Category: Medical, other than PBC

Imminent Death: What Happens in the Last Days and Hours

Here are passages from a few more scholarly journal articles on the subject of what to expect when someone is dying.

The full text of this first article, “Ensuring Competency in End-of-life care: Controlling Symptoms” by Frank D. Ferris, Charles F. von Gunten, and Linda L. Emanuel  can be found here.  It includes 100 works cited, and the great thing here is that there are links to take you to the abstract or full text of the articles listed — if available freely. It looks to me that for at least half of these, such links are provided. Topics covered include:

Approaches to the medical management of pain, depression, anxiety, breathlessness (dyspnea), nausea/vomiting, constipation, fatigue/weakness and the symptoms common during the last hours of life… 

“Is This a Bad Day, or One of the Last Days? How to Recognize and Respond to Approaching Demise” by Geoffrey P. Dunn  and Robert A. Milch [Journal of the American College of Surgeons, Volume 195, Issue 6, December 2002, Pages 879-887] is freely available here. It has a lot of information, including good summary tables of changes that happen weeks to days and hours before death. A few highlights:

One of the most reliable criteria for differentiating a bad day from one of the last days is the patient’s own report. If the patient states “I am dying,” or has a sense of impending doom, experience often proves him right. . . .

To date, there are no validated, consistently accurate, generally accepted models for predicting life expectancy in either cancer or noncancer diagnoses. . . .

A study of 468 hospice referrals reflecting the national pattern of diagnoses admitted to programs showed that only 20% of prognostications of length of survival were accurate within 33% of actual survival. Sixty-three and one-half percent of physicians overestimated survival, averaging five times greater than the actual survival. More experienced physicians were more accurate, and those with a longer acquaintance with their patient tended to overestimate survival. . . .

Regardless of diagnosis, observable changes during the last days of life include (Table 4): profound weakness (asthenia) and bed-bound state, sleep much of the time, indifference to food and fluids, difficulty swallowing, disorientation to time with increasingly brief attention span, low or lower blood pressure not related to hypovolemia, urinary incontinence or retention caused by weakness, loss of ability to close eyes, oliguria [low output of urine], vivid dreams or nightmares, patient reports of seeing previously deceased individuals important to the patient, frequent references to “going home” (not their street address!), or speech content related to travel to a final destination. . . .
Very late changes (Table 5) related to changes in both brain stem and cortical function heralding demise within a day to hours include: changes in respiratory rate and pattern (Cheyne-Stokes, apneas); mottling and coolness of skin from vasomotor instability with venous pooling, particularly in the pretibial [shinbone] region; dropping blood pressure with rising, weak pulse; and mental status changes (delirium, restlessness, agitation, coma). The majority of patients are comatose at time of death, though up to 30% of patients are reported to be alert until moments before death.

“Care of the Dying Patient: The Last Hours or Days of Life” [BMJ. 2003 January 4; 326(7379): 30–34] can be read here. Drs. John Ellershaw and Chris Ward begin with this fairly amazing observation:

We searched Medline from January 2000 to March 2002 in the English language by using the terms “palliative care” and “terminal care.” The search yielded 253 references, but only a limited number of articles were directly related to the care of dying patients.

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Imminent Death: How Good Are Doctors’ Guesses?

This series of  posts continues to look at some fairly technical articles which nevertheless may be of use to you if you are facing the prospect of the imminent death of a family member or friend.

 This study,  “Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study”  by NA Christakis and EB Lamont first appeared in 2000 in the British Medical Journal [BMJ] in volume 320,  pages 469-472, but is available freely without university library access.

This is a summary of their findings:

What is already known on this topic

Doctors’ prognostic estimates are a central element of both patient and physician decision making, especially at the end of life

Doctors’ prognostic estimates in their terminally ill patients are often wrong and usually optimistic

What this study adds

A prospective cohort study of 504 terminally ill patients and their 365 doctors found that only 20% of the doctors’ predictions were accurate: 63% were overoptimistic and 17% overpessimistic

Multivariate modelling showed that most types of doctors are prone to error, in most types of patients

The greater the experience of the doctor the greater the prognostic accuracy, but a stronger doctor-patient relationship is associated with lower prognostic accuracy.

