Chapter 2
Emergency Department
DISCLAIMER
This is my true story, with adjustments for artistic license.
To protect their privacy, I changed names and biographical details of any individuals depicted. All patients are fictionalized and inspired by my aggregate experience as a physician.
Any views expressed are mine alone, and do not represent the positions of my employers.
My writing is not graphic, but it does describe medical details.
On a normal day, I would not even think about the drive from our neighborhood to the hospital. It took maybe fifteen minutes without traffic and required few turns. The kind of drive you can make almost automatically. This day was not normal. As I navigated, I concentrated on each breath and could feel my heart pounding in my chest.
When I was a resident, I took care of Dan, a husband and father with uncontrolled asthma who drove himself to the ED. He was having an asthma exacerbation and did not want his family to see him collapse at home. His condition deteriorated on the way, and he was fortunate he made it to the ED. Dan survived, walking out of the hospital under his own power due to a combination of good luck and outstanding medical care. I knew I was not at the point he had been, but thinking about him was one of many times in which my intimate knowledge of how bad things could get, and how quickly, was not psychologically helpful.
Eventually, I turned, pulling in to the visitor parking lot attached to the hospital. The same garage where I had parked to take Kathryn to same-day surgery that fall. Today I was both driver and patient. Parking on the second level, I walked to the elevator, pausing to rest a few times on the way. Mercifully, the elevator came quickly, and I only had to go down one floor.
Turning out of the elevator and through the small brick wall separating the garage from the hospital, I stared down the sidewalk. The entrance to the ED seemed far, maybe 100 feet away, past the employee entrance to the hospital. I made my way down the sidewalk, noticing my breathing and palpitations as I went. The automatic doors opened, and I walked in. The security guard looked up, greeting me.
“Are you here to be seen?”
“Yes,” I puffed.
“OK, empty your pockets into this,” he said, handing me a small plastic bowl, “then you can walk through the metal detector. Registration is just through there.”
I set my keys and cell phone in the bowl, went through the metal detector, then re-packed my pockets.
At the registration kiosk, I entered my name and date of birth. Then the screen displayed a question:
“Are you having chest pain or shortness of breath?”
For the first time ever, I checked “Yes.”
The computer directed me to the registration desk. The clerk gave me a special triage form, put on my wristband, and asked me to sit down. I followed his instructions and sat in a chair nearby, wearing a mask.
I remembered to text Kathryn.
FYI I’m safe at the hospital
Great
A minute later, the triage nurse peeked out and saw me sitting in the chair nearby.
“Can I offer you a wheelchair?” Her voice was kind.
Misinterpreting this as a question, I replied “I’m OK...just a few steps from here to there.”
I stood carefully and took the few steps over to her, sinking into the triage room chair. Exhausted, I was also relieved to be in the presence of a medical professional. She placed the blood pressure cuff my arm and the pulse oximeter on my finger, waited for the cuff to cycle. When it finished, she noted my vital signs: a heart rate in the 130s and a respiratory rate in the 30s. Not normal.
“You look short of breath, so I’ll keep the questions brief.”
No small talk today. I could see the concern on her face and hear it in her voice.
“Thanks”
“Any allergies to medications?”
“None”
“Take daily medications?”
“Symbicort...montelukast...Zyrtec...famotidine”
“So...I think I know the answer...but what brought you in today?”
“I have asthma...think I got the flu...needing some extra inhaler...despite starting prednisone”
“Any fevers?”
“Maybe 100...nothing high”
“OK, let’s get you back to a room.”
She gestured to the nearby wheelchair, “Can I offer you a wheelchair?” Her voice firmer this time.
Understanding now that this was not so much a question as her informing me that I would not be walking back myself, I agreed.
We wheeled back through the hallway and into a treatment room on the acute side of the ED. I walked the short distance to the stretcher in the room and was placed on the cardiac monitor and pulse oximeter. Laying back to try to rest, I needed the back of the stretcher upright. I could not breathe comfortably lying flat. Or I suppose I could not breathe comfortably in any position, but lying flat made it much worse. My heart rate at rest was in the 120s, and with any movement up to 130 or 140. I was breathing nearly 30 times a minute and hacking intermittently.
