Volume 7

November - 2019

Cover: Maligne Lake BOathouse

I chose this photo for the Art of Emergency Medicine, because it represents a kind of balance between work and relaxation. I was on my way to a conference, but I made sure to have enough time on the way to get in some hiking around Jasper National Park in Western Canada. I got the this spot very early, and I actually worked on my talk while watching the scene change and waiting for the light to be perfect. I try to make sure that I only travel for conferences if they will give me the opportunity to get outside with my camera and capture beautiful scenes like this.

This is a long exposure (320 seconds) using a 10 stop neutral density filter, which is what allows for the significant movement in the clouds.

Letter from the Editors:

Welcome to Art of Emergency Medicine, a curated art blog dedicated to showcasing the creative side of emergency professionals!

We had a wonderful time meeting many of you at ACEP 2019 and sharing our story! We had a small exhibit, but were exceptionally pleased by the turnout and interest. We can’t wait for future events where we will be able to include even more pieces of art and literature by all of our amazing colleagues.

We want to wish everyone an extremely happy and merry Thanksgiving and hope that you are able to celebrate with family and loved ones (even if you’re on shift and celebrating on a different day)!

Why we learn emergency medicine

The opportunity to seek Bears in the wild couldn't be ignored. I found a location where several bears would come to the creek to feed in the early morning hours and set up my spot before dawn. I was rewarded with a the chance to capture hundreds of images from a distance of 15-50 feet away. Checked off a bucket list item!

Something for the Pain

Part I

 Bed 23 wants more applesauce for the dried turkey

 Bed 34 wants her daughter to visit

 Bed 25 wants more T cells

 Bed 2 wants quiet because the ward is too loud and he can’t hear President Reagan on the television

 We do not have applesauce or T cells or family

 We do not have extra hands to drown the noise.

 But we do have morphine.

Part II 

He rolled into the trauma bay at 0200 in agony, mouth agape, face pallid, eyes bloodshot. They rushed him through the double doors, medics on both ends of the gurney, one clamping down to control the bleeding. In my ten years, I had seen plenty of blood—but this was too much. He wasn’t half full; at the rate he was bleeding, he was a far cry from half empty.

The medics gave the report while Dr. Shepherd listened: entry wound, yes. Exit wound, no. The bullet had entered his belly at close range, liked what it saw, redecorated the place, and had shown no signs of wanting to leave. An IV line was initially acquired on the field. Fluids were pushed. The patient was calm and alert. But when they tried to administer morphine, he flipped.

“Yanked the line right out,” said the medic. “After that, we couldn’t do anything.”  

The man needed an emergent surgery, likely laparotomy. For that, he needed to remain still.

We tried to get an IV, but he thrashed with such force to hold us at bay, gnashing his teeth, flailing his arms.

“No, pain, no, pain!” he exclaimed, over and over, as if it were some ethereal blessing, some mantra.

I raised my voice. “Sir, you need to stay still.”

“No! Pain! 24!” The man wrenched his arms and wrapped them in a self-embrace.

I saw the track marks and tattoos. The faded ink crawling up his arms, occasionally broken by pockmarks and pop holes. I assumed the worst, my mind wrapping its dendrites around the “A” word 

Addict.

“Sir, we can’t help you if you keep moving. 

“No, pain. 24 d—”

“Sir, we’ll give you pain meds, but we don’t dose dilaudid that high.”

The man trembled, then his arms went limp. “No pain,” he pleaded, “24 days.”  

By this point, we had fentanyl at the bedside, and were ready to administer intramuscular haldol to sedate him. I raised an eyebrow at Dr. Shepherd, waiting for the okay.

Dr. Shepherd held up his hand. Quietly, he walked to the patient, knelt forward, mouthed something into his ear, out of our hearing.  

The man calmed. We got the line.

“Hold the fentanyl. Only Haldol.”

The patient was stabilized and sent to the OR.

***

He didn’t make it, we found out the next morning. The blood loss was too great, and his body couldn’t compensate for the shock, no matter how many RBCs they infused. 

Later, when asked what he whispered that had calmed the man down, Dr. Shepherd said this:

No dilaudid, no morphine, no fentanyl. No opiates, I promise.

“You administered him nothing for his pain?” probed the M&M panel in the coming week.

No dilaudid, no morphine, no fentanyl.

“So, in other words, you provided him nothing?” queried the malpractice letter in later months.

No opiates, I promise.

The patient died on his own terms, liberated from his demons; free. That’s not something you can give with a needle

From the author: My story takes place in two different periods of the opioid epidemic. The first part acknowledges the powerlessness of providers when faced with the untreatable facets of medicine, and how pain medications may be used as a short-term cure. The second part addresses the consequences of the opioid epidemic.

The Falls of Milford Sound

There are some majestic views within our world. Places that are awe-inspiring because of their size, their beauty, their complexity, or any number of any other reasons. It’s for reasons like this that I believe we are called to be stewards of our planet. We are called to protect these beautiful scenes for generations to come to enjoy, be inspired, and love. Milford Sound is one of those places for me. As you travel out on the relaxing waters, you are greeted by waterfalls that are hundreds upon hundreds of feet tall. Their power is roaring through the Sound as they cut definitive curves and lines throughout the sheer cliff walls left millennia ago by receding glaciers.

Do you want to see your art shared with the community? Don’t forget to submit today!

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This Months Featured Artists:

Andrew J. Park

Andrew Park is a fourth year medical student at the University of California, San Diego School of Medicine. He learned to write (painfully) as a history major at Dartmouth College. His medical interests include emergency medicine, addiction, and narrative medicine. He likes coffee, dislikes coffee stains. On days when his shoulder does not ache, he enjoys surfing and writing flash fiction.

John Warren

A retired Fire Service Battalion Chief, EMT, and Urban Search and Rescue Team Safety Officer.

Justin Morgenstern, MD

I am a community emergency doctor working in Toronto, Canada, and actively involved in online medical education, centered around my website First10EM.com. I have always loved photography, but really got into it seriously after medical school when I found myself with a lot more time to travel and enjoy the outdoors. I just figured out this instagram thing.

Jonathan Warren, MD

A PGY-2 at Harbor-UCLA Medical Center and founder of Art of Emergency Medicine. His hobbies include photography, hiking, Netflix, and dogs. He’s always on the lookout for the next adventure. Find more of his photography on Instagram.

You can learn more about the artists featured in this and other volumes at our contributors page!