Written by Jenny Chen This past week, we went to Royal Seed Home, an orphanage home to 120 children, located about an hour away drive from our house. We and the social workers, Florence, Grace, Harinu, and Abe worked from 9AM to 4PM from Monday to Friday, tracking each child, transporting them from one station to the next, interviewing them formally and informally, and scanning all of documents in their files. Because there are only three social workers interviewing at a time, the children would line up and wait for their turn and we, the interns, had the opportunity to interact with them. Many of the children had marks that resembled white scabs intended into their legs and arms. Flies would land on the babies until someone swatted them away. One boy limped the entire time, his ankle completely swollen and covered in blood. Almost all of the children were soft-spoken and shy, but once or twice a smile would flash across their faces, whether it was when they posed for the camera, or when the interns gave them high-fives after their interviews. At first, it was difficult to communicate with them. I tried asking them questions like what their favorite fruit was or what their favorite Ghanian dish was, and sometimes the children replied, with lips barely moving, whispering “mango” or “jollof”. My interactions at the beginning felt simple, hollow, and empty. I stopped asking straightforward questions, and instead found ways to engage the kids through children’s games. While the kids were waiting for their interviews, we played rock-paper-scissors, Miss Mary Mack, and drew pictures on a whiteboard to form stories. The children quickly opened up, talking and laughing, and headed to their interviews in smiles. After our fourth day at the orphanage, we successfully interviewed all the children and scanned all of their documents, and on the last day, the children of the orphanage performed a Ghanian dance for us. After their performance, we spent an hour hanging out with them – playing soccer and Ampe, a Ghanian game where two people jump in rhythm. I held a baby boy for the first time. When we had to leave after bonding with the kids for the past hour, it was difficult to say bye to them, knowing that I won’t see them ever again. This feeling of melancholy, something that we had been warned against during our training, grew fainter and fainter as our bus drove further away from the orphanage, and became replaced with hope, hope that we made a difference to the lives of these kids, hope that the interviews and CPQs open new doors for the children, and hope that ways of care other than the orphanage will be found for them, regardless of how long it will take.
By Wendy Bravo
I felt that my services as a Spanish translator were extremely helpful today, more than they ever have been previously. Dr. X mentioned how he couldn’t really find the logic in not having interpreters over the weekend, when the hospital can get real busy, and many Spanish and Vietnamese-speaking patients come in. I felt almost as if I were the doctor at times, since the patients look to me when I answer their questions or clarify what the doctor had just told them. I felt that through my services as an interpreter I could help with the number of cases coming in. Dr. X was very grateful and it made me feel good that I was able to really be of service. About half-way through my shift, someone called my name through the intercom! I know it is probably really cheesy, but I felt important because I knew I wasn’t just following a doctor around, feeling like an invisible person. I was an important contributor to the ER.
By Peter Ballard
Pain management is a concept with which I’ve struggled with. How can you tell when someone is lying to you to obtain pain medication? Is it important to identify when this is the case, or is it more important to avoid the chance of turning someone away in pain? Must I bifurcate? So far, I have not seen a single case in which pain medication was withheld by a doctor at SCVMC. I’m naturally empathetic and I suspect that people could easily take advantage of me when I become a doctor if they are capable actors. I’m not sure if this is something to be concerned about or not. I suppose that I do not care whether I’m taken advantage of…but is it in the best interest of my future patients? Does this enable those who are addicted and prevent recovery? I’m still unsure where the balance lies. Pain is such an individual experience, how do I know when pain is real?
Though i am confounded, watching patients in pain today in the ED was more difficult than in the past and pushed me to reflect on my assumptions about pain. Twenty-five minutes after receiving pain medication, our kidney stone patient was feeling much better, and thirty minutes after she was laughing and joking. The contrast was striking and encouraging. Watching the transformation in a patients demeanor was satisfying and I could tell it was needed. The chance to relieve suffering, even temporarily is motivating. Watching her slip back into pain a few hours later was frustrating, but inevitable. This I could tell was real pain.
