patient safety initiatives.

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Section I

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Mid-Summer

Previously, I had labored for more than a year, compiling thoughts and remembrances of fifteen years of emergency patient care, archived and dutifully recorded. Anything more I thought would be superfluous. I thought that there could not be one solitary, additional story to tell as I had certainly seen it all. But, just as hope springs eternal, the story starts anew.

* * * * *

I trudge to the long back hall, which was an Urgent Care Center in its prior life, but now sits empty due to staffing cutbacks in a system that still does the best it can to treat the urban poor—dealing with all of their healthcare needs. It was their safe haven, but it is dark now.

As I glance to the right, there is an examining table for use in a pediatric exam room. Its base looks a little bit like a lion, so I easily can see how it would scare a child. Now it has been relegated to the storage area so that patients can be seen more efficiently in the six rooms still available.

As I round the corner, I encounter a young mom waiting for care. As I look down, I see between me and his mom a defiant, eighteen-month-old, sporting an orange striped top, braided hair, with each braid headed a different direction. He stands there defiantly. As I introduce myself and set out to examine mom he lets out a wail that brings others running. I stop for a second and he stops. I take another step forward, the blood curdling scream occurs again. Then I grasp the scenario: he does not want me to come near his mom. I say, Ma’am, is he doing what I think he is doing? She laughs apologetically and says. Yeah, he doesn’t want you touching his mom. He runs to her leg and clings for dear life. This behavior continues in x-ray where they had gone to evaluate her after an earlier car crash. Every time the technician approaches the film canister, that anguished cry emanates from the x-ray room—even through closed doors. Here, with no carpet and poor acoustics, it sounded like a concert hall.

I am sure there will come a time in his life that he will hold on to something else so dearly, but I would venture to say that it will never be quite as tight as trying to hold on to his mom now, protecting her from the world, even when he is eighteen months old. Everything he knows about this world is in that room with him. It would be nice if life were that simple; I admire his tenacity and singularity of purpose.

Wednesday

As I ease out of the house, it is about 5:30 am, dark—almost black—and cool. My dogs spring out of the house to explore the yard. It seems new to them, too, this damp, misty day; a deer family has been about. They dogs react attentively and dart off into the crabapple thicket. It is late July; it does not feel like the end of summer, but it is already starting. The morning is foggy and misty, with a thick, dense and gray sky, as if the sun has disappeared from the sky forever. There will be rain today, I think.

I remember, at this time of year, something of how the stratosphere flattens out and radio waves are reflected in a way that makes listening to my favorite radio stations nearly impossible. I remember this time vaguely—I think last year. Then I was thinking the same thing: Could the antenna be bad? No, I think this happens every year. I guess there will come a time when I don’t have to worry about this commute, but for now I plow north, cutting through the fog, with just me and the truckers sharing the road.

As I whirl along, the sky is still gray, but with a touch of blue, just bright enough that lawn tractors are whirring, cutting that thick, emerald-green, July grass in the yards that line the hospital exit and entrance lanes.

It is quite the gray day on the inside as well. We see and evaluate a huge number of patients. As the nurses state, it is Failure to Thrive Day. We see female after elderly female, not capable of coping with their home situations. In some cases, as age creeps slowly forward, they find themselves alone in the elder towers, a high-rise apartment building, that whispers to them that they are not to be in their own home for very long. One pleasant gal, eighty-six years old, I think, comes in just because she is weak. She is nattily dressed in a peach and pink, striped nylon top that makes sense in the summer for the geriatric crowd. She is prim, proper, and says she isn’t really quite sure why she is there but she does indeed feel weak. During the clothing change, one of my nurses notes that her right breast is hard and distended and on breast exam I notice that there is likely a cancer that has clearly been growing for years.

I say, Dear, has it often been like this?

She says, Oh, probably two or three years.

I say, Well, do you understand what this likely is?

She says, Oh, I do. I am one with God, however, and I don’t want anything done. I have not told anybody. Her younger friend nods, knowingly. I have kept it a secret, she says.