As one commentator on the study put it,

Doctors may be reluctant to acknowledge that patients they know well are close to death. This can be compounded by the patient’s and family’s preference to keep hoping for the patient to live longer. Those of us who know our patients longer often become attached to them. We, too, hate to admit that death is near.

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Imminent Death and Spontaneous Return to Mental Awareness

The day before he died, my father, who over the course of several years had suffered a steadily decreasing awareness of and interest in his and others’ lives, finally appearing to no longer have an inner life, suddenly, briefly and inexplicably returned to the world. I described this here.

I’ve found out two things since then. There are many anecdotal reports about this phenomena, and there is next to no medical research, explanations, or theories about how this happens.

I can’t really imagine how researching an unexpected event could proceed. I suppose there could be people on call, like transplant teams, but then what? Would the dying person who has returned one last time to engage with the world be rushed into an MRI and subject to various medical tests? Perhaps some would agree to this, if they believed that by so doing others could be spared their suffering, and if they were asked before they lost the mental capacity to make that decision: you can see the difficulties.

I finally found one study about this subject: “Terminal Lucidity in Patients With Chronic Schizophrenia and Dementia: A Survey of the Literature” by Michael Nahm and Bruce Greyson, published in The Journal of Nervous and Mental Disease (December 2009, pp 942-944).

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Imminent Death: Best Guesses of How Much Longer

“Imminent death” is a search term that brings a lot of people to this blog. I am going to be adding more posts on this subject and collecting sources mentioned in a permanent page (as opposed to a post) as I go along.

One problem is that a lot of this material is in journals that you may not be able to look at for yourself because they are subscription only. The best way around this is to find someone enrolled in a college or university and ask to be allowed on via their ID/password. If you can get into a research library, and if the library still purchases hard copies of journals, that is another route. And it used to be true that if that library is a depository for government documents, you had to be admitted — at least to that area (but once in, well…). But that may no longer be true.

So one thing I’m going to do is to quote extensively here.

As I’ve noted before, it is surprisingly difficult for doctors or nurses to predict just how much longer a terminally ill person has left. This study, “Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study” [BMJ. 2000 Feb 19;320(7233):469-72] compared their doctors’ estimates for the time remaining to 468 terminally ill patients to the actual amount of time they survived. Authors Christakis and Lamont reported [emphasis added by me]:

Our study of 365 doctors and 504 hospice outpatients found that only 20% of prognoses were accurate. Most predictions (63%) were overestimates, and doctors overall overestimated survival by a factor of about five. These prognoses were doctors’ best guesses about their patients’ survival prospects, objectively communicated to the investigators and not to patients themselves. …  the tendency of doctors to make prognostic errors was lower among experienced doctors. Moreover, the better the doctor knew the patient-as measured, for example, by the length and recentness of their contact-the more likely the doctor was to err.

These findings have several implications. Firstly, undue optimism about survival prospects may contribute to late referral for hospice care, with negative implications for patients. …Doctors who do not realise how little time is left may miss the chance to devote more of it to improving the quality of patients’ remaining life. Secondly, to the extent that doctors’ …prognostic information affects patients’ own conceptions of their future, doctors may contribute to patients making choices that are counterproductive. Indeed, one study found that terminally ill cancer patients who hold unduly optimistic assessments of their survival prospects often request futile, aggressive care rather than perhaps more beneficial palliative care… Thirdly… disinterested doctors, with less contact with the patient, may give more accurate prognoses, perhaps because they have less personal investment in the outcome. Clinicians may therefore wish to seek “second opinions” regarding prognoses, and our work suggests that experienced doctors may be a particularly good source of opinion.

Some of the key points are summarized here.

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Reading Your Ambulance or EMS Report, Part 2

Picking up from where I left off in my previous post, there are a few more boxes left to read on the Ambulance or EMS Report, and then there is a narrative or Assessment.

