Low Tech Medicine

by William Fyfe,  SOM Class of 2018

Third Prize Winner 2016 Gerald F. Berlin Creative Writing Award

 

The emergency room is quiet as I sit uncomfortably on an old stool Dr. Carpenter procured for me from one of the exam rooms down the hall. She is freshly changed into scrubs and getting ready to start her shift. This is my second day of shadowing as I attempt to get a feel for the pace of a community hospital ED. With hands folded in my lap, I try to find a polite place for my gaze to fall as she clicks and types her way into the hospital’s computer system. For a few seconds, I settle on a disheveled looking alcoholic snoring loudly in the curtain area across the hall, oblivious to the IV fluids poring into his veins as he sleeps off his most recent bender. His short cropped hair makes his head look out of proportion to his bare, protuberant belly, which rises and falls with each loud, obnoxious breath. Dr. Carpenter is unperturbed.

Without looking up from the screen in front of her, she takes a sip from her styrofoam coffee cup and says, “There’s a patient in four who just came in with chest pain and shortness of breath. Why don’t you go see her and let me know what’s going on?”

Wait, did I hear her correctly? “You mean… just head over there now?” I ask foolishly.

“That would be a good first step,” she quips. I watch as her eyes dart back and forth behind her glasses, reading lab results from the screen in front of her.

“Sounds good, be back shortly,” I tell her. I step out of the dictation room and turn right. I take several more steps before I realize I have no idea where room four is. Great, I think. The patient is going to be dead before I can even find her. That thought induces a far more anxiety provoking one. What if she dies while I’m in the room? How do you do CPR again? My last refresher course suddenly seems both immeasurably distant and wildly inadequate.

I follow the hallways around, making a big circle, frantically searching for single digit room numbers. Finally, I find it, just to the left of the dictation room I initially exited. Trying to will the redness from my cheeks, I pause before pulling back the curtain and stepping inside. What am I supposed to be doing again? That’s right, taking a history. In this new environment, I always seem to be finding my body several moments ahead of my thoughts. One question at a time, I encourage myself.

I feel my hand close around the cloth curtain and my body slip inside. I’m conscious of my accelerating heartbeat as I take in the scene unfolding before me. A nurse is calmly entering information into the computer with her back turned toward the patient, who is a young Hispanic woman not much older than me. Shortness of breath is right, I think to myself. Lying there on the stretcher, I can clearly see the muscles in her neck strain as she tries to breath faster and faster. With tears streaming down her cheeks and onto her pillow she looks up and meets my eyes. “Please, please help me. My chest hurts. It hurts so much. Something’s wrong, please.”

As my brain tries to process the information in front of me, my eyes are drawn to her hands. With both elbows resting on the bed, her forearms point awkwardly toward the ceiling, perpendicular to her supine body. Her wrists are flexed unnaturally inward, her fingers contorted and stiff. I have no idea what I’m looking at. Before I can slip out of the room as quietly as I came in, the nurse looks over her shoulder and catches my eye. Nodding her head toward the empty space next to her chair, she invites me over. As I cross the room I can feel the patient’s eyes follow me, still pleading for help.

“Thirty-one year old female, arrived by ambulance, presenting with shortness of breath and constant chest pain for the last hour. She has a history of anxiety and has been seen here multiple times over the last year for panic attacks.” At this last sentence she pauses and looks at me. “Her name is Maria.”

“Thanks,” I offer sincerely. Those few moments of familiar routine gave me time to calm down and think. Obviously, Dr. Carpenter was not sending me off solo to witness an impending cardiac arrest. No doubt she had already reviewed the patient’s prior history and EKG from her computer and deduced exactly what was going on. Walking up to the patient I say, “Ok, we’re going to help you, Maria. Tell me about the pain in your chest.”

Over the next five minutes I work quickly through the set of questions we were taught over the last year, surprised at how naturally they roll off my tongue. She’s scared and thinks she’s having a heart attack, which is doing nothing to help her anxiety. I still have no idea what is going on with her hands. Reassuring her that I’ll be back very shortly, I step out to see Dr. Carpenter.

Before I even round the corner into the dictation room I hear her say, “What have you got?” I step into the room and relay essentially what the nurse told me, adding a few more descriptive details about her chest pain for good measure. “Well, what do you think?” she asks me.

“Ah, it seems like she might be having another panic attack.”

“Ok, so what do you want to do?”

What do I want to do? Nobody has ever asked me that before. “Umm… I’m not exactly sure. It also looks like her hands are all cramped up. I don’t have any idea why.”

Taking pity on me, she smiles. “Ok, so your patient has been blowing off CO2 for the last few hours and now she’s developed a respiratory alkalosis. What happens when your pH gets too high?”

“You get cramps?” My voice inflection betrays my severe lack of confidence.

“Close enough, we’ll walk through it later. Right now, I’m going to show you a neat trick. Take these.” She hands me a pair of trauma shears from one of her pockets. “Cut the bag off of a non-rebreather mask and have her hold it around her nose and mouth so she can start retaining some of that CO2. Low tech medicine.”

Back in room four, Maria is still crying and pleading for help from anyone who will listen. She looks terrified. Walking up to the head of the bed I tell her that the doctor looked at her tests and her heart is just fine. “You’re having another panic attack, and I’m going to help you, ok?” I take a non-rebreather from the wall and cut the bag off, just like Dr. Carpenter taught me. Pulling it open, however, I rip one of the seams, rendering it useless. I grab another, and perform the same maneuver, slightly more careful this time. “Hold this up to your mouth, it will help with the pain in your hands.” Having been through this drill many times before she nods and tries to take the bag from me.

“I’m sorry, I can’t hold it. Please, please can you hold it for me? Oh, my hands hurt so much.” I don’t know, I think to myself, I’ve never done this before. Am I allowed to touch a patient by myself? Maybe I should get a nurse. “Please hurry, oh, it hurts so much!”

“Ok, here you go,” I say as I tentatively bring the bag to her face. A few minutes later, the nurse walks in. Cocking her head to one side she looks first at me, then down to the floor, then back up at me.

“You know, we have brown paper bags. Would you like me to get you a paper bag?” She raises her eyebrows.

“Umm… yes, thank you. That would be great,” I respond. I feel my cheeks flush for the umpteenth time since breakfast.

Standing there, holding the paper bag as Maria tries to slow her breathing, I suddenly become cognizant of how happy I am. After all the new and uncomfortable experiences of the last few days, here I am, alone with a patient. There’s no rush, no decisions to be made, no questions to answer. As I try to calmly convey words of encouragement, I even feel myself relaxing. Maria’s hands start to tremble as her muscles begin, ever so slowly, to loosen.

“That’s it, you’re doing great. Nice and easy.” As her breathing slows, we talk. She’s a mom, with two young children at home, and very proud. She asks me about medical school, and I ask about her son’s recent kindergarten graduation. Eventually, she doesn’t need me to hold the bag anymore, but I stay just the same. Dr. Carpenter doesn’t come and get me. She knows exactly what’s going on. I’ve just treated my very first patient.