Lachlan Rutledge: A Broken Arrow with an Adopted Great Dog and an Overdosed Pulse Oscillator

The Rutledge family lives in Broken Arrow, a sunny Tulsa suburb with a frozen custard shop and a dentistry called Super Smiles. Their front porch has a potted Succulent, an abandoned scooter and a 140 pound Great Dog named Thor.

Their lives are far from ordinary. The last time Lachlan needed to see an allergy specialist, his mother packed the car with his nebulizer and medications for a 14-hour drive to Denver, leaving her husband, their two other sons and her mother, who was undergoing chemotherapy, for two weeks. Later, when doctors told her that Lachlan’s disorder appeared to be causing stomach ulcers — but that the sole pediatric gastroenterologist at Saint Francis wasn’t available for months — she began planning a journey to Dallas.

Ms. Rutledge made Lachlan use a pulse oximeter so he wouldn’t get frightened by the monitor when he spiked his heart rate.

Lachlan tugged at his chest. He didn’t get admitted for five hours. Ms. Rutledge’s hands trembled and tears streamed down her face.

After taking a course of steroids, Lachlan was released from the hospital. He sleeps in his parents’ bedroom so they can check his oxygen levels and administer nebulizer treatments every few hours throughout the night.

FRESH AIR: Dr. Farzon Nahvi, Emergency Room Physician, and Frustration with American Health Care During the COVID Pandemic

DAVIES: This is FRESH AIR, and we’re speaking with Dr. Farzon Nahvi. He is an emergency room doctor at a New Hampshire hospital. He spent the early months of the COVID pandemic on the front lines in emergency rooms in New York City. His new memoir is about his experiences in the ER and frustration with American health care. The book is called “Code Gray: Death, Life, and Uncertainty in the ER.”

Farzon Nahvi is an ER physician at Concord Hospital in New Hampshire and the clinical assistant professor of emergency medicine at the Dartmouth Medical School. Before that, he worked in hospitals in Manhattan. He’s written for The New York Times, The Washington Post and other publications, and has testified before a congressional committee on health care reform. His new book is “Code Gray: Death, Life and Uncertainty in the ER”. Farzon Nahvi, welcome to FRESH AIR.

NAHVI: You’re correct. This is a text message exchange between 15 of us. They are all ER doctors that did their training together, and spread out across the country. The text message thread was there for a while. It’s usually a benign thread where we talk about our lives and experiences. But then it really came to life in the earlier parts of COVID. We shared a lot of experiences.

We were on the ground when this happened, and it felt like we were one step ahead of the guidance we were receiving. One or two weeks later, the guidance would come. We depended on each other for everything from how to handle people to how to treat them. If our family members got sick, we would ask each other to check up on each other’s family members. It covered all of the aspects of life in the early stages of the Pandemic, where everything was done on the fly.

NAHVI: I think it’s a mistake that we didn’t encourage mask use early on, because once we learned that it was, we put a lot of ourselves in danger by not treating it that way. Two physicians that I worked with died early on. I know of one patient transporter and one overnight clerk that have both died. And two PAs, two physician assistants that worked in the ER very closely with me – they didn’t die, but they were young guys. They were in their 30s and 40s, and they were intubated in the ICU with COVID.

So it was a very different time period. It’s hard to remember what it was like because we’ve come a long way since then and the virus doesn’t change on it’s own. I talked to a colleague of mine who is an internal medicine doctor, and she said that it was related to childbirth. The woman had just given birth. She said that the earlier period where you have a big, dramatic experience and then it’s over in a hurry is similar to the childbirth period whereeverything is back to normal.

You look back and say, is it really as I remembered it? Is it really as crazy? And it was. It is hard to appreciate the dramatic episode that it really was because it was so brief.