In the center of my form are vital sign readings. One thing that surprised me at first was that although the EMS arrived at my home at 16:00 and started oxygen at 16:04, the first set of vitals is for 16:15. That must have been when I got loaded into the ambulance. Prior to that, the EMS had to see where I was and what was happening, and get the oxygen started. Then I had to get carried from the house, secured on a gurney,  and then the gurney was carried to the ambulance. While one team member [#709] ran an EKG strip, another [#332] took the first set of vitals and then a minute or two later started the IV.

The team took my vitals every 5 minutes. These included pulse, respiration rate, blood pressure, and oxygen saturation. My glucose was measured and my pupils were marked as =R, which I think means equally responsive or reactive. Skin color/condition was “pale, diaphoretic, cool.” Diaphoretic means sweating. When these three descriptions appear together, something is wrong.

Next is AVPU. This stands for Alert, Verbal, Pain, and Unresponsive. Alert is normal awareness, Verbal means that the patient responds if spoken to, Pain means that patient responds by flinching or pulling away from a source of pain, and Unresponsive means just what it says. Verbal is tried before Pain. Your possible grades are: A, V, P, U.

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Reading Your Ambulance or EMS Report, Part 1

Let’s say you too got hauled off in the ambulance and are as morbidly curious as I am and so got hold of the report your Emergency Medical Services team left with the ER.

Now what? How do you read this thing? What do these abbreviations mean?

I spent a fair amount of time googling these questions, and to save you the bother, I’ll walk you through mine. I have a lot of blank boxes on mine, so I didn’t research these, but I imagine the boxes on mine that are filled are fairly routine. I assume too that the forms are pretty standard from EMS to EMS.

The page I’m interested in is headed by the usual stuff: name, date of birth, allergies, medications, relevant medical history.

The first thing I wanted to see was what happened when.  This is documented in a box called Event Times, roughly in the center of the page. In my case, the first time noted (and a 24-hour clock is always used), 1556 [3:56 pm] is next to “Crew TOC.” I found one reference to TOC as “Traffic Operations Center”; what I think is meant here is time the crew received the call from dispatcher at 911. Next, Enroute Scene, also 1556. Then Arrive Scene, 1600. Next, Enroute Facility, 1622. Arrive Facility, 1629. Available for Call, 1702. This tallies well with what my family remembers, that is, that the ambulance got to our house minutes after my husband called 911 [actually, 4], and they worked to stabilize me for about 20 minutes before leaving for the hospital [22, in fact]. Once they got me to the hospital, they were busy for 33 minutes filing reports and cleaning up the ambulance, I guess, before being again ready for action.

How the ER doctor could summarize this timeline as “She became dizzy and came to the emergency room for further evaluation” remains to be seen.

Back to the top of the form.

The first box I get a tick in relates to oxygen delivery: nasal cannula, one of those plastic tubing things that hook on behind your ears so it stays in place while two little tube prongs deliver air to you through your nose.

I’m going to skip a box for now to get to Medications. Interestingly, oxygen is considered one. I find that at 1604, EMT #709 (the crew is identified by numbers, not names) began giving me a dose of 6 using route NC. NC is nasal cannula. I learned that an NC “can only comfortably provide oxygen at low flow rates, 0.25-6 litres per minute (LPM), delivering a concentration of 24-40%,” so I figure a dose of 6 means 6 litres per minute. At 1617 I received 4mg of Ondansetron [an anti-vomiting drug] by way of my IV.

Above Medications is a place for recording information about IVs. The first two boxes are straightforward: Time and By [whom (id number)]. Next is  Cath. This is short for catheter and is what you and I call the needle. In the box beneath that heading I found “18,”  the size of the needle, no cath, that is usually used on adults.

Next heading is Site, for example, right wrist. Under Fluid Type NS is ticked: normal saline. Rate is designated as “open”; this means that the purpose of the IV was to get fluids into me quickly to help restore falling blood pressure that results from blood loss and shock. Something that might appear there instead is TKO or KVO:  KVO is Keep Vein Open; TKO is To Keep Open. In these cases, an EMT explains, “The drip rate is minimal – only to keep the vein open and to prevent obstructions from forming so future infusions will properly flow. TKO and KVO are interchangeable. Wide open: to infuse the fluid as fast as the vein/cannula/gravity will allow.” The next box is  Amt Infused; in my case,  750 ml.

