#so I will be back on my normal med regimen by tonight

[cr0wc0rpse]

Hm well I’m having a thought now. I’ve missed the past like …… 3 or 4 days of my mood stabilizer. Because I ran out unexpectedly. So that means I missed 6 or 8 doses. So . There is the possibility that the “having multiple ideas for various creative (small) projects” thing is coming from mania. Hm.

[megwritesfanfiction]

Concrete 3/3 (BNHA/MHA Kacchako)

Disclaimer: I do not own Boku No Hero Academia. I am not making a profit off of this.

A/N: Okay, I think this is done... Maybe? I have no idea... 

Concrete 1 Concrete 2

Read on AO3

It reminded her of floating.

She would know.

Her body felt fuzzy and weightless. The sensation had once made her dizzy and nauseous, but with practice and understanding she’d quickly found herself used to the feeling of it.

Uraraka had a feeling that she’d never get used to this.

Though feeling hadn’t returned to her body, neon dots burst brightly behind her closed eyes and beeping filled her ears. Slow, steady, and accompanied by the soft hum of electricity.

If she had to guess, Uraraka would bet she was in the hospital.

In the handful of times she’d been sent to Recovery Girl’s office, she’d never been hooked up to a monitor. She’d woken up on the way to the med room after she fainted during her match with Bakugo at Sports Festival their first year. Aside from normal bumps, bruises, and broken bones, Uraraka could only think of one other time she’d sustained a serious injury.

She’d taken a knee to the head while sparring and was unconscious for a few hours.

Uraraka couldn’t quite remember what had happened this time, but…

“Any change?”

Who was that?

To her right, the shifting of stiff fabric scratched against her eardrums. “No.” There was a heavy sigh followed by partially muffled words, “They said she’d be awake by now.” Bakugo? How long had she been unconscious? “What are you doing here anyway?”

“I’m off duty until Sunday morning.” Boots clicked across the floor moving closer to her. “Figured I would check in on you guys since Iida had to go back.”

Okay, so it wasn’t Iida. She would say it was Deku, but it didn’t quite sound like him. Kirishima had mentioned something about being on duty, so she had to assume something had happened. Knowing Deku, he wouldn’t stop working until he couldn’t move.

Whatever incident it was, Uraraka had to believe it was the cause of her injuries.

She was okay.

Even if she couldn’t feel her limbs yet.

She heard Bakugo huff as he moved again, “I don’t need a babysitter.”

“Just making sure, man.” Kirishima. She should have known.

“Hey man,” she could hear the smirk on his face. “Someone needs to make sure you’re eating-”

The sound of paper crinkling and a whiff of something salty filled her nose. Smelled like teriyaki?

“And that you haven’t been arrested.”

If that statement didn’t wake her up, Uraraka wasn’t sure she’d ever regain consciousness.

The last thing she remembered was Bakugo scowling as she shoved pink and white frosted cookies in her mouth. He’d grumbled something about her “shitty eating habits” when he stole a cookie from her, refusing to admit how good the cookies were.

What exactly had happened to her…? Where did they go after breakfast? And how had her boyfriend nearly ended up in jail?

“Well-“ Why did Bakugo sound so tired? His voice was raspy and weak, not evening trying to but his normal amount of bite in his voice. “I’ve managed to stay out of trouble for the last day and a half.”

What day was it? Kirishima mentioned something about going back on duty Sunday, but she couldn’t remember what day she’d been rendered unconscious.

“I’m just making sure that you don’t punch anyone else out.” Had there been a fight? Had she gone out on patrol with him and gotten injured? Uraraka couldn’t recall being scheduled for a patrol or being teamed with Bakugo. As weird as it was, teachers at UA were aware of their relationship and made sure not to partner them up for patrol or projects.

There may have been one instance when he’d been assigned to be her partner randomly, but teachers had been sure to split them up for patrol practicals.

Kirishima’s voice was light as it faded toward the other side of the room. “You need to eat. Iida told me you didn’t eat last night-“

“I’m not hungry.“

“Kaminari told me you skipped lunch yesterday-“

“Not true. The nurse brought me a coffee and cookie-” A small part of her hoped that she could remember this conversation when she finally awakened. Bakugo had always been critical of making sure that she was eating regularly, especially with her training regimen.

“Mina told me you didn’t eat anything this morning-” It sounded like he was standing in front of Bakugo. “And I am not above telling Uraraka. She’s gonna be pissed.”

He wasn’t wrong. Uraraka was sure if she could move her body she’d sit up and knock some sense into her boyfriend. Warmth was finally beginning to tingle in toes and fingers, but her body felt like lead.

“She has to wake up first.” She’d witnessed her boyfriend fight against impossible odds without batting an eyelash at the odds. Why did he sound so hopeless? His soft sinking tone sent a jolt of fear down her spine as she heard the heart monitor play her nerves.

