Outside of academia: The view from community-based PEM

Dr. Kay Hesse spends part of her time working as a PEM provider at a community hospital. In this guest article, she shares her perspectives on working outside of the world of academics. by Kay Hesse MD MPH Through most of my pediatric emergency medicine training and experience, I never acknowledged that a world outside of the silo of academia was possible for me. I have been the receiving doc at a children’s hospital for many patients transferred in from community hospitals, often on hour-long middle-of-the-night journeys, only to frequently discharge them straight back home again from the emergency department. So when Emergency Medicine Physicians—a privately managed EM physician group—contacted me about taking a community-based PEM position, I had never even heard of them before. My ignorance on community-based PEM was not due to any shortcomings of EMP, but rather was a reflection of my limited view of the world of emergency medicine from within the academic silo. This new venture appealed on many levels. The position included working part of my clinical duties at the children’s hospital so I would be able to enjoy the best of both worlds:  provide PEM care in the community setting yet still participate in teaching and working in a tertiary care setting. Taking this community-based pediatric emergency medicine position seemed like a chance to help prevent unnecessary late night transfers. Additionally, with the community hospital starting a pediatric hospitalist program, we hoped to help our patients by admitting them locally for many straightforward pediatric ailments. As PEM docs not only do we have an increased comfort level managing a wide range pediatric pathology, but our training also affords us the ability to offer PEM education to our general ED colleagues. For example, we now hold regular Pedi ED SIM sessions in the main ED. Being in this community setting has inspired us to explore PEM telemedicine initiatives to further enhance the quality of PEM care to other non-PEM EDs. Although we have found many expertise and equipment areas in need of improvement in the community setting, our work has also been met with enthusiasm by the community hospital. The radiologists are working to improve their comfort with appendicitis and intussusception ultrasounds, orthopedists are more willing to come in for sedated fracture reductions with the mini C-arm, we are stocking fast-absorbing sutures, nasal atomizers, increasing med formulary offerings, and overhauling the code carts. The learning has been a two way street. For example, coming from a well-staffed academic center, it was initially unnerving to perform both procedural sedation as well as the procedure as a solo doc on duty.  However, with an astute nursing and tech staff with me, this process sits with me more comfortably now. And getting to actually do all of the procedures personally has been a great skill set refresher for me. I suspect most of us in PEM are a bit fickle and thrive on variety in our worlds. This combination of independently caring for patients at the community hospital and functioning in a teaching and supervisory role in academia really makes me feel like I am getting to have my cake and eat it, too. As the climate of healthcare is changing, I suspect such opportunities as this will increase across the country. I would totally endorse exploring such ‘hybrid’ positions. I am honored to be serving such an important role for our community and families. Kay Hesse, MD MPH, is the Medical Director of the Pediatric Emergency Medicine program at Lawrence and Memorial Hospital in New London, Connecticut

