The Power of the Powerless

I remember reading a story about a rather wealthy Indian lady who volunteered to work for Mother Teresa for a day, back in the years before Mother Teresa was an international celebrity. This Indian lady arrived at the clinic, which was a house for the dying, and was instantly overwhelmed by what she saw, heard and smelled. I know how she felt, too. Walking into a place like that is an instant sensory barrage of horror and evil. The evil, ugliness and pain are all very sensory phenomena, with their accompanying groans and screams, odors and wounds. The peace and love that the patients experience for the first time in their lives is much harder to see. The sight of raw flesh of a beggar who got run over by a truck is easier to notice than the fact that his wounds have been painstakingly cleaned of dirt, maggots and infection;  emaciated arms and ribs of a man who should weigh 70 kgs but instead weighs barely 30kgs hide the fact that he has just received the first good meal of his life, spoonfed by a woman who has dedicated her life to loving him; the smell of a human being in total kidney failure when his uric wastes are oozing through his pores on his skin disguises the fact that he has just been bathed today for the first time in his life. All of these things are a shock to the system. Even a trained and experienced medical practitioner can be overwhelmed walking into such a scene. Where do you start? What do you do? But this rich lady was a lay person, just an upper caste woman who had a kind urge and decided to volunteer for a day. I can only imagine what she must have been feeling as she stood there, surrounded by the obvious horror of human suffering. She must have been terrified, bewildered, filled with sorrow and helplessness. She must have wanted to turn around, run right back out the door, and never come back.

Fortunately there was something else at work, subtly, quietly, faithfully hidden under the obvious horror. Mother Teresa took this lady by the hand and led her to the most heartbreaking patient of all. A newborn infant was lying on a cushion, alone. Perhaps his parents had abandoned him, or perhaps they were dead. This was not a healthy baby. He was lethargic and emaciated. He did not cry or flail his tiny arms around. He did not startle the way a normal baby should, or grasp with his hands, or even suckle when a nipple or finger was put to his lips. He just lay there with his arms and legs spread out limply around him, breathing with the halting, abrupt, shallow gasps of a baby for whom simply breathing takes too much energy to be worthwhile.

Mother Teresa led the rich lady to this baby and told her simply to pick the baby up and hold him and love him for the few minutes or hours he had left to live. The rich lady protested that she couldn't possibly do that. It would surely break her heart. Mother Teresa only repeated her invitation, and went about her work. Left there in front of the dying infant the rich lady made a choice. She reached down and took that baby in her arms and held him. For the rest of the day she did nothing but love that baby as hard as she could until finally he died in her arms. And her heart broke, but not with anguish as she had expected. It broke with love.

I read this as I was in the first half of the SF medic training course, and it forever changed my view of medicine and healing. As healthcare providers we are trained to save lives. Our thought and energy are bent on staving off death for as long as we can, prolonging life, reducing pain, preventing or mitigating disabilities. All true healers have this goal, but all of us inevitably face the truth that our patients are going to die. Put it off as long as we can, prescribe what we will, in the end death will win. We can only delay it. Sometimes we can delay it for years. Sometimes only for minutes. Sometimes the patient is already dead, but their body just hasn't figured that out yet.

Faced with this truth, each health care provider, from the lowest EMTB to the Surgeon General (who generally does very little surgery from what I hear) has to find his own way of dealing with it. Some choose to ignore it. Some simply shrug their shoulder and move on. Some stop caring eventually. But in Mother Teresa's radical and almost unforgiveable request I believe I have seen the only true way forward. We must look deeply into the horror of death and see past it to the subtle, patient, silent work of love which is operating underneath the horror and pain, stronger and older and wiser than them. In the truly authentic Catholic approach to healthcare there is the acknowledgment that the patient will die, and the deeper knowledge that love is stronger than death. Even if the patient will only live for a few seconds, those few seconds can be lived with dignity. They can be filled with life and love and peace, if someone is brave enough to let God use them to be that gift. Such moments are never wasted.