How bad was she hurt?

“Katsuki-” Kirishima resorting to calling him by his first name without Bakugo’s protest only confirmed the seriousness of this situation. “The doctor said that Uraraka’s surgery went better than they could have asked for. Brain scans are good-”

“She has a brain bleed-”

“Minor, non-surgical-” Personally, Uraraka would never think to associate the term brain bleed and minor, but if the doctor wasn’t concerned she could relax a bit.

“Her hair was soaked with blood and dust when I found her.” A head injury and the sedatives would explain her lack of memory. “I should have gotten her to a medic immediately when I-”

“Stop.” Kirishima’s voice was firm.

Uraraka could feel the pull of stitches against her side and at her scalp as she focused on trying to move.

“I should’ve noticed that she had a concussion.”

“Ka-”

“Like I should have seen that fucking gash in her side.” Had she been stabbed in an ambush?

“Don’t do this to yourself,” Kirishima sighed. “You’re going to have to forgive yourself eventually.”

“When she wakes up,” Bakugo insisted, stubbornly.

The sound of plastic and styrofoam rattling sounded louder in her ears.

“If you don’t eat something, you’re going to be in a bed next to her.” Kirishima’s hand came down lightly on something solid. She imagined there was a little table in her hospital room. “Eat the damn noodles and stop thinking about worst case scenarios. The doctor said she’s doing good.”

The black behind her closed eyes become lighter as she felt awareness returning to her body.

“Eat or I tell your mother.”

“You’ll be back on duty when she comes to the hospital.” Uraraka couldn’t ignore the small smirk in his voice.

“Actually,” Kirishima started with a smirk of his own. “She said she’ll be here this evening with dinner, so I can join you all.”

“Tch.” It was nice to hear the tension ease out of his voice.

Her eyelids painfully peeled apart, the fluorescent light above her head burning her eyes.

“I can’t believe you have my mother’s number.”

Kirishima laughed, pulling a chair of his own next to him, “How are you surprised?”

Uraraka would’ve laughed if her throat hadn’t felt like it was full of sandpaper and cactus needles. With a little inhale and eyes barely open, she watched as Kirishima unboxed the food and placed a covered bowl in front of Bakugo.

“Fair enough,” Bakugo sighed, leaning back in his hair as he shook his head. The skin around his eyes was dark and drawn tight.

When was the last time he’d slept?

He was dressed what looked to be a wrinkled pair of navy hospital scrubs, hair more unruly than usual.

“Stop pouting,” Kirishima said, holding a pair of chopsticks out in front of the blonde. “Eat your noodles.”

Uraraka licked her lips as the corners of her lips twitched with amusement. She inhaled deeply, opening her mouth. “Yeah-” That small word tearing at her throat. “Eat your noodles,” she rasped breathlessly, words slurred together.

Bakugo gasped, lurching forward as he pushed the small table out of the way. He jumped to her beside carefully cradling her head as he looked into her hazy eyes. “You’re awake?”

“Suppose so,” Uraraka breathed softly as she smiled at him.

His hands trembled as cool relief washed over him, hands gently pushing her hair back. “Shit,” Bakugo panicked. “We need a doctor!” He roared, turning toward the door.

“Ow,” Uraraka winced as her head throbbed.

“Shit,” he muttered, gingerly patting her face as he pressed a kiss to her forehead. “Sorry, sorry, sorry…”  

“I’ll go get a doctor,” Kirishima offered as he made his way out of the room.

The doctors swarmed her bedside and pushed him into the hallway. Bakugo had quickly called Uraraka father, then followed up with his own mother.

“Katsuki!”

“She’s awake.” Bakugo peeked back into Uraraka’s hospital room making sure what his eyes and ears had seen were real. Red eyes glanced at Kirishima, confirming his witness was still there.

They’d carefully propped Uraraka up against the fluffy hospital pillows. Her usually bright brown eyes were hazy, but she was awake and responding to whatever questions they asked her.

“Thank goodness,” his mother breathed with relief. “What’d the doctor say?”

“I don’t know yet,” Bakugo look another look into the room. “But, I figure she still has a couple days here.”

“Did you still want me to come by tonight?”

“I guess,” he shrugged, phone clutched against his ear. “Ochako probably won’t mind the visit.”

“Well, if she’s too tired,” Mitsuki started sternly. “I can just bring you kids some food tomorrow.”

“Yeah.”

“You called her father, right?”

“I talked to him before I called you.” he peeked back into the room again. They were removing the blood pressure from her arm. Her eyes were still open, drowsy but alert.

“Good. Don’t forget to keep me posted.”

“I won’t.”

“You take care of her, Katsuki.”

“I am, mom.”

“You must have been worried if you called your mother,” Kirishima commented, a little smirk on his face as he watched his friend hang up the phone. He bit his tongue, forcing himself not to comment on how normal their conversation was.