I say, Well, dear, it is best we bring you to the hospital and get that looked at. She reluctantly agrees.

* * * * *

He is a strapping man; he has his employer health nurse in tow for a urine test because he had driven off the road. He says, Would you believe, a deer ran out in front of me? I say, Sure, I’d believe that. But something isn’t quite right. No, he isn’t intoxicated or under the influence of drugs, but his mental faculties and behavior are not normal.

He says, Well, the state police didn’t.

I say, Well, certainly, everything is possible.

He has a lip laceration that I repair—a large cut through his lower lip. I suggest that I will order a head CT scan, just to make sure. Next I get a frantic call from the radiologist, who says that this patient has a huge cerebral mass—a brain tumor. I go back to size him up, I do another neurological exam. There is, at the least, some subtle abnormality.

I say, Sir, we have a little problem here. You have got a little mass.

He says, Well, what does ‘a little mass’ mean, may I ask?

I say, Well, again, it is a little abnormality in the brain and we want to make sure it is okay. I will have to send you to another hospital. As I go through that every couple of minutes, he calls me back and says, Now let’s talk about this again. I say, Sir, I already have as much information as we probably can get here. I know a good doctor to help you with this problem and I am going to send you there; just trust me.

He has a wry sense of humor, as we joke. My wife is not going to like this. As he heads out the door I joke, Send us a postcard. We shake hands. He has an IV in his right-hand, so he extends his left hand and envelops my own hand with his huge, vice-like grip. He has been a strong working man but today his life has changed forever. He takes the news well, I admire his courage and stoicism. But the uncertainty must be intolerable for him. I hope we helped, but I am not sure. You never know when to confront the issue—now or later. The easy thing to do is just pass them on into the system so that someone else can give the bad news. I usually tell them There is a little abnormality, and those patients that are astute will press and I eventually have to come forth with the truth, but I certainly give them the option to just be admitted blithely ignorant and let the system take its own course without their active input; maybe that is the better way. Worrying about getting a newspaper or what is on the menu for dinner—I would rather have them wondering about those things.

Now they push a wheelchair in from the radiology department with an elderly woman with arm swelling. As I go to shake her hand, her right upper extremity looks swollen and distended. The ultrasound tech says that she has had a blood clot in the large vessels of her neck. This usually has a couple of associations but they are not good, usually cancer of some type. I ask her, Did you smoke? She says, Yes, nodding her head and averting her glance. I don’t usually press the issue, but she knows and I know and that is all that is required. The husband just nods agreement. I say, I am going to have to admit you to the hospital to take care of some of these issues.

She says, Well, what’s wrong?

I say, Well, you know, it is a little bit of a concern. I think on the x-ray you have a little bit of a spot on your right lung. We are going to have to take care of that.

What do you mean, ‘a spot’?

Well, it is not as much a spot, as a mass, in the central portion of your chest where the heart is.

Now, it floods over her like a wave: all of the years of smoking, skin dry and forehead wrinkled with furrows, almost like it has been pre served for posterity. She now knows the dreadful cost of that habit. I tell her we will do our best to make sure things are okay. The husband says, Well, maybe it is worse than we expected.

Worse than expected. I ponder this comment.

I say, Well, maybe it is better than you expect. Give us some time and we will have to get you admitted with some specialty doctors to help take care of you. Doctors for your lung, cancer doctors, and surgeons to get a piece of tissue to know how to proceed here. We will take care of it for you. She seemed reassured. I hope things will be well for her in her current set of circumstances.

As I hurtle homeward, I notice that the summer campground is starting to fill up. I can’t remember: is it time for the Renaissance Festival? I think it is.