Outside of academia: The view from community-based PEM

Dr. Kay Hesse spends part of her time working as a PEM provider at a community hospital. In this guest article, she shares her perspectives on working outside of the world of academics. by Kay Hesse MD MPH Through most of my pediatric emergency medicine training and experience, I never acknowledged that a world outside of the silo of academia was possible for me. I have been the receiving doc at a children’s hospital for many patients transferred in from community hospitals, often on hour-long middle-of-the-night journeys, only to frequently discharge them straight back home again from the emergency department. So when Emergency Medicine Physicians—a privately managed EM physician group—contacted me about taking a community-based PEM position, I had never even heard of them before. My ignorance on community-based PEM was not due to any shortcomings of EMP, but rather was a reflection of my limited view of the world of emergency medicine from within the academic silo. This new venture appealed on many levels. The position included working part of my clinical duties at the children’s hospital so I would be able to enjoy the best of both worlds:  provide PEM care in the community setting yet still participate in teaching and working in a tertiary care setting. Taking this community-based pediatric emergency medicine position seemed like a chance to help prevent unnecessary late night transfers. Additionally, with the community hospital starting a pediatric hospitalist program, we hoped to help our patients by admitting them locally for many straightforward pediatric ailments. As PEM docs not only do we have an increased comfort level managing a wide range pediatric pathology, but our training also affords us the ability to offer PEM education to our general ED colleagues. For example, we now hold regular Pedi ED SIM sessions in the main ED. Being in this community setting has inspired us to explore PEM telemedicine initiatives to further enhance the quality of PEM care to other non-PEM EDs. Although we have found many expertise and equipment areas in need of improvement in the community setting, our work has also been met with enthusiasm by the community hospital. The radiologists are working to improve their comfort with appendicitis and intussusception ultrasounds, orthopedists are more willing to come in for sedated fracture reductions with the mini C-arm, we are stocking fast-absorbing sutures, nasal atomizers, increasing med formulary offerings, and overhauling the code carts. The learning has been a two way street. For example, coming from a well-staffed academic center, it was initially unnerving to perform both procedural sedation as well as the procedure as a solo doc on duty.  However, with an astute nursing and tech staff with me, this process sits with me more comfortably now. And getting to actually do all of the procedures personally has been a great skill set refresher for me. I suspect most of us in PEM are a bit fickle and thrive on variety in our worlds. This combination of independently caring for patients at the community hospital and functioning in a teaching and supervisory role in academia really makes me feel like I am getting to have my cake and eat it, too. As the climate of healthcare is changing, I suspect such opportunities as this will increase across the country. I would totally endorse exploring such ‘hybrid’ positions. I am honored to be serving such an important role for our community and families. Kay Hesse, MD MPH, is the Medical Director of the Pediatric Emergency Medicine program at Lawrence and Memorial Hospital in New London, Connecticut

Bug can cause deadly failures when anesthesia device is connected to cell phones | Ars Technica

I can think of at least one reason phones are being plugged into USB’s…

Federal safety officials have issued an urgent warning about software defects in an anesthesia delivery system that can cause life-threatening failures at unexpected times, including when a cellphone or other device is plugged into one of its USB ports.The ARKON anesthesia delivery system is used in hospitals to deliver oxygen, anesthetic vapor, and nitrous oxide to patients during surgical procedures. It is manufactured by UK-based Spacelabs Healthcare Ltd., which issued a recall in March. A bug in Version 2.0 of the software running on the device is so serious that it could cause severe injury or death, the US Food and Drug Administration warned last week in what’s known as a Class I recall. In part, the FDA advisory read:

via Bug can cause deadly failures when anesthesia device is connected to cell phones | Ars Technica.

In my practice in the ER, there are two types of patients: those who travel with their phone chargers and plug them in, and those who don’t and whose phones are dying. The former will plug into any power port, the latter are the ones asking if anyone has a charger they can borrow.

So, your loved one is in the ICU on the vent, you’ve been calling and texting for what seems like forever, and you get to sit at the bedside. You’d never think twice about charging your phone off the nearest USB port; it’s never been a problem before, why would it be now?

Why that would shut down a ventilator is terrible planning on the part of the manufacturer, and it’ll get fixed. For you, though, don’t plug your pone into medical gear, as apparently some of it isn’t hardened against real life.

 

A191. Campaña "Elegir Sabiamente" (Choosing Wisely): una apuesta por la calidad, el control del gasto sanitario y el profesionalismo

Recientemente se han presentado en REMI [1] las recomendaciones de la campaña “Elegir Sabiamente” (Choosing Wisely) correspondientes a la colaboración de cuatro diferentes sociedades norteamericanas de cuidados críticos [2]. En este sentido, muy probablemente sería también de interés para los lectores de esta revista la referencia a las recomendaciones dentro de esta campaña, de las sociedades de Anestesiología [3], Cardiología [4] y Emergencias [5], dado que algunas de ellas se refieren a ámbitos de la atención a pacientes en situaciones críticas y/o de emergencia.
      
Esta campaña, impulsada por el American Board of Internal Medicine (ABIM), comenzó a desarrollarse en el año 2011 y hasta el momento han presentado recomendaciones más de 50 sociedades de distintas especialidades [6]. La idea de consultar a las sociedades científicas a fin de elaborar por cada una de ellas una lista de cinco procedimientos o tratamientos excesivamente utilizados de forma inapropiada se gestó en el año 2010, a partir de un artículo aparecido en la revista New England Journal of Medicine [7]. En el mismo se argumentaba que las organizaciones profesionales médicas no estaban aportando su esfuerzo en el control del incremento de los costes sanitarios, y que el mito de que los médicos son testigos inocentes que asisten al progresivo incremento de costes sanitarios fuera de control, no debería mantenerse por más tiempo. Si los médicos son capaces de valorar su responsabilidad y sensibilizar lo bastante a otros colectivos en lo que es necesario, podrá mejorar el actual sistema [8].
      