By Mischa Li
It struck me today just how costly healthcare really is. For something as simple as the doctor coming and checking you out and telling you that you have an upper respiratory infection and need to stay home and drink plenty of fluids, you must pay over $1000. Where does all that money go? Certainly not the staff — I remember looking at bills from my primary healthcare provider, and visits were around $500, lab tests around $200. Does it really cost that much to take care of people? What’s making the price so high? Doctors in other countries can take care of their patients for much less, so what’s so different about the U.S.? Is the private insurance system causing the problem (because universal healthcare would be more efficient and cost-effective)? It’s actually an interesting problem that I think would be worth addressing in SCOPE somehow. So many people go bankrupt each year just from paying medical bills; it would be good to somehow figure out ways to bring the costs down.
By Danielle Gonzales
Every time he went into a new patients room he would say, “I am Dr. X and this is Danielle, we work together.” Dr. X answered all my questions, showed me different scans, I would look up the different diseases on the computer while he was inputting notes and we would discuss them and he made me feel as if we were a team and I wasn’t imposing on him.
Furthermore, every time I volunteer in express care, I am reminded more and more of how important it is to become bilingual. Anytime I go into a patient’s room and they are Spanish speaking they talk to me because they think I am the translator. Every time I have to tell them that I don’t speak Spanish, I feel worse and worse. Not only have I learned through my experience at SCVMC that it is important to be able to speak another language from a medical point of view but it has become more and more important to learn, personally. I feel this way because the Spanish language is part of my culture and I feel as though I am not being true to my heritage until I am at least able to speak the language.
By Janet Chu
Currently, there are 47 million Americans without health insurance, which limits their ability to seek and access care. For them, the way that they receive healthcare is through free clinics or more commonly, the Emergency Room (ER). Using the ER as their primary form of healthcare is expensive and they do not receive regular or preventative care. This perpetuates the vicious trend of driving up the cost of providing healthcare in America, which then makes health insurance more expensive, leaving more people without health insurance. It is a health policy issue that needs to be addressed. While the death toll itself is a staggering burden, it is only a part of the picture. The rest of the picture is filled with individuals who deal with the complications of both infectious and chronic disease. I find purpose in the day-to-day struggle that physicians encounter in providing individualistic and comprehensive care for their patients.
At the end of my day of training as a Vietnamese Interpreter, I went on a face-to-face interpretation in the E.R. with a staff member from interpreting services. I was excited because this is the exact environment in which I will be working. We interpreted for an older woman who came in with pain because she could not pass urine. She had the urge to urinate, but physically was not able to; the plan was to put a catheter in for her because her son told them she was in terrible pain. When we arrived, we checked in with the doctor who had asked for the interpreter service. Upon entering the room, the flustered son was demanding that we help his mother. While the doctor was asking routine questions, the patient kept complaining of the pain, continuously asking for a way to enable her to pass her urine. Dr. X was trying to take control of the situation, asking the patient to pay attention and answer the questions. However, she could not because she could not ignore the pain. When the doctor reached over to touch her, the patient screamed “Don’t touch me!” When the doctor heard the interpretation, she was clearly offended.
This made me think of how doctors constantly deal with such patients on a day-to-day basis; they must maintain composure and a sense of professionalism even under such situations. Because the patient was unwilling and unable to answer the doctor’s questions, this created a barrier to providing care. While I agree that the patient should be made comfortable, I understand that the doctor felt the need to understand the symptoms before doing anything so as not to exacerbate the situation. Being a physician means more than understanding the science behind diagnosing and treating disease. The practice and art of medicine requires a holistic approach and understanding of the patent’s physical and emotional needs.
By Xochilt Borja
During my first shift training as an interpreter, I felt truly immersed in my own culture. I remember Dr. X spending a lot of time informing me that many of the patients we see are immigrants, sometimes illegal, and that they are vulnerable because this is a new system, a new culture. This vulnerability sometimes leads them to accept any service they may get, even if it may not be the best. Dr. X said that the ER serves as a safe place for them, providing someone to whom they can relate and express themselves freely. If we do our job right, we can clearly get the doctor the information they need so that the patient is fully served and satisfied. He also said that as interpreters, we have a great responsibility because we act as referees between the doctors and the patients and it is on us to make sure that both patient and physician are well served and satisfied.