Bakugo narrowed his eyes, placing his phone in his pants pocket, “Shut up, shitty hair.”

“Will do,” Kirishima smirked with a satisfied nod as he leaned against the wall across from his friend. “I’m glad Uraraka’s okay too.”

Bakugo nodded, shoving his hands in his pockets. He sighed loudly, looking up to the ceiling as he frowned awkwardly, “I owe you.” The words weren’t quite right to express how good of a friend he’d been to him, but Bakugo wasn’t quite sure how to say it.

“No, ” Kirishima patted his shoulder before stretching his back. “That’s what bros do, man.” He understood.

The doctor exited the room, stepping in front of Bakugo with a smile. “She looks great.”

Bakugo felt his body relax on a loud and long exhale.

“We’re still keeping an eye on that head injury, but hopefully on Monday we can have the specialist come and heal her. And,” the doctor flipped through the chart. “If everything goes according to plan, she should be able to go home on Tuesday. Do you have any questions for me?”

“No, sir.”

“Alright,” the doctor nodded. “I suggest you get some rest yourself now, hmm?” He suggested as he stepped away.

Bakugo ignored the glare and Kirishima’s chuckling. “Don’t you start.”

“What?” Kirishima raised his hands in surrender, unable to contain his grin. He pushed himself off the wall as he started down the hall. “I can’t agree that you need to get some rest?”

“No,” Bakugo frowned watching him walk away. “Where you going?”

“Figured you crazy kids could use some alone time.” Kirishima gave a small salute as he kept moving. “I’ll let the others know.”

Bakugo had forgotten about telling their friends. Kirishima hadn’t even disappeared down the hall, and he was already standing in the doorway. With slow breaths, Bakugo kept his eyes on her sleepy face as she watched the TV mounted in the corner of the wall.

The footage of the building dominated the screen.

Rubble and concrete slabs filled the screen as a reporter recounted the accident.

No villains.

No bombs.

Just a minor earthquake and an unstable building causing the death toll to approach two hundred.

Bakugo couldn’t help but think that it had could have easily been two hundred and one.

“Did I fall?” Uraraka whispered, eyes glued to the screen.

He took slow steps into the room as he cleared his throat. “No,” he replied softly stepped into the room. “You um,” he stopped at the foot of her bed, gently placing his hands on her blanket covered ankles. “You, I think-”

Uraraka slowly turned to face him, eyes widening a bit with worry.

“You and Deku-” Bakugo still hadn’t decided how much of the blame the green haired boy needed to shoulder. “Were helping to evacuate people inside, and when Deku came out-”

He wondered if she could hear how loudly his heart thudded.

“You weren’t with him. I,” he paused, looking at her. “I found you with a kid. You had blood in your hair-”

Uraraka inhaled sharply, trying to recall what he was saying.

“When I took the kid, you collapsed.” Bakugo’s gaze left her eyes as he stared past her. “You had some metal lodged in your side, and you were bleeding really bad.”

That explained the long row of stitches on her side. “Is,” Uraraka cleared her throat. “The kid okay?”

Bakugo nodded, “Yeah, he’s fine. They found his mom.”

She felt herself relax into the bed a bit, ignoring the burn in her body. “Good,” she sighed with a small smile. Her eyes drifted close as she breathed slowly.

“You know I love you right?”

Uraraka felt her head snap up faster than she should’ve. Her jaw clenched, feeling her head throb. “What?”

“You-” He wanted to blame this on the stress of the last few days. “You know I love you right?”

“Of course.” Why would he doubt that?

His hands tightened a little around her ankles. “I thought you were going to die.”

Uraraka felt her breath catch as she saw tears catch on his eyelashes. “I’m sor-”

“You don’t get to die on me, Ochako.” Bakugo’s head dropped between his shoulders as he panted. “You don’t get to bleed out on me, say ‘I love you’, and die in my arms.”

“I-” She wasn’t sure what to say to him. Even without the morphine flooding her veins, the right words seemed impossible to find.

“The last thing I told you was you could have as many those stupid frosted animal cookies you wanted.” His eyes squeezed tightly trying to will away his tears. This was supposed to be a happy moment, and he couldn’t erase the memory of the life fading from her eyes.

Uraraka chuckled, tears spilling on her cheeks, “Come here.”

Bakugo’s head slowly raised, red eyes tired and grief filled.

“Come here.” Her hands padded against the bed, motioning for him to get in.

“I can’t-”

“It’s not like we haven’t shared a bed before.”

True, but- “I don’t wanna hurt you.” The bed was small, and it wouldn’t be comfortable for her to lay on her side.

“Get over here, Katsuki.”

Bakugo smirked carefully crawling into the small bed with her. He pulled her against his chest as her toes tickled against his ankle. Cradling a gentle hand against her scalp, he placed a kiss to the crown of her head.