Into the room came Will, the emergency medicine attending for the afternoon. We knew each other through patient handoffs between the ED and ICU—including during my previous week rounding and multiple times over several years. I was glad to see his face, as he struck me as kind and competent when we interacted. He looked at me, and then up at the monitor. Then back at me, and then the monitor. Will was not reassured.
“I’ll spare you the repetition. I read the triage notes...no med allergies, and you take an inhaler and some pills for asthma?”
“Right”
“What’s going on, Ian?”
“I think I...have the flu...asthma acting up...since yesterday.”
He registered my short, breathy speech.
“Can I take a listen?” He asked, pulling his stethoscope to his ears and approaching the side of the stretcher.
Leaning forward, I tried to take deep breaths, in and out, while he listened to my back. I coughed with each exhalation.
“Yeah, you’re really working,” he said as he listened.
Still coughing intermittently, I continued the history after he finished listening, “...started prednisone...but worse today”
Will stepped back, having completed his exam.
“Ok, so your asthma...have you ever been intubated?”
“No”
“Admitted?”
“No”
“You’re pretty short of breath, my friend.”
“Yes”
“OK, well that’s enough for now. We’ll do some nebs, steroids, and get a swab. Let’s see if we can get you turned around.”
Next in came Jack, the ED nurse who would be taking care of me. He made a cocktail of liquid decadron and lemonade.
“Got a little shot and mixer here for you. Need a straw?” He asked with a smile, handing me the yellow lemonade carton. I liked his style.
“Yes please,” I replied.
“Wait, before you drink that, let me do this,” Jack took back the lemonade and held out the viral swab kit.
Fun. Haven’t done one of those since COVID.
Jack pulled out the small, plastic swab. I braced as he threaded it up my right nostril, rotating. I was reminded how these felt, like someone was sampling my brain.
At least it was quick, “There...all done buddy.”
Between the swab and my asthma, I hacked and sputtered for thirty seconds. The monitor alarmed again for tachycardia. Taking the lemonade back from Jack’s outstretched hand, I sipped it down. I was thirsty, my lips were dry, and it was refreshing. Decadron and all.
Jack unscrewed the nebulizer chamber, squirted in a few vials of nebulizer medication, and screwed it back together.
“Here, take this. You’ve used one of these before?”
A pulmonologist and asthma patient myself, I was familiar. Brandon and Leo had also been admitted once each to Children’s with asthma. Just overnight.
“Yeah...sometimes, I play...a PICU nurse...and RT...at home”
I placed the mouthpiece of the nebulizer in my mouth, and Jack turned on the oxygen at the wall. The chamber began to hiss. I watched the vapor flow in and out of the corrugated tubing, as I inhaled and exhaled through it, slowly.
My dragon breather
What I call my sons’ nebulizer, so they keep it in their mouths when they need it.
I was all set for now, feeling the nebulizer starting to have some effect.
"Here’s your call bell...just ring if you need anything, Doc,” offered Jack, walking back out to the nurses’ station to see who was next up.
After the nebulizer, things felt better, but not great. I saw on my health app that my swab came back positive for influenza A. Will came back in.
“How are you feeling, Ian?”
“The nebs helped...but I still feel tight.” Longer sentences, but not normal.
“I see...well, I think we both know what this means. You can’t go home feeling like you do.”
I nodded, understanding I would be admitted.
He continued, “Honestly, not surprising with the flu and asthma—it’s been a rough flu season. I’ll bump up your steroids and try some more albuterol. And we’ll work on finding you a bed upstairs.”
Will ordered more steroids, an additional hourlong nebulizer, chest x-ray, and labs. Jack came back in to place an IV for labs and meds in preparation for my admission to the hospital. One stick, expertly placed in the large vein in my left antecubital fossa. I had no idea at the time how long that IV would be in my arm.
Hope you enjoyed this latest installment. If you have feedback, I’d love it—DM me or comment below!
thanks for sharing this