"I've been practicing CPR since I was was 12 and yet I have never done it on a real person." This was me this morning as I explained to an attending how all I really wanted to do on my ER rotation was CPR and how I was somewhat disappointed, and more than a little surprised, that I had yet to get the opportunity. I joked, "Maybe I'm a good omen, maybe as long as I'm in the hospital, no one is going to die."
Well, dreams do come true, or irony kicked in, because a bit more than one hour later I was wearing a trauma gown hunched over a patient sweating bullets as I pumped hard on his chest.
CPR is not easy. It is surprisingly difficult, exhausting really. You lean over someone (inevitably at the wrong height such that your back starts aching or you have to be on your tippy toes), you lock your elbows, and then you push down as hard as you can. And then you do that again, over and over and over again. Your arms scream out and when you don't stop, they scream out louder. You realize 2 minutes is an awfully long time. And every time your arms start to lighten up, you remember that you are the only thing keeping the patient alive. It is your hands on his chest, your arms pushing down, your body weight compressing his rib cage and simulating the heart beating and the blood flowing such that your colleagues can feel the pulse in his groin or neck. Your arms, your effort are differentiating life from death. And all the while, all you can think of in your head is, "Harder, push harder, push HARDER," and you sync your hands to the tune running through your head: "Ah, ah,ah, ah Staying Alive, Staying Alive." Or "Dom, dom dom, Another one bites the dust," which is equally effective in tempo, but perhaps a bit more macabre in message. (I tried to sing the former, but ended up with the latter stuck in my head.)"
At 37, this man was not your typical massive coronary artery occlusion leading to cardiac arrest patient. He did not make it. I'll break that news right now. When exactly it became clear that he was not going to make is hard to say. Was it when he collapsed? Was it after the hour they spent in the field trying to resuscitate him, performing CPR the entire time? Was it when he arrived to our ED, chest compressions in progress? Was it when he regained a pulse (albeit slow and irregular) and a pressure (low and nerve-wracking) and was being readied for the cath lab but the attendings for the cath lab could not be contacted - was it that delay? Was it when, after that moment of pulse and organized electrical activity, he slipped back into pulseless chaos? Or was it when, at 8:12, after an hour of CPR and resuscitation efforts and with the parents by the bedside, the code was called?
Codes are interesting things. They are rather gruesome events, but also incredibly well orchestrated, calm, and surprisingly easy to participate in. There are usually somewhere between 10 and 15, maybe 20 people involved in a code. Everyone has a job, and every job is focused and compartmentalized. The exception to this is the person running the code and, perhaps, the attending leaning over their shoulder like a good angel, whispering guiding words of wisdom throughout the code. It is the compartmentalization that makes the whole experience manageable. I knew that the only thing I needed to do throughout the code was step up to the patient, perform 2 minutes of good CPR, and then step away from the patient and get back in the CPR line (a steady, pre-selected rotation of 3-5 medical students and medical assistants). Occasionally I would do something like get a syringe or set up the patient for an ECG, but these were just part of my role in the whole effort - a doer, someone who did stuff.
And during the code there was almost this jovial atmosphere. This sense of, "Hey, yes, we are doing a good job. Things are working, it's all going to be ok because everyone is doing what they are supposed to and everyone is doing a good job of it." And the atmosphere is calm and aloof. We are airy in our approach. We are urgent, but only in the race to do our jobs well and defeat death. Not in the race to save the life of the patient. The patient. I don't think anyone knew his name until 30 minutes into the effort. Even after that realization, he remained exposed, face covered by the bag and mask and hands twitching at his sides (when the patient first came in he was making movements with his hands and fists, despite having no pulse). It was the ultimate dehumanizing experience.
And then, it wasn't. His mom and dad entered the room and suddenly all of the humanity that had been stripped away from the patient came flooding back to engulf him like a shroud. Suddenly E. had a name. The mom asked to hold E's hand and E became a young man with a partner and 2 children at home. The father shouted, "E, don't leave, you are needed HERE E, we need you right here," and E became a 37 year old with a troubled past who had spent the last year successfully picking up the pieces of his life. With each sob that was cried, E became a banker, a student, a runner, a food service worker, an alcoholic, a brother, a lawyer, a vagrant, an abused child, a husband, a father, a son. Each tear shed was a story; each plea to stay was a relationship. And with E's sudden humanity, the train that was our resuscitation effort derailed. We increased our efforts, put on a better show, but our hearts were heavy with the reality that when we stopped CPR, which we knew we would, it would be to pronounce this human, this person, dead.
And a heartwrenching moment, a reminder to watch your mouth:
The code leader says, "Well, we will continue CPR until the priest arrives."
The father said: "What you meant to say was until our son wakes up."
Tuesday, March 9, 2010
Monday, March 8, 2010
Death Bear
I really like this story.