Finally, there is this heading: Attempts. Starting IVs can be difficult. My report shows it took 2 tries to get an IV started. I’ve since learned that most EMS are supposed to make only 2 or 3 attempts at placing IVs before going to the next level, an IO. IV stands for intravascular, vascular means veins. IO stands for  intraosseous, osseous means bone. Let’s put it this way: some of the tools involved in IOs look like mini power drills. I’m not going there. You can if you want. Just click here.

Then we have Cardiac Monitoring and Transmission where it is noted that EMT 709 started a 4-lead EKG on me at 1615. A 4-lead is used for monitoring purposes; should my complaint have been chest pain or something along those lines, a 12-lead EKG reading would have been done.

In Praise of EMTs and Paramedics

Until recently, my experience with ambulances was limited to thinking: I’m glad it’s not me in there, please let it not be carrying anyone I love, godspeed you to help whoever you are, and, if driving, I hope that ambulance isn’t coming up behind me.

But since my recent medical  emergency, I’ve looked into who these people are who arrive in a flash, save lives, and then are gone. They don’t leave a calling card, you never know their names, and if you are in as bad a shape as I was, you might have heard their voices, but likely never saw their faces. They could be standing next to you in line at the store, sitting beside you in the theater, and you’d never know it.

I’m convinced in my case (and I expect it many others), that the Emergency Medical Services [EMS] team saved my life; the emergency room doctor then fixed the problem. But he wouldn’t have had a patient to work on were it not for the EMS. This is why I was so surprised to find no mention of the EMS’s work in my hospital records. Is this common, that their work is ignored, I wonder.

I’ve learned a little about these professionals since then. It’s more complex than you might think. There are First Responders, Emergency Medical Technicians [EMT] (and several levels of these), and Paramedics, and the requirements for these vary somewhat from state to state. Firefighters are also often cross-trained as EMTs, in case you are wondering why firetrucks accompany ambulances.  I’m sure their physical strength comes in handy, too.

Then there are different categories of emergencies: BLS and ALS. BLS refers to “basic life support” and ALS to “advanced life support.” I learned a lot from browsing the forums at www.emtlife.com and www.emtcity.com. A question about the difference between BLS and ALS brought this answer from Michigan but the responses that follow show there are some state-to-state variations:

Basic Life Support Units that are designed for inter-facility transportation and pre-hospital response to ill or injured patients. Each unit is staffed with 2 licensed emergency medical technicians. …

The ALS units have a minimum of one paramedic and one EMT, can administer certain medications, and have advanced airway equipment, cardiac monitors, advanced cardiac life support equipment and blood glucose testing equipment.

What I found astounding is how poorly EMS workers are paid. All I can think of as an explanation is that in a lot of rural America, first responders are often volunteers, so somehow the idea got embedded that if there are people who will do this for free, why pay anyone well? It’s an absurd and stupid answer, but how else can the salaries of these people who deal with a range of dangerous and to most of us disgusting situations be justified?

Consider these facts from EMS Workforce for the 21st Century: A National Assessment [2008]:

…at $12.54, EMTs/paramedics are among the lowest paid of several comparable allied healthcare professions. Medical assistants, at $12.19, make somewhat less than EMTs/paramedics. L.P.N.s/L.V.N.s, at $16.94, have a median hourly wage of $4.40 more than that of EMTs/paramedics although the program length for L.P.N.s/L.V.N.s is quite similar to those for paramedics. …

EMTs/paramedics are among the bottom three categories in wages, making slightly more than nursing aids/orderlies/attendants, nearly $1 less per hour than medical assistants, and about $4 less than L.P.N.s/L.V.N.s.

…Medical assistants have a broad range of direct patient care responsibilities and work under the supervision of a physician, but have no training, certification, or licensure requirements. Low wage medical assistants (at the 10th percentile) make higher wages than EMTs/paramedics.