Sin embargo, es difícil hacer comprender algo a un colectivo de personas, cuando su salario, su poder de influencia o de crecimiento corporativo, no dependen de comprenderlo. No ha existido hasta ahora sensibilidad por parte de los profesionales médicos en cuanto a su responsabilidad en el control de los costes del sistema sanitario. En una encuesta, solamente el 36% de los médicos norteamericanos encuestados estaban de acuerdo con que dicha responsabilidad les corresponde [9]. A pesar de ello, algo está cambiando y la relevancia de los costes se está viendo plasmada en las recomendaciones o guías de algunas asociaciones médicas [10].
      
La primera iniciativa fue publicada en 2011 por 3 sociedades de ámbito de atención primaria (Pediatría, Medicina Familiar y Medicina Interna), dentro de un denominado “Grupo de trabajo de Buena Custodia”. Publicaron 5 recomendaciones cada una de ellas, sobre procedimientos o tratamientos que no deberían utilizarse de forma rutinaria, a través de una metodología transparente y abierta a la participación de los miembros de las mismas [11], demostrándose las importantes y positivas repercusiones económicas que supondría su implementación [12].
      
La campaña ha reclutado hasta el momento más de 50 sociedades de especialidades médicas, cada una de las cuales ha elaborado una lista de cinco procedimientos o tratamientos, que en su ámbito consideran son sobreutilizados. De esta manera se han elaborado más de 300 recomendaciones, todas ellas con un texto iniciado por la palabra “No” [6]. Estas recomendaciones no son algo absoluto, que no deba nunca hacerse, sino que son áreas donde debe establecerse una valoración por parte de los clínicos e incluso una discusión entre éstos y sus pacientes.
      
Los criterios clave que debían influir en la elección de las cinco recomendaciones habrían sido: evidencia, prevalencia, costes, relevancia e innovación. Destacando por tanto para su elección su empleo frecuente, ser potencialmente perjudiciales para el paciente si se utilizan de forma inadecuada, tener una baja evidencia de beneficio y fundamentalmente que su aplicación dependiese exclusivamente del profesional médico.
      
Se intentó desligar el sentido de estas recomendaciones de los costes, dado el entorno político, donde cualquier mención a reducción, sería probablemente interpretada como medidas de recorte o racionamiento. La campaña trata de destacar fundamentalmente no una reducción del coste, sino su aplicabilidad en términos de calidad de los cuidados y de evitar daños a los pacientes. 
      
Al final de todas y cada una de las listas, se explica el proceso que cada sociedad ha seguido para la elaboración de las mismas y se presentan conflictos de intereses de los autores.
      
Aunque muchas sociedades profesionales han publicado la lista de cinco recomendaciones, la mayoría no han detallado con exhaustividad los métodos a través de los cuales las han elegido. En algunos casos, se han utilizado procesos que no han sido transparentes y sin criterios claros de inclusión de los procedimientos. Tampoco se ha asegurado una intervención y contribución importante de clínicos implicados en la práctica asistencial. 
      
La iniciativa Choosing Wisely trata de sensibilizar a los colectivos profesionales en su función de vigilantes o custodios de los limitados recursos sanitarios. La iniciativa recomienda la labor de diálogo y conversación con los pacientes, tratando de sus necesidades reales, preservando una preeminencia del juicio médico sobre la elección del paciente.
      
Lamentablemente algunas de las sociedades participantes han incluido dentro de la lista servicios o procedimientos que correspondían a otras especialidades. De hecho de todas las recomendaciones el 29% se refieren a pruebas radiológicas, el 21% a pruebas cardiológicas, el 21% a medicaciones, el 12% a pruebas de laboratorio y de anatomía patológica y el 18% a otros servicios [13].
      