Thursday

The summer construction season continues. The roads are smooth and fast with new asphalt being laid down over years of wear and tear. As I cut through the fog, I come upon a motorcycle. No, not one of those fluorescent Japanese bikes that have got to be uncomfortable to ride, but a good, old-fashioned, upright chrome and steel Honda. No, not the Gull Wing version with the trunk on the back and radio communication between driver and passenger; rather a 70s-era, rickety Honda with chrome fenders, and a 500 cc engine. This gentleman is likely driving to his industrial occupation, through the fog, old leather jacket flapping, and a faded orange safety stripe across its shoulder blades. This vehicle has seen many a summer, I’m sure. It is an American tradition. Here in blue-collar America everyone wants a motorcycle and a boat, modest ones at least; it is a portion of the summer rite of passage, fiddling with both. Fog or no fog, I am sure that the cutting, stinging mist of this morn will not stop this fellow from riding his American Dream to work.

* * * * *

Perhaps, the hardest thing to do in the emergency department is to take care of young, sick children. It has got to be a scary place for them. My first pediatric patient got a cut on his hand from playing with the bird-feeder. I expect that there was double indignity in that he was doing something I believe he was not supposed to. But he is well-mannered, shy, with a typical summertime crew cut, high and tight, as they say. I explain the pinch, sting, and burn of the lidocaine, a numbing anesthetic; it will put his hand to sleep while we put the stitches in. He may not believe the story, but he doesn’t seem to complain much. As we do the procedure, I ask him if he has any brothers or sisters. He gets strangely quiet. I ask him again and he mouths the words slowly to his mother, You tell, as he is turns the other way. We go on like that for a while. If they don’t answer the ‘brothers and sisters’ question, usually they will tell you about any pets or other animals they may have at home, especially if they live on a farm. But in fact none of those subjects evokes a response. He is stoic and quiet and although pleasant, will not interact much, other than dutifully doing what he is told and, I am sure, hoping to get home.

My next young fellow has an especially tough time. He is pleasant and jovial but perhaps a little overweight and has a rectal complaint, which is not common in his age group. Think about this conceptually: you are a shy pre-adolescent, and you have a problem with your ‘butt.’ Now there cannot be a worse day than that, I would think. Luckily, it turns out to be a little yeast from summer time chafing. He is pleasant and laughs about his experience as time goes on. I hope that he will maintain this good humor throughout his years.

My last silent communicator was seven. He says he hurts in his tummy and he has a fever. As I pull up his tank top athletic shirt, I find he has excoriations in the area below the bellybutton. Mom says that it is chronic eczema. I ask him if his stomach hurts and he says, No. I start in the non-tender areas and work to the area that I expect is going to be causing the most pain. I push, he winces.

I say, Did that hurt?

He says, No. I push again and he winces again.

I say, Did that hurt?

He says, No, quietly. I ask mom, What do you think, ma’am?

She says, I’m not sure. You are his doctor though, you saw him last time.

I try one more time, pushing in the lower right quadrant, normally associated with appendicitis, he winces, and closes his eyes. I say, Did that hurt?

He says, No. It is then prudent to get a CT scan which he can’t fool. Unfortunately he does have appendicitis. But there is no lying in children, no secondary gain. They communicate the truth to you even when they don’t particularly want to. Hopefully, the rest of his summer will be good.

Saturday

As I head across the bridge, through the aging industrial town, I think, The stories that each of these houses could tell! These are the steel-town equivalents of urban row houses, all stacked together. Each has a shared brick wall and other similar construction. The corner ones are marked with graffiti, white and black, already starting to fade. I think this was their version of the patio home in a by-gone era. I am sure the residents were proud of each when they purchased it.

It is early, I drive past and see a woman in bare feet sitting on a porch, opening yesterday’s mail. This stoop is the urban equivalent of one’s deck in the suburban home, usually wood, re-stained every year; tiki-torches abound. For her this mail is communication with the urban outside world where she socializes and spends time with friends and neighbors.

* * * * *

It is 7:00 am. The handoff is quiet with lots of discussion about summertime vacations and trips. The nurses trade photos and stories: who is going where and who just came back. It is a nice rite of summertime passage.