“Of course you love me,” she whispered, digging her fingers into the fabric of his shirt. “You said I could have as many of those cookies you hate.” A smile broke through her tears.

“Dork,” he murmured affectionately against her forehead. “Don’t scare me like that again.”

She tilted her head up, meeting his eyes. “I won’t,” Uraraka promised softly.

“You need some rest,” Bakugo whispered pressing their lips together. Pulling away, his hands gently held her face as his thumbs stroked her pale cheeks.

“So do you.” Snuggling against his chest, Uraraka closed her eyes relaxing into him.

A nap sounded nice. “My mom is gonna come see you this evening.” His arms carefully looped around her as he held her.

“You called her?”

“Yeah,” he sighed sleepily, finally able to relax.

“Hm,” she chuckled lightly as she felt herself drifting back to sleep. “You do love me,” she teased.  

“Don’t you forget it.”

[mentalhealthsessionswithmarc]

Me Vs. Me

As always, I am here burning the midnight oil. Today’s belated Day 3 topic is on Anxiety. Widely diagnosed, but rarely talked about. Research says it’s becoming one of the leading most diagnosed mental disorders in current times. If it is so widely diagnosed, then why is there so little to be said of anxiety? Long story short, people who suffer from anxiety feel a strong sense of insecurity or shame and are afraid of judgment from the listening party. Oftentimes the perceived judgment is completely made up from the party suffering from it. However, people with this disorder feel everything very deeply. It all seems real. How do I know? I have it. Take meds for it. Currently feel it. 

The whole reason why I chose this as a talking point is because I am currently feeling anxiety manifesting in my mind. Not completely sure why this is happening, but it is. So because of said symptoms, I feel talking about it may be beneficial to you as it could be to myself. As I posted in yesterday’s blog, a lot of people who suffer from anxiety do not know they have it. Before I was diagnosed with it, I had no idea what it was. Now that I am versed in what anxiety is and what it feels like, I am going to shed some light on how it can manifest inside you and how you can deal with it. 

Here are some common ways anxiety can present itself. Keep in mind anxiety symptoms vary depending on the person, stressors, and other environmental factors.

1.) Headache that never leaves

2.) Racing, irrational thoughts...oftentimes these thoughts manifest into mental self-conflict...Thus why today’s title is Me Vs. Me.

3.) Sudden, unjustified racing pulse and even heart palpitations

4.) Tremors through the body

5.) Upset stomach

6.) Irrational sense of fear, urgency, and the feeling something bad is going to happen. Keep in mind, even though I use the word “irrational”, the person who suffers feels this all very deeply and believes it is very real. The reason I say “irrational” is because there is primarily no explanation for why the emotional turbulence happens. It just does...and when you’re experiencing it, it is paralyzing.

7.) Tightness in the chest, trouble breathing, dizziness, feeling faint and/or lightheaded.

There are many more symptoms of anxiety, but that alone can take up an entire blog. These are just the most common forms anxiety can take and many of these I have suffered through myself. 

Now that you are somewhat versed on what anxiety can be, I am going to shed some light on how you can deal with it. 

Do you know what doctors say the enemy of anxiety is?

Exercise. Exercise is the leading way physicians say you can eliminate or reduce the appearance of anxiety. Why does exercise have such an effect on anxiety, you ask? Think about the functions of anxiety. Anxiety is as much a physical manifestation as it is a mental one. Almost everyone who has anxiety shows it outwardly. It can be seen. Think about how you feel after a bout of anxiety or even an anxiety attack. Usually by the time anxiety has run it’s course through me, I feel like I have run a marathon and been hit by a truck at the same time. I am physically drained by the end of a bout with anxiety....at the very worst, I would start falling asleep. Sometimes, after I woke up I would go into an anxiety attack, and after I was done, I felt like I hadn’t slept at all and could literally lay back down and fall right back asleep. 

Exercise uses the energy that your mind and body would use to attack you in a positive way. The body produces and releases endorphins while engaging in physical activity. Endorphins are the “feel good” chemicals your brain releases into your blood stream. It replaces the negative energy your body uses to attack you. If you spend your time exercising, you give your mind less energy to make its attack. Plus, working out gives you positive energy, so you won’t feel as burned out as you would normally. I’m in no way saying you have to engage in an aggressive workout regimen to eliminate your issues, but a simple 30 minute session a few times a week, can bring you benefits you wouldn’t think possible. Before I took on my fitness challenge, I used to walk a few days a week, and that alone helped. Be creative. Be active. The more active you are the healthier your mind will get. 

Coloring. The trend of adult coloring books has exploded in recent times. You know why? Coloring has been proven to reduce the presence of anxiety in the adult mind. I know a lot of adults are skeptical to return to something deemed a bit childish in practice, but there are benefits. Coloring provides your mind focus, which is something you do not have when having anxiety. Not only that, but it has a calming effect on the mind. Anything with a calming property is an enemy of anxiety. I have experienced this myself. I had to participate in art therapy in the ward and will admit, it does work.