All of this went through my mind when I saw this video by Tammy Ruiz a Registered Nurse who specializes in Perinatal Bereavement and Perinatal Hospice. I am not at all ashamed to admit that I couldn't watch the full video without tears in my eyes. The work she does is beautiful, heroic and necessary, and alas, all too rare.

Please watch the video and pass it on particularly to any medical proffessionals who are involved in birth and perinatal care. Pray for Mrs. Ruiz and the continuation of her vocation, which is truly a call within a call. Take the time to celebrate life in whatever way you can. This is a solid, concrete answer to the culture of death and a joyful affirmation of the infinite value of every single human person, no matter how small.

Go here to read Mrs. Ruiz's own words on her work.


(The Title of this post is taken from the title of the amazing book by Christopher De Vinck.)

Patients are More Fun when they Aren't Drama Queens

One evening a little girl came into the ER. She was about nine years old, and she had fallen on her outstretched hand while roller-blading. Her right arm was in a sling and she had abrasions on both her knees, but what really struck me when I walked in the room was the fact that she was sitting contentedly and quietly on the edge of the gurney, kicking her legs and looking around with interest. She was little and cute in the way that only little girls are, with messy brown hair done up in a sort of pigtail. She was still wearing shorts and a t-shirt, although someone had thrown a man’s zipper jacket over her shoulders, because the room was cold. Her parents were standing on either side of her, looking anxious, but she had a bright, intent, wide awake look. Her eyes were open all the way and a little extra as if she was perpetually amazed that there was so much in the world to see. She grinned at me as I walked into the room in my scrubs with my beard and that reminded me just how awesome my job was.


“Hello,” I said cheerfully. “What brings you in here tonight?”

“Oh,” she said casually, as if it had just suddenly occurred to her, “I fell while I was roller blading.” Her voice was cute too, very high pitched and squeaky. She said it with a perky attitude like, “Oh, if you must know. It’s probably not even worth mentioning, but you asked.”

I knelt down in front of her and examined her knees very carefully. “Hmmm, yes, I see. Wow. Well, you know, I think we can take care of this. I can call a surgeon and well get you scheduled in. We’ll probably take them off right about here.” I made a slashing motion across her legs right above her knees.

She laughed and squealed, “No!”

“What? You don’t want us to take off your legs? Really? Then why are you here?”

“This!” she laughed and held out her arm in the sling.

“Ohhhhhhhhhh!” I nodded, because it was all so clear now. “So that’s why your arm is in a sling. Oh, I get it. Okay, so what happened to that?”

“I fell on it,” she giggled.

I got her to describe how she had landed, and to point out exactly where it hurt, but she assured me that it didn’t hurt very much at all. I made her go through all her ranges of movement with her wrist and elbow, and then poked and prodded and pinched and squeezed. “Does it hurt here?”

“Nope.”

“Does it hurt here?”

“Nope.”

“Does it hurt here?”

“Nope.”

“How about here?”

“Not really.”

“You know what? I’m not even going to ask you any more questions, because you’re too tough. You could probably be lying on the floor with your hand cut off and I’d ask, ‘Does it hurt’ and you’d say, “No, not really’.” I said the last part in a high, squeaky voice to illustrate how she would say it.

She just laughed at me. Her parents relaxed a little bit when I explained to them that she might have a small fracture but it didn’t look serious and we’d get some x-rays to see exactly what was going on.

For an adult I wouldn’t even have needed an x-ray, although in a civilian hospital I probably would have gotten one just because it’s expected. Since she was a child, though, I wanted to make sure there was no crack in the growth plate. In the ends of every bone in a child’s body is a thin plate of cartilage sandwiched between the end (epiphysis) and shaft (diaphysis). The area where it attaches is called the metaphysis. As the child grows the cartilage grows and gets longer and longer, while at the same time it is being replaced by bone which does not grow. At some point, usually in the teen years, the bone replacement catches up with the cartilage growth and then that limb stops growing. When this happens in all bones of the body the person has reached his or her full height. However, if the plate is damaged while the child is still growing this can cause the growth to be lopsided or deformed or even to stop altogether. Hence the reason I ordered an x-ray.

