Arzhang’s Blog

Gateway to the Hospital

The emergency room is a strange world. It’s both the best and worst of medicine all in one crazy area. In one room someone is getting impacted ear wax cleared from their ear, in another someone is being resuscitated after a cardiac arrest. Some people find their back pain was really a dissected aorta, others find that their back pain is a ticket to a few hours sleeping on a cot inside the hospital away from the cold NYC streets. The ER is the entryway to the hospital. Most people that end up in the hospital first have to go through the ER, “get processed” so to speak. It is also the safety net for the uninsured and those that don’t have access be it by choice or by circumstance (such as a closed clinic on the weekend). If there is one thing in my mind that is certain is that experience in the ER shows you the future of modern medicine and it is a grim one.

I have now worked in ERs on the west and east coast and they are all similar: bursting at the seams. Inevitably stretchers are lining the hallways as the ER gets put on “divert” meaning literally it is full. This is all under normal circumstances. There is no influenza epidemic, no massive plague, no terrorist attack. One can only imagine what would happen under those circumstances. The ER is about getting patients in and out as fast as is safely possible. Delaying may result in the next person getting sicker, or even dying. Yet, ultimately the ER is all about delay. Beds in nearly full hospitals are not ready. Patients wait hours, even days waiting for a bed to get admitted. This “wait” was what our non-nationalized system of medicine was supposed to be somewhat immune from. Consultants from various medical disciplines take hours and hours to see patients as they are stretched too thin. Yet those various disciplines are more competitive than ever to get into. You don’t see new medical schools popping up. You don’t see class sizes expanding even as demand for doctors increase.

The other day I had a 100 year old patient. He was a former doctor at the hospital. He had pneumonia. He was stable but far from well. He was throwing up left and right. The overworked nurses would get to him when they could but he had already soiled his clothes. His frail wife marched around trying to find out when he would get a bed. After all he had served for over 20 years at the hospital and here he was soiling his clothes and people were too overstretched. It was obvious she was becoming very exhausted. I went in the hall and stole a chair for her to sit on. What else could I do? It wasn’t as if I could magically make a bed open up. She came up to me, “You guys are fine but he served here for over 20 years, I never thought we would be treated like this.” I went over to his bed stretchers lining the hallways which were bursting at the seams. I stood in the center of a mass of stretches. I looked 360 degrees around me. They were all my patients. They seemed to all look at me: the women with anemia, the man with pneumonia, the lady with a shunt in her brain. They all had the same look on their face, that of exhaustion but I couldn’t help but think it wasn’t the exhaustion because it was 2AM in the morning. It was that same exhaustion I felt. Maybe it was frustration.

The other day as I was going to clinic for a meeting I ran into a man in the elevator who smiled at me “Hey you’re that doctor that took care of my wife. We’re here for the follow up appointment. ” He got off the elevator, “It’s nice seeing you.”

I love what I do but sometimes it feels like people don’t love each other and themselves. People lack insight into their disease, partially by their choice and partially by the fact that doctors cannot spend enough time with their patients as they are in such short supply for an ever aging population. If only it were about sore throats and coughs. It’s about people on dialysis, people with multiple stents, people with liver disease, people with med lists that have to be typed because who can remember 15, 20, 25 medications. I don’t understand society even though I see it at its most vulnerable. If a system is in such a dire state that if action is not taken it will collapse is it not society that should be compelled to fix it? If anything needs to be “bailed out” is it not this? Would doing so be any more “socialist” than funding banks that made poor decisions and coerced others in doing the same?

There is this notion of personal responsibility that many critics bring up with respect to people. I believe in this, to a point. Yes, many people by poor choices have caused or exacerbated their illness. There are people who took out loans when they did not have money. Fatty food is cheap, and loans by banks were cheap. It was their choice but it was other’s influence that had a large part in it. When the consequences of those actions come to fruition what do we do?