How can this be? Does this make sense to anyone? Am I missing something?

According to http://www.salary.com/mysalary.asp, where I live, EMTs make between $24,000 and $31,000 a year, while medical assistants, who “assist in examination and treatment of patients under the direction of a physician” make $26 – 31,000, and medical billing clerks, $27-32,000. These are all lousy salaries, but is it not astounding that people who are out in the field, making life-saving decisions without anyone there to consult, never knowing what they may encounter, make about the same as those who follow routine orders and less than those who send out the bills?

And as if this weren’t bad enough, if my experience is the norm, they don’t get any credit for their work by the ER departments to which they deliver their stabilized patients, and I could provide numerous examples of belittling depictions of their demeanor as insensitive tough guys, but this  New York Times review of the novel Black Flies by Shannon Burke (who worked in the field for five years) about “a rookie, Ollie Cross, who becomes a paramedic after failing to get into medical school” will suffice:

As Cross begins to break free of his borrowed role, Burke offers up one of the book’s most disturbing images, a tragedy of the everyday variety that produces headlines but quickly fades from the news. Five medics, smoking and arguing, stand at the closed door of an elevator that has plummeted down a shaft. As the door squawks open, the men quit bickering and jump up, reacting to “a tangled mess of limbs in contorted, grotesque shapes, tossed grocery bags, blood and eggs and a bag of Cheese Doodles covering the writhing bodies.” They are so desensitized that it takes a scene of sickening destruction to jar them into cooperative action [emphasis added].

Note that it is the reviewer, Liesl Schillinger, safe in her office, who deems the medics as “desensitized,” even as she notes that when it is time to act, they do so immediately. What’s her problem? Are EMTs and paramedics supposed to stand around solemnly and silently all shift long except for when they are saving lives? Would she be as snarky about surgeons in the hospital locker room bickering before going into the OR?

I’ll end with this summary from EMS Workforce for the 21st Century: A National Assessment [2008]:

Research into the EMS workforce in the United States reveals a complicated picture of a workforce that bridges two distinct environments: healthcare and public safety. This is only one of several reasons why the EMS workforce is a unique group of workers.

The EMS workforce comprises both employed and volunteer workers, a feature unique in the healthcare sector although common in fire fighting. Unlike other healthcare providers, EMTs and paramedics are visible and interact with the public primarily outside of healthcare facilities. However, the nature of their work and extent of their skills are often not well understood by public.

Despite their low pay and benefits relative to other healthcare and public safety professions, EMTs and paramedics are in many ways devoted to their field. There is a strong desire among leaders in the field to advance the EMS workforce.

I can attest to the devotion of the team in HEMSI Vehicle 64 to its mission. I wish I could do more.

091114-G-0000X-001 Coast Guard Station Humbolt Bay assist
SAMOA, Calif. – Station Humboldt Bay crewmembers and Eureka City paramedics remove an injured mariner from a 21-foot pleasure craft at the Coast Guard small boat station, Nov. 14, 2009. The man was injured while crossing the Humboldt Bay bar when a large swell threw him against the side of the vessel’s cockpit. U.S. Coast Guard photo by Petty Officer 2nd Class Gregory Brush.
Air Station Los Angeles medevac (FOR RELEASE)
LOS ANGELES – A paramedic from the Los Angeles County Fire Department records a patient’s information inside a Coast Guard rescue helicopter Oct. 3. The patient was medically evacuated from the cruise ship Osterdam 30 miles off Point Conception after it was suspected that he was suffering internal bleeding. (Coast Guard photo/Petty Officer 2nd Class Ken Fuerstinger)
SEARCH AND RESCUE (FOR RELEASE)
KODIAK, Alaska (Aug. 5, 2004)–Petty Officer 2nd Class Mark Capra, Petty Officer 2nd Class Dave Southwick and Petty Officer 2nd Class Kathy Hayes assist Kodiak paramedics as they remove a litter bearing Wilmer Anderovich from an HH-60 Jayhawk helicopter here. Anderovich was medevaced from Old Harbor suffering from gastrointestinal bleeding. Anderovich was transported by ambulance to Providence Medical Center here. USCG photo by PA1 Paul Roszkowski

At Risk for Esophageal Varices and I Nearly Bleed Out from a Gastric Ulcer: How Weird Is That?