Source: https://www.npr.org/2023/02/21/1158491524/an-er-doc-reflects-on-life-death-and-uncertainty-in-the-early-days-of-covid-19

How do you feel about the first time therapists? (Laughter and Reaction). I’m okay, but it’s not like that

NAHVI: I’d say, yeah. I mean, in the text message thread in the book, there are parts where we have colleagues kind of asking each other, hey, is it safe to use our work health insurance to see a psychiatrist for this? I have seen a lot of first time therapists because of this. And I think it’s not just that people were dying, and it’s not just that this was a scary time for us. It’s also, as I was saying, this kind of loss of confidence in our system making the right calls to protect us.

It’s not good for the CDC or our health care institutions at the highest levels to say “okay, you know there’s this big scary thing that’s happening, but you guys are in the position to protect ourselves” when it’s one thing to say. And it might be risky, but we’re all in it together. But it’s another thing to say, hey, this big thing is happening. We’re calling on you to help out, and, you know, we’re going to support you 50% of the way. A majority of people felt that trust in our institutions wasn’t as high as we wanted it to be. And because of that, it became a much scarier time. And I think maybe the PTSD comes from that.

NAHVI: For the first time in my life I did. There’s this wonderful collaboration between those of us who are in it together and texting one another. There’s a bunch of therapists that got together and decided to help out in the early stages of chronic bronchitis, but they weren’t ER doctors and they decided to support us rather than against us. And they got together and provided free therapy for anyone who wanted it, no questions asked.

I’ve never been in that situation where I felt like I needed therapy. Because it was available, and because the people who were helping us were genuine, I took him up on it and it was very helpful. And I am appreciative of that. And I think, right now, three years later, I’m doing OK, and I’m doing pretty well. It’s probably because of the experience I had.

NAHVI: At that time, there was a lot of anger. I’m not necessarily an angry person by nature. That’s not something I go to for. I was very angry during that time period and had someone to help me through that, which was very valuable to me.

Source: https://www.npr.org/2023/02/21/1158491524/an-er-doc-reflects-on-life-death-and-uncertainty-in-the-early-days-of-covid-19

Life in the ER: I know a 43-year-old woman is trying to get out of the hospital when she isn’t breathing

So the book is about life in the ER. And you describe being on duty in an outer borough of New York once when you get word that an ambulance is on its way with a 43-year-old woman who has not had a pulse for 30 minutes, and the ambulance is still six minutes away. She’s not going to be resuscitated and she’s dead. What are you going to do when the ambulance arrives?

The person is called “NAHVI.” You know, it is. Yeah. We need to make sure that we’re all on the same page. We communicate my thoughts to the team while I lead the attempt to resuscitate the female, and we also talk about the fact that we have a 45-year-old female. She came in with X, Y or Z. We did X, Y, or Z. We didn’t feel a pulse. We don’t have a return of circulation. It has been 45 minutes. I think that it’s time to call the code and time of death. Should anyone have any ideas? We need to make sure we’re not missing anything since we want everyone on the team to give feedback. Sometimes our nurses have great ideas, our physician assistants have great ideas that we’re missing, and it’s very important to continue that.

DAVIES: Now, her husband arrives a few minutes later, and you and the team are still working on her. And you give him the option of staying in the room and watching. And I’m picturing this ’cause you describe it. And she is, you know, on the table, naked and unresponsive, being subjected to a lot of, you know, invasive stuff. There are tubes and IVs and chest compressions going on. I could imagine it would be traumatizing for a husband to see this. Do you think it’s a good idea to have a relative or a loved one in the room?

If someone didn’t make it and died, all of the effort was made to keep them alive. And, I mean, we could go through the research and the data, but I think a lot of people experienced this during COVID itself, when people weren’t allowed there. It is horrifying to see a person die, but we should not be in that room and not watch it. And a lot of people had to go through that during COVID.