Is it not then a double standard when we chose to bail out one group and not the other? Have we not by our actions as a society put money as a higher cause to act on than our health? Is that the “choice” we are making? People have a responsibility for their actions, but as people in a society do we not have a responsibility to act to improve our society and help others make more sound decisions. Choice is not a simple a, b, c response. Doesn’t the 300lb man with diabetes know that white bread is bad for him? At first glance it is his “choice” that he eats white bread. But having been around enough people with disease I can tell you it is never that straightforward. That 300lb man may live in a certain section of Harlem where for wheat bread is nearly nowhere to be found. Then again maybe that same man has wheat bread and chooses not to eat it. This is despite the variable of mental illness which is much more prevalent than people can imagine. Is someone ravaged by depression, bi-polar, or dementia really making a “choice” that is the same “choice” as that of a mentally healthy person? Nonetheless at the end of the day if he spirals downward he will end up in the ER. There is no distinction between those that made poor choices and those that didn’t. He will sit right next to the 100 year old doctor. In making the assertion that you will chose to treat those who made the right choices and let those that made poor choices suffer, you are making a choice to judge without enough information. If in a court of law you have to prove beyond a shadow of a doubt is it different in a hospital? With such overburdened resources there is really no way to assess who made bad choices with appropriate options and access. That is the luxury of philosophers and those that aren’t on the frontlines. But every so often you will get a smile in an elevator that reminds you why you are on the front lines.

It’s a strange world indeed.

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More than an Election

The past month and a half have been very busy.  I learned a lot, helped a lot of people.  Yet, I lost focus.  I lost balance.  I missed the voter registration in NYC so I didn’t get to vote, in an election that I wanted more than ever to vote in.

Over the past eight years I have been incredibly vocal about my disgust for how this country has been run.  I’ve traveled to numerous countries during this time and first hand have experienced how the image of the US has been tarnished.  I saw how misguided our leader’s world view was compared to what I actually saw with my own eyes.  I have seen a so called “conservative” who believed in the free market to solve all our problems resort to one of the largest government subsidies of all time and at the same time have his party call the opposition “Socialist”.  I have seen an economic crisis, two wars, and terrorism all in such a short period of time.  There were more than ample issues for candidates to debate about.  However, shortly after moving to NYC I realized that what was evolving was far beyond just “issues” in a campaign.

Working near the border of Harlem I get a tiny glimpse into the lives of people who come into our hospital.  As I walk to work every day and around the city invariably I see the numerous street vendors most with some form of Obama gear.  Pins, bumper stickers, Che-like images on T-shirts.  In the blistering sun and cold ice-like rain they are there selling and promoting.  People from all walks of life bought the stuff and wore it proudly  Day after day after day.  At construction sites I would hear blue-collar workers talking about Obama and why he was the guy to go for.  At the hospital nearly everyone I saw were anxious to cast their vote for Obama.  I saw young black teens on the subway, their bags sporting Obama pins.  I saw reggie artists with Che-like obama shirts.  Campaigners with Obama posters constantly patrolled the streets at all hours.  As election day came there was a sense in the air that something was different.  It was perhaps a superstitious sixth-sense feeling of something to come.  Despite my infinite frustration at myself I knew this was a day I was going to remember.

I went to Rockafellar Square.  Thousands of people lined up; a blue banner representing Obama towered over McCain.  Obama had 207 votes.  A white woman stood with a star poster welcoming Obama, the back of her head had an Obama mask on it.  The clock struck midnight and just like a lightning bold the blue banner shot up as the West coast came back big for Obama.  The large monitor had Obama on it and declared the next president.  The crowed exploded.  Years of anger, frustration, and loss of hope all came out in their chants.  “BUSH YOU’RE FIRED!  BUSH YOU’RE FIRED!”

That transitioned to “OBAMA!  OBAMA!”

A pause…

“USA! USA! USA!”

A black woman came in, her eyes in total shock imbracing the white woman with the Obama mask. “Thank you.  I’m fifty years old.  Thank you for everything!”  In Harlem people danced in the streets.  Tears of joy were shed.  I couldn’t help but become tearful.  It wasn’t about the economy, the war, or the environment.  It wasn’t about Bush.  It was about something that couldn’t be put into words.  It was about those voters who voted for the first time.  It was about the poor black kids in Harlem that wanted to believe in the impossible.  It was a movement.