Aromatherapy. I know it sounds weird, but essential oils can be a key weapon against mental illness. For anxiety, try something with lavender oil. It does have a calming effect on the anxious mind. Even drinking something like a lavender herbal tea or having a lavender bubble bath is a very healing practice.

Last, but not least, talking. Again, whether it is to your therapist or a trusted friend/family member, talking is one of the healthiest ways to get this demon out. Despite the insecurity you may feel, you have to assert yourself over what you feel. You can change your perspective. Honestly, you are only as much of a victim to your mind as you allow yourself to be. I know that phrase sounds harsh, but it is true. If you keep everything inside, do you know what’s going to happen? You are going to self-destruct. I know that from experience. I did it twice. 

Take control of your life. Get active, get creative. The more active you are, the healthier your life and mind will be. I can’t stress it enough. YOU HAVE TO WANT IT TO CHANGE IT.  Gaining control over your mental illness is similar to driving a car. Only you can take the wheel. Once you can see the warning signs, you will know where to turn and how to steer. You can also hit the brakes when you approach whatever has been impacting your life negatively. 

As always, I hope this helps. It has certainly helped me tonight. 

Best wishes,

Marc

[borderline-queen]

Dec. 31, 2020

Update from yesterday. My crazy BPD brain continued into this morning. I didn’t want to text sexy pharmacist first, but I ended up doing so anyways because it was 9:30am, and he hadn’t said anything to me yet. I know he gets up much earlier than that usually, so it was driving me crazy that he hadn’t texted me. It took him him over an hour to respond to my texts which drove me even crazier. I started freaking out and thinking about who brought him his meds yesterday and if it was another woman and if he let her stay and spend the night with him and maybe that’s why he wanted to stop texting so early - so that he could focus on her? And maybe he was taking so long to text me this morning because he was still with her? I was so outrageously upset over this and was convinced he was trying to hurt me or punish me for not being there for him yesterday. I started getting irrational, thinking about how I hated him and that I’d get him back and ruin him for doing this to me, telling myself that he underestimated who he was dealing with. Completely insane.

Anyways, so here I am, getting myself all worked up and pissed off. I woke up with a raging UTI and made an appointment at one of the clinics inside the pharmacy chain we work at. I ended up making the appointment for the clinic about 5 minutes from his house just because they could see me ASAP. He finally texts me back when I’m getting to my appointment. He said he still feels terrible and has been resting & sleeping a bunch. He told me to keep him posted on how my appointment went, and I told him I was right around the corner and to let me know if I could bring him anything.

He asked for the basic stuff - Gatorade and soup. I got him that plus a few more things and brought them over to his house. It was really good to see his face. He looked so sick and tired. He didn’t kiss me because he doesn’t want to give me the flu. We were both surprised that I don’t already have it. He would’ve been extremely contagious Sunday when we spent the entire day together and literally swapped spit all day. He said we were lucky that I didn’t have it, and he didn’t want to test our luck. I wanted to kiss him so badly though. I didn’t stay long because he looked really tired, and I wanted him to get back to resting. Once I saw him, it really solidified how insane I was being. He definitely did not spend the night with another woman; he looked absolutely exhausted and couldn’t stand for more than 10 minutes at a time.

I felt like some of his texts this morning before I saw him were still kinda off. I just have to keep reminding myself that it’s not me. He’s just so sick that he doesn’t have the energy for playful or flirtatious messages, and I shouldn’t expect that from him right now. He did send me some cute messages after I left his house about how he can’t wait to start feeling normal again so that we can get back to our usual activities. 🥰

I’m sad we can’t spend New Year’s Eve together. My fiancé is away, and it would’ve been perfect because the pharmacy is closed tomorrow, so we could’ve had some drinks at his house and spent the night together. I wanted him to be my NYE kiss this year.

We’ve been texting throughout the day while he’s awake. He just texted me an hour or so ago saying that he started having UTI symptoms too 2-3 hours prior. I was pretty shocked, and I’m kind of embarrassed. I know it’s common to get a UTI after having sex with a new partner, especially with how much sex we’ve been having, so I wasn’t embarrassed before. But now I’m embarrassed that he has one too 🤦🏽‍♀️. I don’t want him to think I’m dirty or gross or be angry at me because now he has the flu and a UTI simultaneously. He seems pretty chill about it, but ugghhhhhhh. He tried to find an urgent care to go to for it tomorrow but couldn’t find one nearby that’s open for New Year’s day. So his brother (who’s a dentist) is going to call in the same antibiotic regimen that I was given for him. I told him I felt bad and that I wanted him to give me his flu germs so that we could suffer equally. Of course, he said he doesn’t want that and that it’s better that one of us is well so that we can take care of each other. I thought that was sweet. I offered to go pick up his antibiotics tonight for him. He said it can wait til the morning so that I don’t have to drive in the rain at night with crazy NYE drivers. I know it’s simple, but I love that he cares about my safety like that - it just feels nurturing. So I told him to just let me know and I’ll get them in the morning for him.