For today’s parents, unfortunately, drugs of abuse figure prominently in the urban setting. One of the nighttime holdover patients complains of abdominal pain and after a fairly extensive workup, the only thing that turns up positive is a significant state of dehydration indicated in the urinalysis, that tests urine for various conditions, one of which can be dehydration. This typically occurs after extensive drug ingestion: two to three days of using stimulants are followed by requests for pain medicine to ease the coming down process.

When confronted with this issue, she looks away with an avoidant glance. I discuss the need to get some control of this addiction, as there is a significant number of major medical maladies that can supervene if her use persists. Hopefully my discussion of her bowel having a heart attack will sink in but I’m not sure. As I glance at her thin frame with purple, sparkly, nail polish chipped away from her finger and toenails, I’m not sure she is listening.

Soon after, the second patient comes in with right facial numbness and weakness, a condition that again can be associated with a stroke. Pretty quickly, after some discussion, illicit substance use is on the table for discussion. Not only does this patient present now with a neurological deficit, but she has had a previous stroke that is reported on her driver’s license. It is unfortunate; the working classes are often saddled with these problems. As both patients are readied for admission, I hope that someday they find peace in their day-to-day existence and leave the yoke behind. I am uncertain whether this problem is more common here, or in the suburban hospitals. I guess it really doesn’t matter much. The effects are brutally disruptive whatever side of the fence you are on.

Section II

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End of Summer

Monday

It is cool as I go in, the low 60s. The fog has been lying low over the horizon the last few days. It will be in the 80s later but since the earth cools rapidly at night, there is this thick, dense blanket-like fog. In the distance it forms layers—a dozen dense sheets of white and gray stacked atop one another. There is a flock of geese that seem almost disoriented. They are flying in their typical v-shaped pattern and then they veer left, veer left again, and land. Half of the flock flies off in one direction, and the rest in another. This must just be their appointed resting place. I am certain they are better navigators than this. But now the sun burns brighter, going from a simply beautiful reddish- to a golden-orange color, even as I watch. The fog gently dissipates.

It is my sister’s birthday today. I dropped a cake off yesterday and a card and I hope this day will bring her peace. A birthday is not automatically a joyous occasion. I can’t imagine what her days are like, spending literally every waking hour caring for a debilitated family member. Now that is true devotion.

* * * * *

I introduce myself, as I often do, and there she lies, frail and quiet. As I extend my hand, she grasps it limply, in a demure, polite way that I am sure serves her when she is well.

I ask if she feels poorly. She says No, not really. But she has become weak after chemotherapy today. She is sick but she minimizes her symptoms as much as she can. I notice her wedding band and then her engagement ring, a quarter-carat diamond, single solitaire. In today’s age of five- and ten-carat diamonds, of various hues—yellow, rose, green— this one stands alone. She has worn it for sixty-five years. He got confused on the way back to the room and couldn’t find her. His face lights up when he finally finds the right room and the right wife after sixty-five years of marriage. Will she be all right? he asks.

I say, I certainly hope so, we will do our best sir. I hope to God that if anyone has a good outcome day, she will.

* * * * *

Severe illness occurs frequently in rural areas. It is not uncommon to have two or three simultaneous emergencies. A gentleman comes in with a numb foot; he has had a recent neck fracture, high in the cervical region, and everyone assumes that to be the problem. But in talking to the patient, we quickly realize that the high level—the cervical—spine does not control the legs. I say, Sir, did anything else happen to you when you were sick recently? It turns out that he has had a subdural hematoma for which they stopped his coumadin, the blood thinning medicine he had been on for ten years. Why were you on the coumadin? I asked.

Why, for my heart rhythm. I think they call it ‘a-fib’. he says. So now it all becomes clear: the coumadin was stopped. We flip up the bed sheet and find he has a cold left foot, pale from lack of blood flow. Quickly to radiology and probably an operation to salvage this leg that had carried him for so many years. Hopefully a red flush will then replace the waxy white appearance that it has taken on.

Just about the time this case is done, one of the nurses calls from the adjacent bed.