By Dr. McCullough
Four Quads (Quadriplegics)
During a recent trauma shift I met John (name changed) (quad #1), a vibrant C5-6 quadriplegic with a wonderful new wife, a brand-new van (now totaled), and recent baby he had conceived in the “natural way.” Since his diving accident in high school John hadn’t missed a beat of the drum of life. His eyes and smile lit the room from the trauma gurney where he recounted the funniest story we had heard in some time in the ER.
C5-6 ‘quads’ (cervical transaction between the C5 and C6 vertebrate two levels below Christopher Reeve’s injury) can actually control part of their arm and shoulder, not a complete quad as we think it. The higher you transect, the more you lose. Christopher Reeve breaths with help of a ventilator. Two levels lower, at C8-T1, you can use your hands. Spinal injuries almost come in clubs because the deficit patterns are so specific, depending almost entirely spinal injury level.
In sum, at C5-6 one can pull but not push, with no finger movement. But if notched into a steering knob on the right hand, and a modified throttle and break on the left, a quadriplegic at C5-6 can, barely, but safely, drive an adapted car, usually a van.
Years ago, my uncle Ted (real name) (quad #2) let me drive his van in college when he wasn’t using it, so I am personally familiar with the controls. He had broken his neck being active too, as a helmeted motorcyclist enjoying the Oregon countryside where I grew up. Like John, my uncle Ted’s injury ignited his spirit and appreciation of life. Ted taught me medical lessons long before medical school, especially about spinal cord injuries.
For John, getting his new van was Christmas and a birthday rolled together. Freedom. An open road. Less dependence.
John was out for his second test-drive, on a local highway when his throttle jammed. 55, 65, 75, 85, 95mph. Quite a powerful engine, more so than the brake which shortly ground through after dropping the speed to 40. The engine overpowered the brake. Back up. 45, 55, 65, 75, 85…….
John is quite a storyteller, even from the gurney; his facial animation makes up for his lack of coordinated arm movement, even imitating the 8-cylinder engine noise accelerating back toward 100mph.
John’s wife gazed glowingly as he came to the climax of the story. “I figured I better get off the highway or I was going to die.” Sure enough.
Off-ramps can’t take those speeds, so John just jumped it. Through a perimeter fence, traversing an open area, piling an inner fence, smashing a barrier, over a curb. Each obstacle absorbing some speed. Down to zero, stalled in the dirt.
But the only reason to have such an open space in the crowded Bay area was that this was Lockheed’s military research wing. And all the security guards saw, or at least what they reported to the S.W.A.T. team, was that a white windowless van has just penetrated all their defenses at 80mph.
Helicopters. Sirens. M16’s. Laser sights. “I was lit up like a Christmas tree.”
“Step out of the car.” The megaphone boomed.
“Hands over your head.” Came the second request.
Neither of which is really possible with a C5-6 injury.
“If I still had my goatee, I think I would have been toast.” John proposed.
Certainly, the post 9/11 anxieties accented the whole affair.
Eventually, the laser sights lowered; an ambulance was called (just to be safe). This brought John’s pleasant story, and happy conclusion, to the tail of my long shift during which two others had died in unrelated illnesses.
I admitted John to the hospital just to be sure his sore neck was ok. It was — CT scan negative — and he went home today.
I never learned the name of Quad #3; I will call her Julie. We briefly met in the hall one fresh Sunday morning near the spinal rehab which is in the same wing as the ER. Her injury was fresh, as evidenced by the back brace she wore. Hands flat, electric chair movement controlled with her chin — a C4-5 injury at best.
Julie’s mischievous grin and presence in a main hallway made it clear she was playing hookie from the rehab unit. I enjoyed Julie’s smile so much that I circled back around a parallel hallway for the privilege of greeting her smile again.
A study on quadriplegia and happiness showed that, within 2-3 years, following the initial shock and regrouping, that quadriplegics usually return to their baseline levels of happiness. Julie didn’t seem to want to wait that long. Her smile radiated so deeply from within that it seemed to be formed more by her spirit than her lips.
Although I’m usually happy, Julie’s grin and playful laughter as she hid from the nurses and basked in the morning sun, made me wonder how long, with all this medical education, it had been since I had smiled and laughed like Julie did, so fully consumed in the moment.