He said he may be able to stay up til midnight, but if he can, he’ll send me a virtual NYE kiss. 🥰

[bigyack-com]

A Doctor’s Diary: The Overnight Shift in the E.R.

My choices as a doctor in the emergency room are up or out. Up, for the very sick. I stabilize things that are broken, infected or infarcted, until those patients can be whisked upstairs for their definitive surgeries or stents in the hospital. Out, for everyone else. I stitch up the simple cuts, reassure those with benign viruses, prescribe Tylenol and send home.Up or out is what the E.R. was designed for. Up or out is what it’s good at. Emergency rooms are meant to have open capacity in case of a major emergency, be it a train crash, a natural disaster or a school shooting, and we are constantly clearing any beds we can in pursuit of this goal.The problem is, traffic through the emergency room has been growing at twice the rate projected by United States population growth and has been for almost 20 straight years, despite the passage of the Affordable Care Act, and through both economic booms and recessions. Americans visit the E.R. more than 140 million times a year — 43 visits for every 100 Americans — which is more than they visit every other type of doctor’s office in the hospital combined.The demand is such that new E.R.s are already too small by the time they are built. Emergency rooms respond like overbooked restaurants during a chaotic dinner rush, with doctors pressed to turn stretchers the way waiters hurriedly turn tables. The frantic pace leaves little time for deliberating over the diagnosis or for counseling patients. Up, out.Private exams on stretchers in hallways, patients languishing without attention for hours, nurses stretched to the breaking point; all of it has become business as usual. I think about this on nights like tonight, when I start my shift inheriting 16 patients in the waiting room. I think about what I will learn that these people need, and about what I will fail to provide.Image

10 p.m.

Work starts simply enough. Twenty-two-year-old was drunk and drove into a tree, now has a sore elbow. The X-rays are normal and he is sober enough to walk: discharge home with girlfriend. Woman with a migraine holding a towel over her eyes and a crumpled blue emesis bag in her right hand, for when she vomits. I start the standard “migraine cocktail” of IV drugs and turn off the lights in her room. I will wait until she feels better, then discharge her, too.More. A woman six weeks pregnant with cramps and vaginal bleeding; I check whether her miscarriage is inevitable. A drug overdose, likely a suicide attempt; I clear for psychiatric care. Homeless man with foot pain, back pain and a cough, but here mostly because it’s too cold outside. I hand him a sandwich.Then an ambulance crew rolls a gaunt man with one leg toward me on a stretcher. The paramedics hand over a thick packet of paperwork from his nursing home and walk away. I read the label: Jean-Luc. Age: 38.Jean-Luc doesn’t have a typical amputation stump. His left hip is also missing. According to his file, 10 months ago an aggressive strain of bacteria attacked his thigh and quickly began to liquefy his flesh. Antibiotics would not work fast enough; the only way to stop the bacteria’s spread was to cut out the infected parts.The paperwork tells me nothing about who Jean-Luc was 10 months ago. All I know is that those few hours of surgery rendered him dependent on nurses for most things he used to do himself.I leaf through Jean-Luc’s packet and find a scribbled nursing note. Someone was concerned that his urine looked different the past few days, and this morning he spiked a fever. Did he have a urinary tract infection? Jean-Luc’s belly is tender over his bladder, and his urine looks cloudy and smells pungent. I send some samples to the lab.

1:18 a.m.

You get little hints about the quality of nursing homes from the patients they send us. If a patient’s hair is combed and his clothes are neatly pressed, the nursing home is probably decently staffed. Most impressive is healthy skin. The skin of a bed-bound patient is paper thin; keeping it intact, like the unbroken film on a French pudding, requires a herculean effort.Jean-Luc’s skin had not been so fortunate. He had a bed sore; it was less than an inch wide, but I could probe an instrument through it to the bone. Once such holes form, doctors don’t really know how to coax the skin to heal itself. Creams, high levels of oxygen, even maggots — nothing works reliably. This is going to be a problem, I think to myself.Forty minutes later, the lab results come back positive for a urinary tract infection. I start Jean-Luc on antibiotics. The E.R.’s role is considered completed at this point. Up, not out. The waiting room is busy; I should admit Jean-Luc to the hospital for IV antibiotics and free up his stretcher.I look over from my desk. Jean-Luc is polite and not a complainer, but I can tell he is depressed. A month ago the nursing home put a catheter through his penis and into his bladder, presumably because emptying a bag is easier to schedule into a shift than running over every time he rings a call bell asking for help, and safer than letting him sit in his own urine, which would further break down his skin.But for bacteria, that plastic tube is a boulevard into the body. He would be better protected by a condom catheter, which catches urine the way a condom catches semen. I start to mull this over when a nurse calls me: “Gina, Bed 5 is vomiting and says she needs more pain meds.”