A conversation that moves as a thread throughout the book is what happens here as you describe it. But it’s interesting that you tell us in the book that there’s no set standard for how long you continue CPR after you’re not getting a pulse. This team and you really work on this woman. At some point, it’s clear that it won’t be successful. And you have the husband here, and you want him to feel comfortable that everything that could be done was done. You spoke to the team. I’d like you to kind of just reconstruct this, what you say to your team, ’cause it sounds to me like part of that is done for the benefit of the husband.

But also, it’s this dramatic thing where someone’s about to die, and we want everyone in that room, whether that’s the patient’s family members or anyone that’s on my team with me, to feel comfortable with that. I would never want someone to say, hey, I think we should have done this after. We review that. As long as everyone buys in and we are all on the same page, we proceed, and the time of death will be 10:32 a.m. It usually ends that way.

NAHVI: Questions about what they know are the first thing you do. Before I even say anything, I say, hey, we were in the same room together. Tell me what you know up until this point, and let me fill you in on the rest. And that gives me some time to actually get a better understanding of who this person is. What are they aware of medically? What have they seen? How am I going to speak with them? I use it to frame my conversation. And then, I might fill them in on the rest.

Generally in life, if we have friends or family members and they’re going through a hard time, we tell them everything’s going to be fine. Usually, we give them reassurance. I had to come and confirm that after someone came in for the first time and they probably had fear in their mind that something bad was going to happen. And I was fighting this deep, deep desire inside of me to not want to tell her that truth, to try to avoid that as much as possible.

And the ER’s a tough place to break that news because we have no information except that you have cancer, right? If you go somewhere else and you get a biopsy, we might be able to say this is the type of cancer, or this is what the next step is in your treatment, or this is the prognosis. We don’t know much. She had cancer, so I only told her that. And every follow-up question, we don’t really have the answer to that. It makes it more difficult.

NAHVI: Yes, absolutely. I was recognized immediately after I walked away. I just – kind of my mind was reeling, that, oh, geez, I didn’t even tell her (laughter). I had to have a conversation with myself, and confess that I didn’t communicate as well as I could have. So those things that I was talking about, those bad things, it does look like you have metastatic cancer.

NAHVI: I do not think that she was confused. I think she knew. I think she probably held on to some hope ’cause I didn’t close that book for her. But I think that she knew.

Source: https://www.npr.org/2023/02/21/1158491524/an-er-doc-reflects-on-life-death-and-uncertainty-in-the-early-days-of-covid-19

When someone dies, how do you remember? NAHVI: And what you’re going to have to do next step, when you have to go back to the ER

There’s not a lot of information that I can give you when someone dies, it’s the next step of your process or it’s your treatment. It is reassurance for someone that they did the right thing and that the paramedics that took care of the patient on the way to the hospital did the right thing. And I might give them specific examples of the things we did to try to resuscitate her and how those were unsuccessful. It is important for me to let them know that everything that could have been done to save that person’s life was a failure and that it was not something we were able to treat.

They were called daemons. The husband was allowed to sit with the wife’s body, and then you spoke to him. At some point, you need to put in your notes. I mean, you fill out a death certificate. You put in your notes. The notes that you write are going to be reviewed by the hospital’s business department. What are they going to be looking for?

NAHVI: Yeah. Yeah, a lot of things – the ER is a busy place. It’s a chaotic place. We have a number of rules on visitors and who is allowed to do what. But when someone’s died, we generally let their family members do what they feel that they need to do. There are no visitor rules anymore. If four or five people want to come in, that’s OK. They can stay in the room with the patient.

You write about death and how physicians deal with it. I’ve asked you to read a little selection from this here. This is near the end of the book. You want to just share this with us?

DAVIES: It is something that is a part of your life. Your father-in-law stopped breathing when he became ill with COVID and you mentioned it in the book. He was not near you. He was picked up by a crew that was going to take him to the hospital. You called the ER where he was being treated to check on him. You didn’t know that he had died until the clerk answered the phone. How did you know?

