Just like on TV

I was pontificating on the differential diagnosis of a 'worst headache ever' with my preceptor . . . sub-arachnoid hemorrhage, encephalitis, stroke, cluster headache, mass effect . . . when one of the other emergency docs pops his head in the door.

Hey, there's a witnessed arrest coming in in v-tach, this would be as good one for you.

Oh, great! The words pop out of my mouth perkily without processing them.

Gown, gloves, and I stroll into the trauma room following paramedics, nurses, a respiratory therapist and two emergency docs. Standing at the back, observing, seeing what I can learn from this demonstration of the efficiencies of our wonderful medical system. Until the doc gestures at me to get to the head of the bed and thrusts the laryngoscope into my hand. Say what?!?

Have you intubated before?

Yup. Which is the truth, in fact, prior to this moment, my intubation success rate is 100%. That is, in the OR, with no stress and lots of time.

Our 'v-tach lady' had collapsed directly onto her face. A purple goose-egg was starting to swell up on her brow, her nose and chin were scraped and her front teeth loose, jutting out at strange angles and bleeding. Also of note, she had no neck and a receding chin. This combination is any doctors nightmare. It means that the magical smooth intubations you see on ER are in no way possible. And yes, its me currently holding the scope, not an ICU doc, not an anesthetist who has done thousands of these, and certainly not Noah Wyle, just little old me.

Okay, its a one shot deal. Go for it. 'Enough with the drama,' I silently say to my attending.

Metal blade slipping across the tongue, I haul on the handle desperately trying to see anything remotely resembling those golden vocal cords. All I see is blood and tongue. The sickening crunch of metal on teeth as I inadvertently preform a dental extraction and the nurse removes the loose tooth so it doesn't get in the way. When you learn this on the model in med school the head makes a little beeping sound when you lean on the teeth too hard . . . no such warning beep here.

Suction please. I can't see anything. Sluuuuuuuurrrrrrrp.

The emerg doc takes over, tries twice. Eventually getting in a bougie to thread the tube into place. He said it was the worst intubation he'd ever seen. Which didn't make me feel so bad.

I'm under the impression that the emergency department is great fun. Probably because I'm not the one who's really responsible for the patients in the end. But like any rotation there's the good that bad and the ugly.

The good. I got to sew a nose back together that had been sliced cleanly by the knife of 'This One Guy' at 2am when the patient had just been minding his own business out on the street.

The bad. I've had to do a significant amount of DREs (digital rectal exams . . . where the digital part has nothing to do with a Nintendo Wii . . . Wee.)

The ugly. My first ever 'trench foot' experience. Named after what happened to soldier's feet in the world wars from walking around in wet trenches for months on end. To describe it would be too traumatic for all those involved. Smell. Rot. Geeahrgh.

One thing I have learned: if you have friends called 'This One Guy' or 'That Bitch', don't give them your PIN number/welfare check/go drinking with them because they will without a doubt take off with your money/slice your nose open/sleep with your best friend/steal your drugs. In fact, maybe consider not seeing them at all, ever, and getting some new friends.

So yeah, its just like on TV. We even make out in the supply closets now and then.

Crack-a-Lackin'

She sat across the table from us crossing and uncrossing her legs. Pushing herself up in the chair, shifting back and forth. Fingernails scratching endlessly, her knee, back arching to scratch her flank, then her head tilts to the side to itch behind her ear. She looks at me intently, then switches to the psychiatrist next to me, back and forth, and back. She wears a pink tank top and a shirt worn as a skirt that reaches nowhere near her mid-thigh. A smile on her face never pausing in her speech for a reaction.

"I just need some passes I feel so couped up in here there's no air I need some fresh air I have to go to my NA meeting tomorrow its not that I don't like it here I just get so bored just give me a chance to prove to you guys that I can do this I swear I didn't touch his pipe yesterday he just blew the smoke in my face that's why the test was positive I just need some passes I'm so done with him he stole my check he said he was going to make money with it but he just smoked it all away I told him he can't visit me anymore because he tried to sell me drugs after that and why would I stay with him a boyfriend should give me drugs if he's dealing I just need a pass just to go for a walk and get some fresh air."