2:28 a.m.

Cynthia, in Bed 5, recently completed a round of chemotherapy. She tells me her pain and nausea have been unbearable, just as they were two weeks ago, when she was here after her previous treatment. I examine her, check her labs to make sure there isn’t another reason she is dry-heaving and type in a request for a hospital bed.Cynthia is on a state-of-the-art cancer therapy, available only at a few of the top centers in the world. It is also expensive, experimental and extraordinarily taxing on her body. The discussion with her oncologist must have been difficult: the possibility of improvement weighed against the risk that the treatment could cause her to spend most of her remaining days in hospitals, hooked up to IV drugs.For the E.R. visit, Cynthia will be charged more than $1,000 plus about $600 in professional fees for the few minutes of critical thinking I expended on her. That is the thriftiest part of this arrangement: Her admission stay for several days in the hospital will be billed at about $10,000.To the hospital’s finance department, each case like Cynthia’s is another base hit, a fuss-free bill to collect from the insurance company requiring minimal work from E.R. personnel. But to what extent will this hospital stay prevent Cynthia from returning in two weeks, when she is again due for chemotherapy?Maybe a different regimen of cancer drugs would sit better with Cynthia. But finding it involves trial and error and is seen as work that doesn’t have to be done — work that could get the oncologist in trouble for rocking the boat, that exposes the hospital to liability. A plan focused on keeping Cynthia out of the hospital would require more frequent check-ins at her home, which the hospital isn’t set up to do. We are choosing the path of least resistance for us, even though it is the path of last resort for her.One in five people who stay in American hospitals are on the same morbid merry-go-round as Cynthia and Jean-Luc and will wind up back in the E.R. within one month of leaving. We tell ourselves the E.R. is meant only to stabilize patients, that someone else will handle the rest. But the problems I punt in the E.R. are also punted by the hospital’s doctors upstairs and by primary care doctors outside. No matter where I send patients, these gaping holes in care fester, like bed sores tunneling to bone.So I wait in the E.R. for the same patients to return even sicker and even more dependent on the hospital. I’m thinking about this when an overhead speaker calls me to the resuscitation room for a “Level 1,” the highest level of urgency in the E.R. I hang up on Cynthia’s oncologist and head to the north side of the department.

4:12 a.m.

A young woman is gasping loudly through the oxygen mask that paramedics put over her face, screaming, crying and thrashing all at once. She swats at the nurses trying to hold her arm down to place an IV, and at the technicians cutting her clothes off with shears. Her sweat prevents the electrical leads we try to attach to her chest from sticking.This is routine for us. Many things can make a patient acutely agitated: pain, drugs, rapid blood loss or a shortage of air. Until we know the cause, we carry on even when patients resist. With little explanation, we surround them on all sides, pin them down and undress them, placing probes and leads while we get our bearings.Someone tries to calm the young woman down while I scroll through her electronic chart. Mariah is 23. She has severe asthma and has been to the E.R. many times. She has bipolar disorder. The last time she was in the hospital proper, two months ago, she left abruptly once her breathing stabilized, before we could send her home with an inhaler and a steroid regimen for her asthma.As far back as I look in her records, I find no visit with a primary care doctor. Like many patients in the E.R., especially younger ones, she doesn’t see any other doctors regularly. In effect we have been her primary doctors, although we didn’t know it and didn’t do much primary care.I close the screen and look back at her. She is now on the monitor, the beeping display of her heartbeats and respirations scrolling along in green and red like a stock ticker at the bottom of the evening news. The numbers are terrible. She isn’t resisting us anymore, and her breathing has slowed. Mariah is starting to look confused.We had achieved a sense of control, but it evaporates in an instant. Everyone starts moving quickly, jumpily, trying to suppress the sinking feeling that this is not like the other asthma flares we see, that this person is too sick for us to save. We focus on our roles. I’m worried she will stop breathing, so I come to the head of the bed and tell her we’re going to sedate her and put her on a ventilator.Through the breathing tube and the IVs, we give everything we have already given, again: albuterol, epinephrine, magnesium, helium, antibiotics, lidocaine. Nothing is working; her lungs remain stiff and in spasm. Her heart slows, then stops. We start chest compressions and push more medications. We probe her heart and lungs with the ultrasound, trying to find something we can reverse. Nothing.I look at the senior doctor in the room. He knows I’m asking if there is anything else we can do, and he shakes his head. We record the time of death.

5:47 a.m.