Es necesario establecer una metodología clara en la elaboración de las recomendaciones y una implicación en aquellos aspectos más importantes de cada especialidad médica. Los conflictos de intereses deben dejarse de lado y dar valor fundamental al profesionalismo. Por el contrario, sociedades del ámbito quirúrgico han incluido únicamente dentro de la lista de cinco procesos o procedimientos aspectos de importancia menor, y no han abordado procesos quirúrgicos en los que se ha demostrado una extraordinaria variabilidad en cuanto a su aplicación [13].
       
Las recomendaciones elaboradas por el Colegio Americano de Médicos de Emergencias (ACEP) son un claro ejemplo de un buen hacer en la elaboración de la lista de las cinco recomendaciones [14]. Se creó inicialmente un grupo de trabajo que elaboró una encuesta distribuida a todos los miembros de la entidad, en relación a medidas que tuviesen las características anteriormente citadas. Los resultados de la encuesta se agruparon en dominios, y un panel de expertos utilizó una técnica Delphi para priorizar las recomendaciones. Se realizaron múltiples rondas de votación para elaborar una lista de prioridades de las estrategias que eran más coste efectivas y que producían mayor beneficio a los pacientes. El proceso fue por tanto transparente y con la colaboración de un gran número de especialistas. Un subcomité se encargó de realizar el soporte científico para todas y cada unas de las propuestas, que finalmente se llevaron a la lista de cinco recomendaciones. Asimismo, se estableció un panel en donde aparecían los conflictos de intereses de todos los implicados en la elaboración de las recomendaciones [15]. Este estudio nos da a entender la necesidad de una clara metodología para la elaboración de las recomendaciones de la campaña. 
       
Aparte de la transparencia en la elaboración de la lista y la rigurosa metodología, resulta absolutamente necesario un siguiente paso, que es medir estas intervenciones y medir la posible reducción en su utilización que la aplicación de la campaña pueda producir, así como incorporar a otros profesionales, como enfermeros y farmacéuticos.
      
Otro aspecto importante de la campaña es la necesaria implicación de la opinión pública y de los pacientes. Entendiendo que, más procedimientos y más tratamientos no aseguran mejores cuidados sanitarios y que incluso pueden ser perjudiciales para ellos, y suponer una utilización inadecuada de los recursos sanitarios.
      
Se confirma por tanto la necesidad de un claro cambio de paradigma. Si antes considerábamos que un tratamiento o procedimiento médico es bueno y cuánto más aplicación del mismo será mejor, en el momento actual el paradigma sería intentar hacer más, haciendo menos y aplicar el mejor cuidado al menor coste [16, 17].
      
En la necesaria mejora y adecuación de la práctica asistencial, son distintas las iniciativas emprendidas. La campaña Elegir Sabiamente es una de ellas, y se podría unir a las emprendidas por el británico National Institute of Clinical Excellence NICE (“Do not do”) [18], por el grupo de trabajo GRADE [19, 20], o en España por DIANA Salud [21].
      
El pasado día 2 de abril la Asociación Médica Canadiense y ocho sociedades de especialidades médicas presentaron una lista de 40 pruebas diagnósticas, tratamientos y procedimientos considerados como no necesarios en todas circunstancias [22, 23]. La campaña ha sido llamada “Choosing Wisely Canada´s” o “Choisir avec Soin” en su versión francesa. Similares iniciativas se están desarrollando en otros países como Holanda, Alemania, Dinamarca, Italia, Nueva Zelanda, Australia o Israel [24]. En el Reino Unido se ha desarrollado una campaña similar titulada “Too Much Medicine” para tratar de llamar la atención sobre la amenaza para la salud de las personas que tienen los sobrediagnósticos y el consumo de los recursos sanitarios de forma innecesaria [25].
      
Demasiadas pruebas a personas con procesos no relevantes o incluso sanas, y no suficientes cuidados para personas enfermas producen desigualdades sanitarias, minan el profesionalismo médico y dañan tanto a los que necesitan un tratamiento como a los que no. Gran parte de nuestro tiempo y nuestros recursos se dedican a quienes menos lo necesitan y se detraen esfuerzos de aquellos más enfermos y más vulnerables. La excesiva medicalización está dañando tanto a enfermos como a sanos.
      