As it turned out her growth plates were fine. The only damage was a torus fracture of the radius and ulna. Another characteristic of children’s bones is that they are softer and more flexible than an adult’s bones. Under stress they tend to bend and wrinkle rather than crack, somewhat analogous to the difference between a green twig and a dry stick. A torus fracture (also known as a buckle fracture) occurs when the outer layer of the bone, the cortex, wrinkles under pressure. It's pretty easy to see in this example from medscape. Follow the long bones up towards the wrist and you will see a buckle in each side of the bone. Hers looked very similar. She thought it was pretty cool that she could see it on the x-ray.

So we put her in a short arm splint to immobilize the wrist and signed her up for an orthopedic consult a week later. She was still chatting it up with the nurse as she fitted the splint, and I just had to go in to watch. If only all my patients had a sense of humor like that.

Scope of Practice

One night the EMS brought in a girl who was found unresponsive in her home. By the time she arrived at the ER she was answering questions, mostly appropriately, albeit with a significant delay. We were able to get a complete but contradictory history from her. She denied remembering anything, although she said she had had one drink and some marijuana with her friends that morning. We told her this looked like a drug overdose but she didn’t respond to that. She was a very pretty 21 year old, but she was far too thin for her body type and her forearms were crisscrossed by dozens of fine white scars. Physical exam was mostly unremarkable, except for a general lethargy and delayed/weakened motor responses in her extremities, and her pupils which were pinpointed, no focused and sluggishly reactive to light. She did not have the ability to follow a light with her eyes. All ocular movement was erratic and saltatory.


We did a urinalysis (UA) tox screen on her and it came back hot for barbiturates. Looking back in her file I found that this was her fourth time in the ER for prescription drug use. To top it all off, she was a pharmacy tech.

We had a long discussion with the ER doc about what we could do. We were all agreed that she shouldn’t be working in a pharmacy, but he said there was nothing we could do without violating patient doctor privilege. I argued that the laws contain a clause that states that if the patient is in imminent danger of causing harm to herself or others we not only have a right but a responsibility to report it to the appropriate authorities. In my view if a druggy is handing out drugs, her dipping into her own stock is the least of my worries. My worry is that she’ll be high at work and she’ll mislabel a bottle or put the wrong pills in it, or the wrong dose, or give it to the wrong patient and that could literally kill someone. Has it happened yet? No. I don’t think waiting for it to happen is a good plan. She needs to get fired for everyone else’s safety.

And what about her? Why the drugs and the alcohol and the cutting? Her mother showed up at the ER and wanted to take her home against her will. The charge nurse explained to her that we could not release her into anyone’s custody because she was not a minor. We could not keep her if she didn’t want to leave, we could not sign her over to her mother if she didn’t want to go. Her mother argued back, unable to see the plain facts of the situation through her grief and frustration. Didn’t we see that if she went back to her own house she would just get stuck with her friends again, and these friends were really bad. It was all their fault her daughter was doing drugs. If the patient could come home with her she (the mother) would keep the bad influences out of her life and she would turn around. Why couldn’t we just see that?

I couldn’t help but wonder, if that parental love hasn’t been sufficient thus far, what makes her think it’s going to become magically effective now? Regardless, legally there was nothing we could do. Like it or not, she was 21 years old. She was legally responsible for her own decisions and we could no more remand her into her mother’s custody than we could detox her. She was not in danger of her life. She was not overdosed, she was just stoned. That’s what those drugs are supposed to do. Even if she had been in danger the only treatment is to stick a tube in her stomach and pump out any pills that haven’t been absorbed, dilute with activated charcoal and support heart rate and respirations until the effects wear off.

What was up with her? The problem was far beyond emergency room scope of practice. Did her parents not love her? Had she been abused as a child? Had she not been able to find any good friends? Whatever the myriad single elements that made it up, they all came to one thing. The problem was that she had a deep, throbbing, aching, abysmal hole in the depths of her soul. That is beyond my scope of practice.