Update: The current (November 2014) hypothesis among my doctors is that whatever they were called in my past posts — Dieulafoy lesions, Cameron’s erosions, or bleeding ulcers — all these bleeds have their source in the portal hypertension which comes from cirrhosis which is caused by my auto immune system attacking my bile ducts, that is, my primary biliary cirrhosis.

If you’ve read any of my posts on primary biliary cirrhosis (PBC), you were probably surprised by yesterday’s post that there wasn’t some sort of medical muddle involved. Wonder no longer: there was. It’s just that my emphasis was different so I left it for today.

I’ve written about being at risk for esophageal varices as a result of having PBC. These are swollen veins (like varicose veins), caused by portal hypertension (itself caused by cirrhosis [in the case of PBC — there are others. Click through to a site devoted to patients’ experiences with it]) in the esophagus. Left untreated these could “burst and bleed into the gut.”

But I had an endoscopy just this past January that showed only a trace of varices, and in such cases, 96% of people are trouble-free for at least 1-2 years (then they do another scope).

Of course, that means 4% of people aren’t.

So as soon as I regained consciousness in the ambulance, I alerted the chief EMT to tell the folks in the emergency room about this. And when I got there, I told them myself.

I will refrain from elaborating on how it feels while being transfused to have to repeatedly explain primary biliary cirrhosis and spell Urso Forte [the drug I take for it] to the ER nurses, and later my floor nurse and abdominal ultrasound technician.

However, following the endoscopy performed there in the ER trauma room, the GI who did the procedure reported that I lost enough blood to require four transfusions not because any esophageal varices burst, but because of a “gastric ulcer spurting blood.” He repaired it with three hemostatic clips and put me on pantoprazole.

But how weird is that? To be at risk of burst esophageal varices and have a gastric ulcer burst instead?

I reviewed my endoscopy report (high marks to the GI, who actually gave me a copy of my own medical report!) and found the location of the ulcer to be the cardia. Googled that, and discovered it is right where the esophagus becomes the stomach, and, in fact, for many years there was debate as to which organ it belonged to.

Now then, there is a new kid on the block at the hospital: the hospitalist. This person is sort of in charge of patients who come in through the ER and whose regular doctor doesn’t admit or have any role in their care. Like me. It took me two days to get someone to tell me who was really in charge of my case: the GI who did the procedure, or the hospitalist.

When the hospitalist visited me, I explained about my surprise that my bleed was gastric and not related to portal hypertension [PBC]. I told him that I didn’t have a local GI, but that I was under the care of a hepatologist at the UAB med center.

So the next day he returns, and says, “Good news: you don’t have to have a liver transplant.” I thought yeah, duh, but let him continue. He told me he had set up an appointment with the hepatologist who would do another endoscopy. And I said that sounds great, but what about this report from the GI deeming the cause of the bleed to be a gastric ulcer? The poor guy looked confused. I suggested he go back and have another (an initial) read of  my endoscopy findings.

But the hepatologist’s office and I agree that I should be seen by him. I have so many questions: can a burst esophageal varice adjacent to the cardia be mistaken for a spurting gastric ulcer? Is it really possible to have such an awful gastric ulcer and no abdominal pain? Can portal hypertension cause a gastric ulcer? Will this happen again? And will I have no warning other than feeling steam-rollered before it does?

And just how weird is it, if it was a garden variety gastric ulcer, for this to happen to a person who has to worry about bursting varices?

Stay tuned.

Melena, Hematemesis, Hypovolemic Shock — and A Lot of Love

Gore alert: Medical terms in title refer to situations involving blood, blood, and more blood.