I know her job. I know what she’s doing. She’s sitting by a computer reviewing a list of patients. And she has a lot of stuff going on. And she’s very busy. And if it’s a patient with an ankle sprain or with, you know, even a heart attack, you get that information. And you look it up. And you kind of say, all right, I’ll get back to you in a little bit. But when she looked at the board, I presume, and she saw that we were calling for my wife’s father and he died, she just changed her tone completely. And it was very evident to me of exactly what happened on the other end of that line.

You write that you’ve never been used to death despite being around it so much. People are wondering how you deal with it. How do you handle it?

NAHVI: People answer a lot of questions for this. I believe the truth about what we do is that we just ignore it. We pretend that it’s not there. And we don’t really acknowledge it. And that’s our culture. Medicine is an apprenticeship culture where we see people before us, and we mimic the way they do things. For better or worse, the way it’s always been, we just ignore it.

There’s a lot of people out there who believe that this type of separation and detaching is necessary to ensure that you don’t get attached to those experiences and are unable to perform your job. I think that’s a mistake. I think that’s certainly a coping mechanism, but I think it’s a poor coping mechanism. I don’t think you could pretend to be unaffected by this stuff. And one of the reasons I wrote this book was to kind of explore that, for myself and for others to share in that experience.

DAVYS: Yeah. It’s interesting, you know? You say ignoring it is just a way to get back in there and handle it the next day. It’s not healthy in the long run. And I’m wondering what the alternative is. I mean, writing a book, for you, was helpful. But that’s…

But then one time, I was an attending physician. I was supervising one of the residents that I worked with. And at the end of a code, someone had died. We called a time of death. He spoke on his own. “I hope everyone can stay in the room for another 30 seconds,” he said. I just want to appreciate that a human being has died. He said that we didn’t know who this gentleman was. We don’t know his name. We can assume that this gentleman had people in his life that he loved and people who loved him, just like we did with our loved ones. So in recognition of that and in recognition that someone has died, let’s just have a moment of silence. The entire thing lasted 15 seconds. It just made me experience those things in a whole new way.

And I copied him. He was a resident of mine. I was supposed to be a supervisor teaching him, but I took that from him. And since then, I’ve been doing that every time that someone dies in the ER. And every time I do that, I have people come up to me – nurses that I work with, technicians, respiratory therapists – and they say, thank you for what you’re doing. So you can tell that there’s this unmet need of how we deal with things in the ER. I don’t think I have all the answers to everything that could be done to make this better. I know that we can do better, despite the fact that I have experienced it before. We need to begin this process by starting talking about it and figuring out how we can have a conversation about it.

NAHVI: They’re trying to make money, Dave. So there’s billers and coders, and they exist in a whole different universe than we exist in. We live in the clinical space, but we are employees of a hospital, and they too are employees of a hospital. They have methods to get what we write for profit because they live in different buildings and work on computers. So they try to find phrases such as “hey, this indicates a level of sickness which can be a code that we put in to get billed for this or that.” They bill us from what we do.

Source: https://www.npr.org/2023/02/21/1158491524/an-er-doc-reflects-on-life-death-and-uncertainty-in-the-early-days-of-covid-19

A note on daemons, and what happens when a patient goes into an emergency room to see an ER doctor — a disturbing case for me

And in this particular case, it’s kind of disconcerting for me because this person just died, and it’s not really front of mind for me, but I have to write this note, and I do it. You have to make a note to document what happened, so the note is not problematic. But then kind of I’m very well aware of all the steps that happen down the line.

NAHVI: It depends on the hospital I’ve worked for. I’ve worked for public hospitals who do have a mission to just take care of people. And no, I don’t get that pressure there. But many of the private hospitals I work for, there’s a phrase that’s called strive to five, meaning try to get that Level 5 billing code, you could say.