For me personally it was a wake-up call to find balance and take care of things that are important no matter how busy I am because it does matter.  I had a renewed sense in a country I had been so cynical about.  It was an American “reboot.”  No matter how tempting it is to be cynical this election showed an alternative to the fear and cynicism we have become so accustomed to.  And as far as the challenges we face and whether we can address them: yes we can, yes we did, and yes we will.

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2:30 AM

The night was going smoothly, the numbers of pages were few, yet the whole day I had this unsettling feeling.  Perhaps it was a lack of food.  I decided to order in.  I looked at my watch seeing it was around 1AM.  Even though it’s NYC even here the options on the Upper East Side are limited.

I decided to order some pizza from the only pizza joint that was open to deliver.  A half hour later the pizza man delivered my slices.  I walked down the dark halls of the hospital going to the front door to get my food.  I went back to my call room.  The slices were half cold, greasy.  I didn’t care.  It was late.  I had barely eaten.  I ate the slices feeling a bit of regret as the nausea had started to set in.  I was tired, still with an unsettled feeling in my belly.  I figured it was the food.  I hadn’t gotten any significant calls that night.  Things were going well.  I lay on the old, squeaky bed in the cold call room.  My eyelids were growing heavy, maybe I would get some sleep.  Just as I was about to dose my pager started buzzing.  I tried to open my eyes, clumsily dialing the number.  The nurse on the other end had a scared, cold tone: “The patient’s heart rate is in the 20s he is unresponsive.”

I ran out the door down the stairs trying to figure out what i was giong to do.  I was tired, confused, anxious.  As I walked to the floor it was official “Team 7000!”  It was a code.

A frail 80 year old African American man with a curly white beard lay unresponsive in bed as the nurses started putting an oxygen facemask on him.  I quickly grabbed the pacer pads to put onto his chest.  His heart rate was in the 20s.  I was confused, half thinking it was a dream.  Perhaps I was dreaming all this, I was just lying down a second ago.  Yet the look of urgency on everyone’s face told me this most definitely was not a dream.  The senior residents came rushing in.  One quickly started a femoral line.  Just then someone yelled, “I don’t feel a pulse.”

I did what was reflexive.  I started doing chest compressions.  My angle was off, my body tired, stomach naseated, I pushed on his chest.  I climed on top of the bed pounding down, feeling the deep crunching sound of ribs being broken.  I handed it off to my fellow co-intern.  Back and forth we went, each cracking ribs as we went on.

“I feel a pulse.”

He was back.  We called the ICU and waited for him to be transfered.  I looked over at him a breathing tube in his throat.  He had no family, some remote friend, maybe relative lived in Alabama.  Nothing.

I looked over only to see his left chest expanding like a balloon.  “Why is his chest like that?”  His lungs had been punctured causing air to leak around them into the subcutaneous tissue.  I quickly pressed down trying to force the air back into his chest.  The cardiothoracic surgeon came and looked in his lungs with the bronchoscope.  He had a tumor.  We knew it all along but it didn’t help his situation.  The surgeons put a chest tube to drain his lung.  A while later I dragged his bed to the ICU.  We dragged him through the dark halls, the same halls I was in a few short hours ago anxiously awaiting my food.  All the while to the ICU I was giving him breaths of air through the bag mask.

It was now 6AM and as I tried to collect my thoughts for the day ahead I realized my nausea had settled.  The feeling of uneasiness was gone.  I would like to think I knew that this was coming.  You never do.  You have an unsettled feeling, a sixth sense, mostly you have no warning at all.  Dinner at 2AM, CPR at 2:30AM.  Now it was time for a nap.  Luckily it was in my own bed at home.