Oh doctor, could you please come here? This is the emphatic way in which they sometimes suggest, Doctor, you better get your butt over here. As I roll in the door, I again shake a patient’s hand as he minimizes his chest pain symptoms. I look down quickly; an inferior wall heart attack. He gets the clot buster story. A couple of quick referral phone calls and now we have two helicopters in the air. The first one lands while the second one hovers. Both patients are off in fifteen minutes, lickety-split. Severe illness really is frequent in rural areas.

As I drive home that evening, it is hot. The car thermometer reads 108°. This is indeed a benefit of an all-black car. When I was younger, it would have been an annoyance. Now as I am firmly middle-aged, my old, tired bones actually relish the warmth. I remember my grandmother’s saying the same thing about her arthritis. Come to think of it, that ache in my leg hasn’t left now for six months. I guess I have arthritis myself. Now there is a full circle operation if I’ve ever seen one.

Some of the leaves are already turning color. It is early August, certainly too early for winter, but they have indeed browned. This summer has been frighteningly short. Soon the snow will fly I am certain.

Wednesday

It is a dark morning—5:45 am. As I drive north, cars are heading south in a 20:1 ratio. Traffic is particularly heavy this time of day. It is foggy and the sky is still dark with the diffuse light of early morning; you can tell it won’t be a sunny day.

The day starts sort of slowly. There are three or four nighttime holdovers that are all dealt with and sent on their way within the first hour. There is about an hour of downtime when the nurses trade stories—how busy the weekend was—and discuss two events: one of our nurses’ leaving, and a staff member’s having a first baby with attendant baby shower plans.

The former event had to happen; she has been an emergency department nurse for thirty-one years and that is certainly enough. You would hope that the career of soothing souls and bodies should certainly earn her a place in heaven eventually and I hope that is the case. But for now, it is off to another career. She wants to work in an office, ‘nine to five’ and that is the way it is going be. She is going to a different city in a different part of the country, a brave new world. They are trying to assemble a remembrance list of some of her favorite patients and we even have a name memorial list for those who have passed. These patients are our friends and family; they will remain near and dear to our hearts and hopefully hers.

The baby shower is clearly to be a more joyous occasion. Our physician’s assistant has been with us completing her first year, a true treasure and joy to have around. The nurses are anxiously planning. There will be scrapbooking, gag gifts, and real gifts. They devote a huge amount of time to this endeavor. As I often suggest, she is clearly our most valuable employee and her lucky baby will have approximately thirty aunts and grandmothers right from the start.

* * * * *

One of our first patients is just tired. He looks slightly jaundiced. I ask his wife what the situation is and she says that they are visiting from North Carolina where he receives his medical care at the VA hospital and that his doctor there has called them here to suggest that he has a bronchioloalveolar lung cancer. This is certainly not a report any of us would want to receive and then realize that most likely he has a metastatic lesion to his liver—the reason why he has this back up of bile, giving him the yellow color, malaise and lethargic condition. The family seems stoic but what a horrible feeling. The wife ducks around the corner to shed a quick tear and then turns back up at her husband’s side to put her best, optimistic face forward.

It seemed like everybody is tired today. Whether at home or in the nursing homes, they are all just weak, or, worse yet, experiencing the infamous weak and dizzy. The nurses cringe when they hear that complaint. Vague, nebulous, sometimes something horribly wrong but most times, thankfully, nothing at all. Just weak, they say, as their eyes flutter.

They are now coming in three or four at a clip. The nurses are getting frazzled, the work-ups are all the same; blood work, x-ray, urine testing. There are no quick turnaround patients and the work is starting to wear the staff down. When all of the beds are full and we have people in the hall, a car crash is all we need. Typically there are no injuries, in a low-to-moderate speed collision, but everyone usually has the same complaints: headache and neck pain, requiring more x-rays and more testing.