Were mine a glass house, what you would ordinarily see are four people: Mom, Dad, 14-year old Daughter, and 20-year old Son sitting in separate rooms, staring at separate screens. Even holidays aren’t so different; each year they come chugging along with annoying regularity — and I still can’t figure out how to get on board. Orchestrating Hallmark Moments, creating those Special Memories your family will cherish for a lifetime, all that is beyond me. No surprise then that Mother’s Day barely registers on our screens.  But I’ve something better than a lifetime’s stack of cards (and why do people give greeting cards to people they live with, anyway?): my fractured memory of this past Monday afternoon.

Last Saturday night we returned from a 3200-mile+ roadtrip out west, so Sunday I wasn’t surprised to be really tired. Monday wasn’t any better, and I had no appetite but no stomach pains, ate a banana and some soup.  I wasn’t even that surprised when I had the most horrible black diarrhea. I put this down to culinary karma — what did I expect after eating a sausage pizza at a truckstop in rural Arkansas? But Husband was concerned and called to get me a doctor’s appointment. The nurse said I needed to get to the ER, asap. I learned later that this was blood I’d passed, blood mixed with stomach acids: melena.

I resisted. I’d just have to sit there for hours. Besides, I couldn’t even get to the refrigerator and back without having to lie on the floor to rest. Looking back I see how odd it was to think that a reason not to go to the ER. I relented, but told my husband, who needs a total hip replacement, that Son would have to help me to the car.

We hadn’t reached the door when I said I needed to rest, so Husband went to get the air going in the car.

And then I started vomiting up huge black clots of blood. I wasn’t seeing what was going on at this stage, but I was hearing it. Husband called 911 for an ambulance. Dispatcher heard collie barking, said to get him secured. Rascal wouldn’t leave my side, but Daughter and Son together pulled and pushed him out to the backyard. Then both returned and as Husband talked with dispatcher the two of them followed her instructions, keeping me on my side as I continued vomiting up this foul black matter (hematemesis). They told me later I was flailing around, maybe convulsing or seizing, with my eyes wide open but my pupils not right. I certainly wasn’t seeing anything. I remember their stroking me, kissing me, telling me they loved me.

The EMTs and fire truck arrived in minutes. The kids say that the first guys in backed away, until the woman in charge came in and told them it wasn’t trauma (did they think I’d been shot?). Because of the position of our door, deck, and steps, getting a stretcher in wasn’t an option, so they had to haul me out to a gurney placed on the sidewalk. I remember being rolled into a blanket or something. And that’s it, for a while.

Although they worked on me outside, I remember nothing til I was loaded into the ambulance. My guess is I’d lost consciousness, but they started oxygen as soon as they got me out the door so by the time I was in the ambulance I was aware of talk about my blood pressure, getting needles in both arms, hearing the sirens when after 15 minutes or so I was stabilized and we got moving, and I have a few visual memories of the Head EMT and inside the vehicle. I think at some point I must have been between stages 3 and 4 of hypovolemic shock.

In the ER I soon was given two transfusions; later I was to receive two more. I remember the Head EMT telling the nurses they had a very anxious husband pacing in the waiting room who need to be allowed back as soon as possible. Then she was gone.

I became alert enough to be interested in the trauma room. There are posters on the walls telling RN 1, RN 2, RN 3 — up to 6 or 7, I think, exactly what to do and even where to stand relative to the patient’s bed. Someone cut my housedress off, just like on TV ER shows. I complained about the pain the large IV needles were causing me, about being thirsty, about needing to get the blood out of my hair. That was really gross. Even though I couldn’t move my arms I could feel that blood was stuck in my hair, and when I looked at my pillowcase, it was totally red. Not a priority, however.

I ended up having a spurting gastric ulcer repaired via endoscopy, and was home less than 48 hours after the ordeal began.

And what was going on while I was in the ER? Son was cleaning blood off the carpet and Daughter was cleaning everything else in sight.

When I came home, my collie was waiting on the deck in the 102° heat, somehow knowing I was on my way. My bed was made with fresh linens, and Daughter had imposed order on the clutter of the bedside table. She spent a good hour getting all remains of adhesive off my badly bruised arms.

Ever since I got out of the hospital and home with my family, I’ve been uncharacteristically cheerful, bouncing off the walls buoyant.