Con la expansión de las tecnologías médicas, técnicas de imagen, biomarcadores, secuenciación genómica, etc., y el fenómeno claramente comercializado de “venta de enfermedad”, es necesario establecer acciones en diversos frentes, que incluyan la educación y el entrenamiento, la investigación, los cambios de política y la defensa del sistema sanitario. La crisis económica y la necesidad de mantener un sistema sanitario público y universal hacen necesario el establecimiento de medidas seguras y adecuadas para evitar el daño que está produciendo la excesiva medicalización de la vida de los ciudadanos [25].
      
Se calcula que los costes sanitarios suponen un 10% del PIB y que aproximadamente un 30% de las intervenciones sanitarias son de dudoso valor, con lo que un 3% del PIB podría invertirse en otras áreas sociales o incluso del propio área de salud donde las necesidades o la cobertura no fueran las deseadas. Por otro lado, la perversión del sistema ha llevado al pago por servicios, medidas de desempeño que han dado énfasis al volumen más que al valor, claras actuaciones de medicina defensiva y finalmente excesivas expectativas de los pacientes, demandando servicios sanitarios innecesarios. Es necesario educar a los profesionales y a los pacientes en relación a los sobrediagnósticos y sobretratamientos [26].
      
En España el Ministerio de Sanidad ha presentado recientemente el proyecto “Compromiso por la calidad de las sociedades científicas”, al que se han adherido por el momento 39 sociedades, y en el que en una primera fase han trabajado 12 sociedades, que a finales de 2013 presentaron sus recomendaciones. El objetivo, similar a la campaña Elegir Sabiamente, es disminuir las intervenciones que no han demostrado eficacia, tienen escasa o dudosa efectividad, o no son coste efectivas [27]. Pero en mi opinión, quedan varias preguntas por responder. ¿Se harán solo de cara a la galería, sin entrar en los procedimientos y tratamientos más relevantes? ¿Se llevarán a cabo con una metodología adecuada, de forma transparente y abierta a todos los miembros de dichas sociedades? ¿Se medirá y evaluará su grado de seguimiento y su impacto global? ¿Serán capaces las sociedades científicas de deshacerse de sus conflictos de intereses y de sus intereses corporativos? [28, 29].
      
En resumen, la participación de cualquier grupo profesional en la elaboración de recomendaciones para adecuar la calidad y racionalizar los costes, deberá basarse en:
  • Metodología adecuada
  • Transparencia y participación del más amplio grupo de profesionales
  • Selección de procedimientos o terapias de clara repercusión en los costes sanitarios y de cuestionable utilidad para mejorar la salud
  • Posibilidad de medir y evaluar estos procedimientos y las repercusiones que la aplicación de las recomendaciones puedan suponer de cambios de práctica
  • Desarrollo de un auténtico profesionalismo, sin conflictos de intereses ni corporativismos
Y a nivel de cada uno de los centros sanitarios sería aconsejable la constitución de “Grupos de trabajo de mejora y adecuación de la práctica asistencial y clínica”, de carácter multidisciplinar y multiprofesional, que evalúen las distintas recomendaciones, o las de mayor impacto en su medio, intentando llevar a cabo una política de educación y de formación al respecto para intentar mejorar.
      
El camino no es fácil y se va producir una transición muy difícil, pero a fin de cuentas es necesario el liderazgo profesional para llevar a cabo iniciativas como ésta.
      
Estas campañas llaman al corazón de los valores del profesionalismo médico y a recuperar los ideales del juramento hipocrático. Realmente son todo un reto y un desafío para los profesionales.
      
Juan B. López Messa
Complejo Asistencial Universitario de Palencia
© REMI, http://medicina-intensiva.com. Abril 2014.
      