In the midst of it all, a relatively young lady comes staggering in claiming that she is tired and has been fatigued for years. The nurses are now completely exasperated; I am not sure whether one nurse will herself collapse or will try to do the patient in. Sometimes there is a fine line. It then turns out that the patient has a chronic headache history for which someone had prescribed a long-acting analgesic. Since she has a headache today she decides to take three of her pain tablets plus her sleeping pill, and then is so sedated that she is unable to walk. Well, that certainly sounds like a good plan to all observers involved.

She then knocks over her Mountain Dew, sits in the spill and proceeds to extract paper towel after paper towel to wipe off her lower extremities, as she staggers around the room. We scan her head, and then, thankfully, find her blood work to be okay. I tell her that we will likely be admitting her to the hospital for observation. About ten minutes later she says she feels fine and is ready to go home. She gets out of bed, and signs the paperwork, and walks out the door, as easy as can be, with all of us scratching our heads. Is there a secondary gain issue—another agenda? Or did the pain pills just wear off? I guess we will never know.

The day ends just as gray as it started. The rain comes, misty and light. It seems more like London than the northeast as the fast-moving car peels away through sheets of rain and mist.

Thursday

As I drive to work the fog is as thick as the proverbial pea soup, not just in the low-lying areas but for the entire drive. The temperature has dropped from the high 80s to the high 50s—30° in one night. Perhaps this portends the kind of winter that is to come. On the last leg of the trip, it really gets dense. For all intents and purposes I cannot see and then I wonder if it is the fog, or is it my eyes. This aging thing isn’t such a great deal after all.

As I stroll back to the surgical room, I observe my first patient, gauze wrapped around his left index finger. I introduce myself, How are you, sir? He sits bolt upright, poker straight. He had a dark blue, farmer-checked shirt and working man’s jeans. What were you doing? I ask.

He says, Well, yeah know, the blade shroud has a plastic cover and I reached up over to move the blade, and she caught me! It is as if he had been bitten by a wild animal. His wife slowly shakes her head.

I say, Don’t worry, we will fix that. I say, You’d have been okay if you had the little missus watching you. You are not going to be allowed to work alone again. As they both chuckled. I say, Sir, do you remember your last tetanus?

He says, Why of course, November 1, 2001.

I say, What is so special about that day?

He says, Well, I got cut then too. So here in this day and age of people not remembering their disease processes, let alone their medicines, this young fellow knew the exact time and date of his last tetanus shot.

* * * * *

As the medics roll her in, she is writhing about, like in The Exorcist. Bellowing at the top of her lungs, yoo . . . ooo! The man mountain of a medic says, She apparently stopped taking her insulin five days ago because she ran out. I think to myself, This is probably not the only time that this has happened. Even though I know she is twenty, she may never hit twenty-five. She is so dehydrated from high sugar that we are unable to get IV access. I have got to put a catheter into a large vein that lies deep within the groin. Although we numb her up, as best we can, metabolic-induced coma blunts her response. I know it has probably got to be painful. Her mother then comes and says that she ran out of insulin. I suggest again to mom that she knows her daughter’s young, fragile body will not tolerate many more episodes, as catastrophic as this. Mother says, Well, what are we going to do?

I say, Right, what are we going to do?

Mom stays around for about a half an hour, but then as her daughter gets better, she leaves. This is surprising since she seemed very attentive. When the admitting physician comes to get some additional history, I say, Gee, that is curious; mom left. And the nurse added that mom wanted to go home because when her daughter gets better she would yell at her. I thought sadly, that is one set of family dynamics that is on the road to ruin. Luckily we got her stabilized for the ICU stay. A glucose of over 1000 g/dl and a pH of less than 7.0, a horrible metabolic condition. The human body does not do well under these conditions. But young, non-compliant diabetics often feel they are impervious to the ravages of this disease. Unfortunately, by age thirty, forty, or fifty, loss of vision, renal failure, and amputations because of poor blood flow will convince them otherwise.