She is young. On the streets since she was a teen and has never been in a relationship where she wasn't abused and taken advantage of. Its not a unique story. She's friendly with a bright smile and her slightly spread eyes give a hint of fetal alcohol syndrome. She turns a trick now and then when she runs out of money which she needs for her fairly substantial crack/cocaine addiction. Her mood is upbeat as she shifts and squirms in her seat. A disposition that turn directly to tears and irritability when we tell her she can only go on pass with staff. Her outfit has changed four times in the last 15 minutes before the interview. The girl is practically hopping in her chair and being eaten alive by her cravings. There is no doubt in our minds that as soon as she is discharged or goes on pass she'll use again.

So how does one react? Do I feel pity for her? Is she a hopeless case? Does she bring this cycle of sexual abuse and drugs on herself? Drugs that cause terrifying hallucinations of bodies being hacked to pieces that bring her into hospital.

I can't. I feel none of those things. I see her as a young woman who never had a chance. Who society has failed starting several generations ago. It makes something burn inside of me, something bittersweet. Her actions don't frustrate me. Her return to crack and her abuser don't surprise me anymore. I see smoldering hope in her eyes, and I don't THINK its just the bloodshotness.

I'm learning a lot about inner-city life. I know how much crack is a lot of crack, I know which the less seedy of seedy downtown hotels are and I know how to ask how quickly their check has gone to what drugs. But my problem is that I still trust people. And yes, its a problem but I see myself changing, for better or worse I'm not sure. My naive questions about abuse are now worded very differently, the queries about sex trade now flow naturally off my tongue. People hurt each other and they lie, steal, and cheat. My conundrum that I repeatedly come back to is how to keep my skin thick and my heart soft. For life to make any sense I have to believe that people are good, we're all just out there doing our best, a bunch of people trying to be. Each one of us with flaws and baggage.

Tasered

A few weeks ago a man arrived at the Vancouver airport from Poland. He was acting strange, pacing back and forth and speaking in a language his fellow passengers didn't understand (presumably Polish). His name was Robert Dziekanski, it was his first international flight and as the story goes he was visiting his mother. A new country, a strange language, sleep deprivation, exhaustion. I can all too easily imagine the rising anxiety he must have felt, much like I felt on the Slovakian boarder with Austria a few years ago, but I digress, I just got harassed, not tasered. To get to the point, the police were called, approached him, tasered him and he collapsed. No CPR was started for 5-8 minutes. Last I checked, police officers are trained to do it. The paramedics arrived, but by that time his heart wasn't even twitching anymore.

It made me sad.

It made me think.

Cops have a tough job.

Also, tasers suck.

Three patients of mine experienced police force recently. One is stocky and muscular. I completely understood why he needed five officers and a paddy wagon to be brought in. He sported a dislocated finger and a gruesome black eye, the white of his eye bright red with blood. No need to taser this guy of course.

The second, well, I can see how she might be feisty but the truth is she's a tiny five foot Asian girl who weighs 100lbs soaking wet, okay, maybe 105. The police officer felt 'threatened' as she proceeded down the road towards him (with no weapon) so he 'bumped' her with the police car before they got out and tasered her. She definitely needed the taser she got. Oh, can't get my tongue unstuck from my cheek.

The third, also aggressive, out of control in his apartment. I had never seen the actual results of a taser before. A bruise the size of a pomelo, Citrus maxima (yes, we always use food to describe sizes) on his torso with two central dots where the actual 'taser' parts of the taser stick in the skin.

Now don't get me wrong. I'm glad they're using a taser gun and not the bullet variety, the whole point of it is to reduce mortality. People get out of control, they go 'crazy', for medical and non-medical reasons and really, I probably actually trust cops . . . most of the time. I sure wouldn't want their job.

But I don't think Robert Dziekanski was crazy. I think he was anxious and scared. And no one took the time to assess the situation and try to understand him. I'm starting to think that everyone expects the worst from people . . . especially when they are agitated and in an international airport. We all make mistakes. Maybe it hit home because their mistake cost a human life, and that's not so far from my personal fears.