Enlaces:
  1. Critical Care Societies Collaborative – Critical Care. Five Things Physicians and Patients Should Question. [REMI 2014; 14(4): B80]
  2. Choosing Wisely Critical Care [Enlace]
  3. Choosing Wisely Anesthesiology [Enlace]  
  4. Choosing Wisely Cardiology [Enlace
  5. Choosing Wisely Emergency Medicine [Enlace
  6. Choosing Wisely Doctor Patient Lists [Enlace
  7. Brody H. Medicine’s ethical responsibility for health care reform—the top five list. N Engl J Med 2010; 362: 283-285.
  8. Dyer O. The challenge of doing less. BMJ 2013; 347: f5904. 
  9. Tilburt JC, Wynia MK, Sheeler RD, Thorsteinsdottir B, James KM, Egginton JS, et al. Views of US physicians about controlling health care costs. JAMA 2013; 310: 380-388. 
  10. Pollak A. Cost of treatment may influence doctors. New York Times, 17 abril 2014. [Enlace
  11. The Good Stewardship Working Group. The “Top 5” Lists in Primary Care. Meeting the responsibility of professionalism Arch Intern Med 2011; 171: 1385-1390.
  12. Kale MS, Bishop TF, Federman AD, Keyhani S. Top 5 lists top $ 5 billion. Arch Intern Med 2011; 171: 1856-1858.
  13. Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing Wisely- The politics and economics of labelling low-value services. N Engl J Med 2014; 370: 589-592.
  14. Schuur JD, Carney DP, Lyn ET, Raja AS, Michael JA, Ross NG, et al. A top-five list for emergency medicine: a pilot project to improve the value of emergency care. JAMA Intern Med 2014; 174: 509-515.
  15. Grady D, Redberg RF, Mallon WK. How should top-five list be developed? What is the next step? JAMA Intern Med 2014; 174: 498-499.
  16. Less is more. How less health care can result in better health. Arch Intern Med 2010;170:784-90
  17. Kox M, Pikkers P. “Less Is More” in Critically Ill Patients. JAMA Intern Med 2013; 173: 1369-1372.
  18. NICE [Enlace]
  19. GRADE [Enlace]
  20. Rochwerg B, Alhazzani W, Jaeschke R. Clinical meaning of the GRADE rules. Intensive Care Med 2014.
  21. Diana Salud [Enlace
  22. Choosing Wisely Canada [Enlace]
  23. Choosing Wisely Canada. Things you should question. [PDF
  24. Kermode-Scott B. Nine Canadian medical bodies launch campaign to reduce unnecessary medical tests and treatments. BMJ 2014; 348: g2673.
  25. Glasziou P et al. Too much medicine; too little care. BMJ 2013; 347: f4247.
  26. Baker DW et al. Design and Use of Performance Measures to Decrease Low-Value Services and Achieve Cost-Conscious Care. Ann Intern Med 2013; 158: 1-5.
  27. Ministerio de Sanidad, Servicios sociales e Igualdad [Enlace]
  28. Sitges-Serra A. Tecnología o tecnolatría: ¿a dónde van los cirujanos? Cir Esp 2012; 90: 156-161.
  29. Lopez Messa JB. Hacia dónde debería ir la medicina. [REMI 2013; 13(9): A178].
      

Bingo Resilience

Her wary eyes, magnified from her thick-lensed spectacles, watched my every move as I pulled Room 21's curtain to the side and entered her room. In her early eighties, it was apparent to me that my entrance into her life was more important than the abdominal pain that brought her to our Emergency Department. In the corner sat a slight man with wispy gray hair poking out from the border of his baseball cap, his elbows resting on his thighs as he leaned forward in his chair. His wrinkled face and tired appearance made me question if this man was her son or husband.

I returned my gaze to this patient and gave her a smile as I approached her bedside. Her stoic face softened slightly as I watched the corners of her eyes relax. Her mouth's edges lifted slightly into a hesitant return smile. She was on guard.

Arriving to the side of her cot, I extended my hand to introduce myself. "Hello, Ms. Westin. My name is Dr. Jim and I will be taking care of you today while you are in our Emergency Department."

"Hello, Doctor," she replied, barely grasping my hand in welcome. "Please call me Bertha."

"Nice to meet you, Bertha," I answered before turning to the gentleman in the corner of the room and approaching him. Once again, I introduced myself.

"Thank you, Doctor. My name is Sam. I'm her son."

Her son. Standing closer to him, I could see that Sam had his mother's eyes--slightly hazel but more fatigued-appearing. My mind wanted to know what in his life was giving him this look of defeat.

"Nice to meet you, Sam. Thank you for being here with your mother today."

Sam nodded to my words. My response words--actively thanking him for taking the time to accompany his elderly mother to the Emergency Department--were something I had been saying for the past few years to adult children who accompanied their elder parent to our department. It was my way of acknowledging and validating their efforts in helping their ill parent in a time of need. Of putting to the side their own needs and demands. Of dropping everything at that very moment to be at their parent's side during an Emergency Room visit. This supportive action was one that I respected immensely. Often, it was the adult child who could convey just a little more history or provide just a bit more support that could make a difference in my course of treatment of their parent.