* * * * *

As I get to the end of the day, she comes in buried at the bottom of a heap of blankets with her left leg flexed up. She is roundish, and as the rolls of excess push out from underneath her stretch top and pants—the gray athletic version that kids wear—she almost looks grotesque. Ohhh, she screams. She keeps her leg in a flexed position.

I say, What hurts?

She says, The hip.

I then try to start with areas of the leg that do not hurt to do the exam. I start to move her foot. Ohhh, she screams.

I say, I thought the hip hurt?

She says, It does.

I then move her ankle. Ohhh! she screams. And so it goes leg, knee, and finally the hip itself—the area of most interest. I say, Well what hurts the most?

They all do, as she bellows.

As the little boy next door looks around the curtain, I find that the EMS crew made some notation of her having stopped taking her pain medicine. I ask, Did you stop your pain medicine?

She says, Yes.

I say, Well, why did you do that?

She says, Well, I figured, if I was coming here, I didn’t want to wreck anything.

I say, Well, I still don’t know that I understand.

She says, Them goddamn Percocets® are not worth a shit.

I say, Ma’am, that is pretty strong pain medicine. (Ironically, it’s essentially the same medicine.)

She says, They stopped my OxyContin®. Those worked. Matters are quickly clarifying themselves for us. The logic of stopping the pain pills and so causing one to present in the most debilitated way possible, certainly still escapes me. I think there might be a muscle spasm component so I offer a sedative-like medicine, which actually seems to help, suggesting that anxiety can be a very large part of the pain process. In this version, however, the husband mutters as well, She shouldn’t have stopped that goddamn pain medicine. I am sure they had other things to do this evening. It was an extremely busy two days.

Tons of patients come in; it is just amazing to see how many sick folk there are in the community.

As I drive home, thank God the sun is brilliant and bright enough to almost blind you. As I glance at the azure-blue sky on the horizon, another perfectly good day draws to its close.

Sunday

As I head out on the half-hour drive to work, a huge buck—a male deer—leaps over a wall in front of me. He has to have leapt laterally twenty to twenty-five feet; it is simply amazing. The morning is cool, as a high-pressure weather system rolls in. Perhaps fall is here, at least an early taste.

We get started right away, three or four patients in the first hour. Then the brand-new intern, who has been polite and dutiful, asks if she can go to the cafeteria. I say, Sure, as I joke. We try never to miss a meal around here. She then comments, You guys take meals here? That’s great. She says, Yesterday I almost got a little sick in the morning without something to eat—no coffee, as she scurries up to the cafeteria. I hope she always gets the opportunity for her morning repast. I know there are some mornings that she will not, as this is the nature of medicine today.

One of our patients has a chronic keratitis, an eye inflammation. As I go back to see the patient, who has only been in the room approximately fifteen minutes, including the time for the resident to see her and ask questions as well, I am greeted with quite a sight. She is lying recumbent on a bed, under a couple of blankets on a warm, summer day, with a telephone draped out of the wall, eating french-fries from a Styrofoam®- tray that she sent her ten-year-old daughter to the cafeteria to get. Sometimes we can see this behavior—this sort of nesting home environment— when patients have been in the department for a prolonged time period with various conditions. But in this case, the patient has been here for only fifteen minutes.

As I ask her to sit up, her daughter ministers to her, Put your head right here, Mommy, in a soothing, reassuring way. We continue the physical exam using a slip lamp—an eye microscope, essentially—to evaluate the minute surface of the eye, but discover little. Her eye pressures are within normal limits, no glaucoma. While her daughter holds her hand, I marvel at the maturity of the little girl. It appears she takes a significant amount of responsibility in this household.

We have a smattering of other emergency cases, acute asthma, acute GI bleed. As we discuss each, the resident seems especially interested, which is a little unusual. So I ask her, How have you managed these clinical problems before?

She says, Why, I have never seen acute asthma or an acute GI bleed. By now—in August—they should have had a couple of rotations. I say, Didn’t you see these conditions in the other departments when you rotated?

She says, Why, no.

An interesting comment. As hospitals get more and more specialized, the actual focus of practice narrows so that