Sometimes, people ask those who work in the trauma center and public hospital how they work around such pain and suffering. Good question. I think the acuity of events often stirs a sleeping authenticity we seldom get to enjoy from others.
I have come to enjoy helping trauma patients, not for the blood, nor even for the trauma at all, but because, for windows of brief lucidity, the entirety of humanity, decency, and compassion sometimes emerges. Priorities are set right. Bonds of family and friendship are polished and reinforced. I like medicine for this, emergency medicine in particular, because it reminds me, as it reminds the patients, of the echo of the meaning in their lives.
Quad #4 was a lesson in assumptions. Drunks and drug addicts often arrive in cervical collars to protect against potential neck injury (as do about half the ambulance patients). Recently an ambulance arrived with a patient (I will call him Brian) for transfer to ‘rehab.’ He appeared disheveled. At first glance, this garnered a homeless appearance.
One of the ER nurses asked the paramedic “which drug,” which is a fair question as someone enters drug rehab. The sober patient piped in, “I just broke my neck at C6.”
Spinal rehab, not drug rehab. We all took a breath. For us, a little collective humility; for Brian, a new life trajectory.
I walked over, laying a hand on his shoulder, looked Brian directly in eyes and told him we would do everything we could, meaning that rehab would. I tucked a loose blanket in. My Uncle Ted had taught me long before my medical school that quadriplegics have problems with heat regulation; perhaps Brian was already too cold and didn’t know it. With complete lucidity, he just said “thank you.”
In the past hour since the injury, Brian had clearly lived a year — obviously, visualizing his new life, or trying to. He stared straight up, watching the ceiling go by as the paramedics whisked him off to spinal rehab.
I hope he gets to work with Julie during therapy.
By Peter Ballard
Dr. X and I have a laugh each time I remind him that the word of the day is “ageusia” from a patient we saw that had a history of acromegally and was now experiencing loss of taste sensation. Another Dr. X patient led to my doing a tremendous amount of research on Diabetic Keto-Acidosis.
Dr. X taught me to always ask a patient what you can do for them and to never settle for blindly following procedures. “Use your brain!”
Dr. X taught me to always encourage patients to stop smoking.
Dr. X modeled the importance of addressing the personhood of the patient.
Dr. X displayed how to make each patient feel that they are the only one that matters, even if it is only for a moment.
Dr. X taught me the importance of a sense of humor and to always anticipate how an ER patient may physically harm you and prepare for it.
Dr. X showed true humility.
Dr. X spent time explaining how to make career decisions in medicine.
Dr. X displayed some of the best bedside manner I have seen in emergency medicine.
Dr. X taught a no-nonsense approach to medicine.
I have never enjoyed learning so much.
By Ann Leu
The nurse was obviously really annoyed and rightfully so. It was a hard procedure to watch, as the patient was very obviously very uncomfortable. But the surgeons were determined and made multiple attempts– with her hand inserted, with one forcep, with two forceps, by injecting air inside with a large syringe, nothing worked.
The nurse can really serve as an important advocate for the patient. Communication between all members of the healthcare team is so important to bring the best quality of care to the patient.
On a completely different note, it has been such a great experience shadowing doctors in the ED. I have learned so much and it has made me that much more excited to start medical school. I am sad to leave, but I shall return! How cool would it be if I were to come back to Stanford for my residency? It would be so great to be able to come full circle. I started at SCVMC as a volunteer in the information desk, which provided such a great foundation for my knowledge of the hospital as a whole. I started to build my confidence, to practice talking to patients , and to communicate with people of all backgrounds and tempers. Cora and Kathleen have had the pleasure to watch me grow and to progress to SCOPE, and it has been wonderful to share that experience with them. I will miss them! I also feel I have made some friends in the ED, some techs, RN’s, registrar, and lastly, MD’s. There are a number of doctors and residents that I’ve really enjoyed working with and feel that I could really see myself fitting into the culture. Though I hadn’t really considered emergency medicine, it is now a definite possibility in my mind. Who knows what the future holds? Maybe I will be back in 4 years!