There is a silent pause in the room. Before it passes, the unit secretary hands me the packet of paperwork for the deceased.A death certificate differs from other medical records. It presents not one lone diagnosis field but four nested together, each line asking for the proximal cause of the line above. In the first line I write the diagnosis: cardiac arrest. I consider why her heart stopped, and in line 2 — “CAUSED BY” — fill in: respiratory failure. Line 3, CAUSED BY: severe asthma exacerbation. I am ashamed, but I know the cause of this as well. In line 4 I write, CAUSED BY: no medications at home to control her asthma.This is the first patient all shift for whom the modern E.R. and I have acknowledged the root cause of illness. Our failure was not today but a few weeks ago, when she was last in the E.R. and we didn’t find a way to get her asthma inhalers to her at home. Maybe we assumed the medical team upstairs would handle it; maybe that team expected a primary care doctor would do so. Now our failure is the bottom line in black ink, pressed into the carbon-copy pages that will accompany Mariah’s body to the morgue.Should the emergency room treat only emergencies? More than 80 percent of our patients arrive without sirens blazing, by walking in or after parking their cars with the valet out front. A rash that won’t stop itching, a lower back that won’t stop aching, a child who won’t stop vomiting. If their problems aren’t in our manual of emergency conditions, we say they are misusing the E.R. and try to dispense of them as quickly as we can. But here they are, having waited six hours to see me, asking for help. What to do for them?I click a few perfunctory buttons in their charts. I say there’s nothing life-threatening going on as I hand them boilerplate discharge paperwork to sign. Someone calls me to see my next patient. I send them back to their families, jobs and responsibilities equipped with little more than these unceremonious goodbyes.Almost one in 10 — 8.2 percent — of these discharged E.R. patients return to an E.R. within three days. What I leave unaddressed — persistent pain, nagging uncertainty about a diagnosis, a social dilemma — tends to stay that way, begetting yet another visit. An E.R.’s success is measured by how fast it sees these patients, not by whether it breaks these cycles.The waiting room is empty now. I review the labs on an elderly man in Bed 3, enter the admission details for Cynthia and Jean-Luc, check that the woman with the migraine feels better and print her paperwork, and look at my watch: 7:00. My shift is over.

7:01 a.m.

Although the E.R. was built to quickly get the sick “up” into the hospital, it has exposed, better than anywhere else, what patients lack while “out” in their otherwise private lives. Patients like Cynthia and Jean-Luc will survive devastating diseases under our care “up” in the hospital, but we send them “out” unable to sustain their precarious conditions without us. Patients like Mariah make their needs clear in the E.R., but we are too busy to meet them, and by the time they come back it’s often too late.From 2012 to 2014 the federal government, recognizing that neither up nor out was solving the problem for a growing group of patients, financed an experiment at the University of Colorado. The typical E.R. has surgeons on-call to treat patients with broken bones; following that model, the E.R. in Colorado set up a team on-call for patients with broken homes.Disadvantaged patients who kept returning to the E.R. were matched to social workers, health coaches and doctors who visited them where they lived and kept in touch for several months. By staying involved after the E.R. visits and not letting details fall through the cracks, the team reduced these patients’ need to revisit the hospital by 30 percent compared with the need of those in a control group.The E.R. at Yale, where I work, addressed a different group in need. Elderly patients who came to the E.R. after a fall were offered a follow-up at home. There, they were screened for risk factors that might lead to another fall, such as loose rugs, medications that increased their risk of balance problems, or lack of necessary equipment or support at home. Over the next month, those who received such visits called 911 about half as often as similar patients who did not participate in the program.Programs like these are not considered the E.R.’s core business, so they often rely on grants — and they end if funding dries up. Of the slim resources that E.R.s do set aside to address patients’ barriers outside the hospital, most are put toward hiring social workers and care managers. But these employees, stymied by mountains of paperwork and unrealistic patient loads, never get outside the hospital to see their patients, either. The programs at Colorado and Yale succeeded by framing the E.R.’s resources differently. They recognized that the E.R. staff could identify problems that were destined to arise after discharge — and empowered those employees to help. Both programs orchestrated follow-ups outside the E.R; those teams worked on the day-to-day problems at home that go unaddressed in hospitals and clinics and can cause catastrophes.As I zip up my bag, I head to Jean-Luc’s room to talk to him about urinary catheters. But when I arrive I find only our custodian with a mop, pulling the crumpled sheets and throwing out the extra tubes of blood. Up or out; Jean Luc is already up. His fate is out of my hands now, and I worry that he won’t keep his spirits up, that his bed sore will never heal.Only a few minutes have passed, and the waiting room has filled up again. A man with a nosebleed has arrived. A nurse hands him a nasal-compression clip and a basin to spit in. He and his wife look around, wondering how long they will have to wait. By now, Jean-Luc’s bed is freshly made. For this couple, his quick move upstairs was a blessing. It means that, on my way out, I can tell them that they will be called back soon. A room just freed up. Read the full article