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Looks

As a kid I hated going to the doctor; absolutely hated it.  I didn’t like the uncertainty.  There was the stick in the throat which inevitably made me gag.  The prospect of getting a shot.  There was the smell of disinfectant in the air.  I may go as far as to say I was scared to go to the doctor.  Luckily I didn’t have to go too often to the doctor and when I did they could usually pick up that I was scared and would comfort me.  I wasn’t sure what made it obvious to them.  I just stared blankly when I came into their office.

They say most communication is non-verbal.  The other fraction of is read between the lines, and a minority is actually spoken.  I remember a particularly frustrating patient on my medicine rotation as medical student in Seattle.  He was a “tough” guy, one who didn’t like doctors.  He always gave this annoying sigh when I walked in the room.  He was irate that I had to wake him every morning to check up on him.  I was beginning to think the guy was a real jerk.  He belittled me and always treated me like crap criticizing every little thing I did.  All I was trying to do was help.

One night I found that he had suffered a small heart attack.  The next morning he was his old self, insulting me and asking not to be seen in the moring.  Earlier that day he had kicked ou the cardiologist who came to see him after his heart attack.  He didn’t want the help.  I was fed up.  I expressed my frustration to my resident.  Later we went to his room and the patient again started to go off on us.  My resident, far more experienced that me as a third year student put it out there, “Are you scared?”  As if by magic the whole act came crumbling down.  His eyes looked downward as if the jig was up.

“Yeah.”

Suddenly I felt guilty.  I learned a lot from that patient.  I learned never to judge patients.  One who you may feel is a jerk or difficult may just be coping that way.  People react in different ways to stress and while as a child my fear of the doctor was manifest in a silent blank stare, his was to lash out at those around him.  Luckily he had a doctor who picked up on it.  From then on I became a lot more perceptive about how people act and the looks they give.  The looks speak volumes, not only about patients but about doctors as well.  They tell the story that often times word can’t or lie about.

There is the story of my night on call as an intern when the nurse called me in to see a patient that was short of breath and breathing 60 times a minute.  His eyes were wide open, he would follow my every move.  They seemed to quiver, tears wanting to form but couldn’t.  He could barely speak from his shortness of breath.  He started to get chills and shake.

“What’s going on?”

He looked at me his eyes pleading.  Thing is, I didn’t know what was going on.  No one really did.  Was he bleeding internally?  Was he infected?  Between his rapid breaths he looked over, “I…I..I’m ssccarred.”

My residents came to the bedside and saw the severity of the situation.  He couldn’t breathe this fast for long.  He needed to be intubated.  She looked over at him, “We need to put a breathing tube in your throat.  I think it is the best thing for you.”

His eyes darted across the room as if looking for something, or someone.  He was panting, desperately trying to get some sort of reassurance, but our eyes were also off int he distance trying to figure out what was going on.  Nonetheless his eyes lazered in on me.  “Do…do…do.. you… th..think it is a gooood i…i…idea?”  Only this time it wasn’t only his eyes that were on me but also my resident.  It was a feeling I hadn’t really felt before, that what I thought mattered. It was part of the transition out of medical student mode things.

“Yeah…I think it is a good idea.”

Within minutes the anesthesia team had come by and put a breathing tube in his mouth.  Every so often while he was awaiting transfer to the ICU I had to push in sedatives to keep him from waking up, to keep him from fighting and opening his eyes.  Maybe it was for the best until we could figure out what was going on.  But often you don’t have the luxury of time.

Then there is the most disturbing look of all.  It was around 6 in the morning when I heard that over head rush of adrenaline.  I ran to our patient’s bed where a code was called.  A mass of my co-interns started to get vitals and put her on oxygen.  The residents soon came and led the code.  Soon enough I was in that all too familiar position doing chest compressions, behind me a hoard of doctors, a family sobbing out in the hall eyes on the floor trying to come to terms with what had happened.  I hadn’t really eaten anything for breakfast and it was sheer adrenaline that kept me going.  As I was doing compressions there was a moment where things seemed to slow down, the mass of people in the room seemed to dissappear as I looked down at our patient’s face.  Maybe it was one last effort to communicate, a boost for us to keep going, it was probably from the jolt of pounding on her chest but one eye lid came up and I saw a dull black pupil, fixed, dilated.  There was no glimmer, no emotion, no plea, just darkness.  I kept going, frantically, hoping it would change.  Fixed.  A couple more compressions.  Fixed.  Dull.