NAHVI: Well, it’s terrible. I mean, I think there’s a lot of injustices in our health care system. We see it all the time. And it’s funny because I think when you’re in med school, you’re told by your professors all the time that you’re going to be entrusted with these important situation with your patients, and you have to really value that trust that patients put in you. They don’t tell you the other way around. They don’t tell you about the shame of being a doctor, sometimes, the shame of being a part of a system that makes you complicit in the problems, and you can’t help people that, even though they need your help.

So her chemo – her oncologist wasn’t able to see her anymore because she didn’t have insurance anymore. So he or she referred this patient to our hospital, which was a public hospital where I was working at the time. She wasn’t aware that she was going to see an oncologist. So she just came to the emergency room. And I thought there was a misunderstanding.

I saw her, and I said, you know, I’m an ER doctor. I – if I could treat you, I absolutely would. The tools I do have are not the ones I need. I have no ability to do that. And then we ended up kind of going from there. I ended up in the emergency room with her.

They were called daemons. It would take her weeks or months to get an appointment with an oncologist, she said. And she knew that if you come to the ER, they have to treat you, right? I mean, so she figured, hey, you can’t send me away.

NAHVI: Yes, that was what she told us. She said that there was a law stating that if you’re uninsured, you have to go to the emergency room. She’s correct. Except for the caveat that she had a great comprehension of the situation, but not that we have to treat you in the ER, that was what made me so uncomfortable at that time. You have to be evaluated according to the law. And whatever we can do to stabilize you, we have to do.

She was stable according to this legislation. So she had cancer, and she was dying, but she was dying slowly. She wasn’t dying quickly. So she was technically stable. I had to explain to her, that, yes, you are protected by this law, but we cannot help you, you have cancer and you’re dying.

I am not an oncologist, but I don’t want to be one, so that is what I am. I don’t have chemotherapy. I’m not trained for that. I have no idea how to do that. And in the eyes of the law, you’re stable. And she kind of got a little upset, rightfully so. She said that if I was dying quickly you had to take care of me. All bets are off since I’m dying slowly. And I had kind of no choice but to agree with her.

There areDAVIES: Right. You mentioned a case of a patient coming in who had a serious case of pharoahia after taking antibiotics they had bought, I think on a pet supplies website. You said it was poison control. And the guy who answered immediately had a guess about what kind of antibiotics. Please share it with us.

A man is telling a story. Well, so this lady, she took – actually, I remember the specific antibiotic was erythromycin. Some neurological side effects were related to her taking fish erythromycin. So she had something called ataxia, which is a change in your balance and your gait. So she lost her balance. She could not walk well because of her eyes twitching. And the grand irony – and you can’t make this stuff up. It’s just so terrible. She came in, and the whole reason she had taken the fish antibiotics was that she had a job interview coming up. She overdosed on fish antibiotics and fell down a staircase during her job interview after she took the fish antibiotics.

I just can’t identify where she went wrong – right? – where someone would argue that she should have done better. The lady is trying to do everything right. She was working hard to try to get a job so that she could get health insurance, but she didn’t at the time, so she did the best that she could to try to get herself a job and health insurance. And yet even that process caused her to have some CNS – central nervous system – toxicity and then fall down a staircase, and she ended up in the ICU.

NAHVI: I think it’s made me a better doctor and a better person (laughter). I think these stories live within us, whether we acknowledge them or not. And they percolate, and they come out in different ways. And I think really sitting down and processing them and kind of getting a better understanding of them has made me get a better understanding of life itself. These stories are an exploration of life in the ER, but they’re not really about life in general. The ER is like life in its most extreme state. There’s nothing unique about it, right?

The ER is a fascinating place because of its contradiction. This place is where you can get the care you need, no matter when you want to come. And yet no one ever wants to go there, right? We put needles in you. There’s long wait times. You can’t get any rest. It’s America, so it’s expensive. There are only people who want to be there in this funny place, so it’s a place where you won’t see any other people. And we see extremes as a result. Understanding medical, ethical, social and health care extremes helps you understand how you feel about things in the wider world.

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