Of course.

Of Flu and Football in Tuscaloosa and Beyond

I found some encouraging information about the prevalence of H1N1 or swine flu on the campus of the University of Alabama in Tuscaloosa:

— FLU IN REMISSION: The flu virus circulating through the University of Alabama campus in recent weeks appears to finally be on the decline.

“It seems much, much better,” John Maxwell, director of the UA student health center, said Wednesday. “We randomly have checked some during the day just to see if we’re still seeing it. I think (Tuesday) and (Wednesday), we haven’t seen any positives. That is good news.”

Where did I find it? State news, local news, education news? Dream on. It was buried several inches deep in the Friday, Sept. 18,  on-line edition of  the sports pages of the Mobile Register.

It seems sometimes, if it weren’t for sports reporting, we’d no news at all from our Alabama campuses.

Even the NPR affiliate in Birmingham, AL, WBHM found H1N1 among college students in Alabama only worth a mention in the context of game days.   Andrew Yeager’s September 18, 2009, report,  Tide Flu, noted that

Sports Economist Andrew Zimbalist says canceling a game at a small, division three school such as Stillman is less problematic than at a division one program. There’s more at stake for big universities.

“For the schools themselves they can generate in ticket sales millions of dollars in each game. And then they have television contracts. They have television contracts that can also generate millions of dollars or the equivalent of that per game.”

Beyond that, Zimbalist points out if a season is interrupted by cancellations, it could affect perceptions of teams making it to post-season play.

“That becomes tainted if one of the contending teams misses a game or two because of a swine flu epidemic.”

What’s Stillman?

Stillman College, founded in 1876,  is a small (~1050)  four-year liberal arts college affiliated with the Presbyterian Church, and is, like the main campus of the University of Alabama, located in Tuscaloosa.

When 37 of its players and several coaches had flu symptoms in the days leading up to its opening game, the College cancelled the game and the SAIC marked the game up as a  forfeit to Stillman’s opponent, Clark Atlanta.

The team’s coach, L. C. Cole,  told Tuscaloosa News sportswriter Andrew Carroll,

We had to make a decision in the best interest of our athletes. We didn’t want to do any further harm. The college did the best thing as a precaution for our team and our student body too.

This is Cole’s first year at Stillman. Responsibility and integrity: not just talk from this coach.

Meanwhile, down at the University of Florida, we have this from Florida Gators Head Coach Urban Meyer:

“It is a panic level of proportion I’ve never seen before,” Meyer said Sunday, a day after his team’s 23-13 victory over Tennessee. “You hear about, I think, Wisconsin had 40 players. Ole Miss had 20 players. My wife, with her great insight, said, ‘Do you realize the swine flu and everything is hitting the Florida campus last week.’ My gosh.. . .

“We’re trying the best we can, but it’s real,” Meyer said. “We go to the extremes. They get a separate dorm room for them. They get a separate hotel room for them. They put them right on whatever the flu stuff is. Our guys, our team doctors, they’re on it as fast as you can get on it.”

And the Gators have all now had seasonal flu shots. The Associated Press’s Mark Long reported:

The regular flu shots were the latest course of action. They came about a week after one school official predicted that as many as 40 percent of students could catch swine flu.

Uh, what exactly is the connection between those two sentences? The shots available now are the seasonal flu shots. They aren’t going to keep the Gators safe from H1N1.

The AP report goes on to note that only 3 Gators were sick with flu during last Saturday’s game against Tennessee.

[Jeff] Demps, [Jermaine] Cunningham and [Aaron] Hernandez all played against Tennessee on Saturday, but none of them seemed up to par. Demps, who had a 101-degree temperature, ran four times for 31 yards and a touchdown. Hernandez caught four passes for 26 yards. And Cunningham finished with one tackle. “They were beat up pretty good,” Meyer said.

Playing a guy in a contact sport who is running a “101-degree temperature”? That might be how they “go to the extremes” in Florida, but I’d rather have my kid playing for Coach L.C. Cole (the Stillman coach, remember?).