I looked into the black hole as sweat started to form on my brow.  I was tired.  I had seen that black hole before, the story it told, the same ending it always seemed to give.  Three exhausting hours later, everyone came to grips with the ending.  The family came in eyes conflicted by looking at the ground and at the body before them.  The patient’s mom came in whaling, “she’s so precious!!”  I came out of the room and threw my glove away.  I didn’t know if I was more tired, exhausted or frustrated.  Half our team was in the bathroom crying.  I briefly looked over at my colleagues involved with the code only long enough to catch a glimpse of people’s expressions.  A glimpse was all I needed.  No one was really looking at each other.  Eyes were fixated on the floor, brows furrowed.  What could have been done?  What did we do wrong?  It wasn’t much past 9AM when we knew we had to move on.  We were on call that night and we had no choice but to look ahead despite wanting to dweel and look back.  Still just as a kid in the doctor’s office, I was still scared.

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The not so awkward silence

It’s amazing how much can be said by silence.  In our ever changing (unfortunate) move to assembly line “pack as many patients as you can” medicine often patients are given the opportunity to talk.  Some times it’s what they don’t say that speaks the most, that tells their real story.  

The other day I had a patient with metastatic breast cancer.  I had just got done pronouncing the death of a 39 year old woman with breast cancer metastasis to the brain when I came to visit her, so I knew the prognosis all too well.  It was late.  I didn’t even bother to check my watch.  A shadowy skeleton of a figure was slouched in bed, the stubble on her shaved head catching the hints of light in the room.  She slowly moved her eyes up.  Her lips were curled down, defeated.

“Hi I’m Dr. Fallahi.”

I asked a few standard questions.  She recited her history like she had done countless times before.  She looked up at me, “I don’t want to do this any more, I’ve been going through this since 1989.”  She spoke in that agonizingly soft voice of someone that has gone to hell and back.

“I went through chemo.”

She looked up at me. Silent, as if expecting I knew what it was like. Her eyes told the story.

“I feel so weak.”  She then looked at me as if longing for something.  Here eyes intent, lips somewhat curled as if  it wanted to give some sort of smile of desperation but couldn’t.  There wasn’t much more that needed to be said.  No one was going to cure her cancer.  For that matter things were going to get worse.  She had metastasis to the lung, bone, and and she was starting to turn yellow from her liver metastasis.  I could have tried to lighten the situation with some sort of optimistic anecdote but I knew it wasn’t the time.  I finally broke the silence, “I’m so sorry.”

As I left the room, I looked back at her, paused.  This time she broke the silence with what I would like to think was some attempt at a smile, “Thanks for your help.”

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So Much More

Being a doctor is not what it used to be.  More and more doctors become jaded at the system and on one hand who could blame them?   Insurance companies are becoming increasingly invasive in our decision making.  Paperwork is at an all time high.  Compensation is decreasing while work is increasing.  Still I find it hard to become jaded when I go home at the end of the day because in the end it is the reason I went into medicine, patients, that keep me going.

The other day I had a patient come in on a wheel chair.  He had been shot in the back paralyzing him below the waist.  The injury had caused other problems as well.  Due to his spinal injury he had a major erectile dysfunction and medicare had turned down his prescription for essentially an injectable viagra.  He was determined to have his case re-opened.  Like many things in our overly insurance run medical system his case was not looked over carefully.  Medicare didn’t even know he was a paraplegic.  I drafted a letter stating this was a common problem in people with spinal injuries and this patient was in fact a paraplegic.  His face was eternally grateful for essentially a medication refill but to him it meant so much more than that, it was one step towards being “normal.”  I just hope the insurance companies see it that way.