It was a loving gesture that was not lost on me.

I turned back to Ms. Bertha and began questioning her. She had developed abdominal pain in her midepigastric to left upper quadrant about four hours prior to her arrival. It was not accompanied by any nausea, vomit, diarrhea or constipation. She had no fever. She denied any chest pain, shortness of breath, or recent trauma. She denied any urinary complaints. This abdominal pain was unusual for her. It had presented soon after she had eaten a BLT sandwich for lunch. Of course, like Murphy's Laws would dictate, the pain had completely dissipated by the time I examined her.

As I questioned her, I could see her slowly letting her guard down with me. She began to smile her big, beautiful smile more easily. She became more conversive. She became down-right fun. We laughed together at some of our small talk while I finished my history-taking and began my physical exam.

Her physical exam was perfect. Nontoxic. Benign. I couldn't find a thing wrong with her.

Because of her age, we did the standard precautionary testing, including blood work, an EKG, and a urinalysis. While waiting for her test results to return, I stopped in several more times to perform recheck exams and make sure she remained comfortable. She did. Each time I stopped in, I became more and more aware of her piss-and-vinegar disposition and sense of humor. Especially talking about Bingo, she seemed to light up at the sense of fulfillment this church-going sport brought her. "Yeah," Sam added, "don't try to get between Mom and her Bingo chips." Ms. Bertha, it seemed, did not take lightly to losing a recent big prize by one empty block on her card.

Finally, I went in for the final time with all of her returned test results. All results were normal and favorable.

In the few hours I spent with her, I continued to appreciate Ms. Bertha and her son, Sam. I was happy for both her feeling better and her excellent test results. I was happier at the sense of caring that existed between mother and son. I was happiest that, at age 83, Bertha seemed to continue to enjoy life and found beauty in the simple things that it offered. I was also appreciative that losing a Bingo game still evoked passion from her.

On review of her previous visits, I had noticed that she had never been to our ER before. I questioned her on this prior to discharge.

"Ms. Bertha," I said, "I noticed you haven't been here before. What made you nervous enough to come in for your abdominal pain today?" I wanted to make sure I had covered all of my bases before safely discharging her to home.

"Oh, that was probably my doing," Sam answered. "After the past few years," Sam continued, "I didn't want to take any chances with Mom's health with her belly pain today."

"Plus," Ms. Bertha added, "I really hated my doctor the last time I had to go to the ER. That was in 1975." She paused slightly before continuing with a wink of her eye. "Don't worry, though, Dr. Jim. I really like you."

I must have blushed at her kindness because she called me out on my "red cheeks."

"Can I ask what has happened in the past few years to you, Ms. Bertha, that had made your son worry about you today?"

And then, Ms. Bertha's real story came rolling from her mouth, her words tumbling right into the pit of my heart.

With a mixture of sadness and smiles, Ms. Bertha and Sam, in the next five minutes, told me how Ms. Bertha's life had played out to this point. She had lost four children--two sons (one to cancer and one to AML with a concurrent brain tumor) and two daughters (one tragically in the late 1980s from a motorcycle accident). Her husband had died five years earlier. In the past year, she had buried two siblings. This recent loss of her siblings had convinced Sam that his mother's abdominal pain was going to bring terrible results. Sam was her only immediate family left.

When they were done sharing, I could only shake my head in disbelief. I grabbed Ms. Bertha's right hand between my two and warmly rubbed it. "Ms. Bertha," I said, "I can't even imagine how you could share your smile and piss-and-vinegar attitude (saying piss-and-vinegar made her giggle like a young school girl) with the world after all that has happened to you. What keeps you going?"

She looked me in the eyes, her magnified hazels piercing my soul.

"Bingo," she answered.

We all laughed. Her resilience and true personality made me smile. My goodbyes to Ms. Bertha and Sam were heartfelt.

As I stepped from Room 21, I was hopeful that, thanks to Ms. Bertha's inspiration, I too would find my "Bingo" someday.

I will keep looking...

As always, big thanks for reading. Ms. Bertha and her son were an inspiration to me. I am constantly amazed at the gift I have been given to meet so many diverse and beautiful people. 

What's your "Bingo?"