The other day as I was doing walk in visits in the clinic I saw a female patient’s name pop up on my screen.  Under reason for visit it stated that the patient was depressed and tearful.  As I called the woman’s name she slowly came in, trying to old herself together still trembling, eyes glossed over.  As she sat down she barely looked at me.  In the modern insurance-centric world of medicine this wasn’t a “regular” doctor’s visit.  The woman explained to me how she was scared for her life and that was the reason she came in.  Her daughter and grandchild were recently assaulted and stabbed in Central Park.  One was beaten with a hammer and sent to the ICU.  The criminals were free and they knew where she lived.  She didn’t feel safe at home so she came to me.  Needless to say I put her in touch with people that could help her out.  I billed the visit as depression for the insurance folks.  In eyes of the healtcare system that’s what she was, but as a doctor there was so much more to that visit.  It is because of that “so much more” that despite all the hours, paper work, insurance and lawyers I find joy in my work and how I keep sane on those tough days.

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The Invisible Tourist

Growing up in Idaho was tough.  In a predominately Mormon community of cookie-cutter looks my dark hair and features never did fit in.  People soon figured I wasn’t Mexican which pretty much meant folks were confused as to “what” I was.  My sister to this day angrily recalls kids at school teasing her.  She had it worse than I did.  We were the ones that got funny looks.  It sucked.

Yet as I tour yet another country this time Istanbul, Turkey I came to appreciate those very features.  No matter where I go people never see me as a tourist (that is until I pull out my map or speak English).  Even when I speak English like today they assume I’m Italian.  Perhaps it is because I’m in the midst of making a film, but this trip more than before has made me think about the world around me.  I see things differently, looking for images, looks, emotions.  Being “invisible” affords you the opportunity to look at things more from the inside.

As I walk people don’t ask me to buy shirts, they just assume I’m like the other 14 million people in the fourth largest city on earth.  As a result, although I am a tourist I have the privelege of getting immersed.

The first thing that hit me in Istanbul was its beauty.  Lush green hills and waterways connecting Europe and Asia.  The people are exotic and beautiful.  Features break the norms.  Bright eyes, with dark hair.  Dark eyes with light hair.  Light skin, dark skin, inbetween skin.  Turkish, German, English, Italian, Farsi fills the air.  The next thing that struck me is how much it was like Iran.   Walking down the street the clanging of metal, old motor cycles and workers resonate.  Their is a tactile feel to products.  People still “make stuff.”  The air smells of dust, diesel and Chanel perfume.  An industrialized nation and third world mix.  As far as the eye can see are goods, shoes, belts, bags, shirts, mostly knockoff of designers.  While people must know these are fake they still buy them.  Perhaps it is trying to live the illusion of wealth.  The burden of money is constantly present.  A little girl with black hair and a red scarf, alone at night on a crowded sidewalk begs for coins a she taps her plastic bowl.  People rush to put coins in her bowl.  After half an hour her piercing teal eyes look out, glossy, lost, scared.  Down the street tourist fill the fish restaurants as traditional Turkish music is played.  At least culture is maintained somehow, albeit by entertaining outsiders.  But hey, at least people have time to vacation so kudos to them.

From my vantage point however, I feel like the tables are completley reveresed.  Almost without exception within two seconds I can tell that a group is from America or not.  It is a complex thing to explain but it is unmistakable.

I walked tonight to a small dessert bar and ate four different types of baklava (with an obvious thought to a few friends).  As I sat there by myself eating I looked over at my server, a guy with dark hair and features who was on his break.  He was eating a few pastries quietly in the corner.  His eyes were tired, it was 930PM and he was stuck feeding visitors like me.  As I left I told him how great the baklava was.  He gave a warm smile, his eyes lit up.

I walked the long way back to my hotel, not once did anyone ask me to buy anything.  Not once did I get a funny look.  Sometimes it’s good to be “different”

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Tulip Festival

Here is some footage I shot of the tulip festival.

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Pillow Fight at Pike Place Market

This is a pillow fight that took place at Seattle’s Pike place market. You can also view the HD footage hereas well. 

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Conversation

This was a test I did to try out the shotgun mic on the camera.

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