I think this is similar to one of the duties those of us in healthcare professions are lucky enough to have. We are semi-anonymous professionals in front of whom individuals bare all. We are rarely members of the same community as our patients and, as such, we are, essentially, blank. I've talked about this before - this blank slate concept - but this is a new and beautiful incarnation of the idea. In truth, almost anyone who has ever been in the service industry has, at some point, been a Death Bear to someone else. By listening to, absorbing, or even just witnessing a stranger's pain without judging it or engaging with it they are able to help that person start the healing process.
I think this is similar to one of the duties those of us in healthcare professions are lucky enough to have. We are semi-anonymous professionals in front of whom individuals bare all. We are rarely members of the same community as our patients and, as such, we are, essentially, blank. I've talked about this before - this blank slate concept - but this is a new and beautiful incarnation of the idea. In truth, almost anyone who has ever been in the service industry has, at some point, been a Death Bear to someone else. By listening to, absorbing, or even just witnessing a stranger's pain without judging it or engaging with it they are able to help that person start the healing process.
Tuesday, March 2, 2010
Minimize
The ER is unlike any other place in the hospital. Tragedy, disaster, shock, pain, agony, fear linger unchecked around each patient bed. There is little room for comfort, reassurance, paced improvement, or doctor-patient relationships. Those can be found on the upper floors. The ER is not a place for healing, but rather for the stabilization and "packaging" of patients before they go to other places in the hospital. As such, the arc of illness is rarely completed in the ED. For sure, more people are discharged from the ED than admitted, but those people were rarely very sick to begin with. And, without a doubt, lives are saved every day in the ED, but saving a life is very different from healing one.
Because of this, and because emergent situations are best dealt with using algorithms, it is easy to dehumanize patients in the ER. Not only is it easy, it is expected and, to some extent, necessary. If you know that no matter what a patient looks like, where they come from, or what their name is you are, first and foremost, going to evaluate their ABC's (airway, breathing, circulation), the larger picture of who they are becomes less important. For certain you want to hear the story of their main complaint - their signs and symptoms - and a few important details about their social situation - where do they live, do they drink alcohol or use IV drugs, do they have anyone to take care of them when they leave here. This information, however, is not used to build relationships, but rather to determine the diagnosis of the patient and expedite the discharge. Doctors are often criticized for minimizing the patient and maximizing the disease, but in the ER, this actually makes sense. Here we are taught to sort sick from not sick. Names make less sense, so you remember patients by their diseases.
This dehumanizing runs counter to most of what I am drawn to in medicine. But I also find something very appealing, and almost comforting about it. The ER is, to some extent, the most socialist, egalitarian place in our country. Without a doubt, the people who see the ED as a place for primary care and urgent care needs come from a certain underinsured, underserved demographic, but they aren't the only people who come to the HX ED. Trauma knows now boundaries and as the major trauma center for the state and several surrounding states as well as a world-reknowned orthopedic and burn center, people from all extremes of society pass through HX ED. And everyone gets care. As they pass through the ED doors, they (more or less) become their condition, and they receive whatever care their condition asks for. In determining what a condition calls for, no one asks, "what is the patient's insurance," and that is a beautiful thing.
That said, the flip side of not asking "what is their insurance," is that no one is asking, "is this test really necessary." Actually, that's not entirely true. Everyone asks that question, but everyone follows it up with, "It's very low yield, but we might as well do it to rule X out," or "It's not necessary, but it is standard of care, so. . ." Clinical judgement is a dying art and we, as medical professionals, need to revive it if health care reform is going to stick.
Because of this, and because emergent situations are best dealt with using algorithms, it is easy to dehumanize patients in the ER. Not only is it easy, it is expected and, to some extent, necessary. If you know that no matter what a patient looks like, where they come from, or what their name is you are, first and foremost, going to evaluate their ABC's (airway, breathing, circulation), the larger picture of who they are becomes less important. For certain you want to hear the story of their main complaint - their signs and symptoms - and a few important details about their social situation - where do they live, do they drink alcohol or use IV drugs, do they have anyone to take care of them when they leave here. This information, however, is not used to build relationships, but rather to determine the diagnosis of the patient and expedite the discharge. Doctors are often criticized for minimizing the patient and maximizing the disease, but in the ER, this actually makes sense. Here we are taught to sort sick from not sick. Names make less sense, so you remember patients by their diseases.
This dehumanizing runs counter to most of what I am drawn to in medicine. But I also find something very appealing, and almost comforting about it. The ER is, to some extent, the most socialist, egalitarian place in our country. Without a doubt, the people who see the ED as a place for primary care and urgent care needs come from a certain underinsured, underserved demographic, but they aren't the only people who come to the HX ED. Trauma knows now boundaries and as the major trauma center for the state and several surrounding states as well as a world-reknowned orthopedic and burn center, people from all extremes of society pass through HX ED. And everyone gets care. As they pass through the ED doors, they (more or less) become their condition, and they receive whatever care their condition asks for. In determining what a condition calls for, no one asks, "what is the patient's insurance," and that is a beautiful thing.
That said, the flip side of not asking "what is their insurance," is that no one is asking, "is this test really necessary." Actually, that's not entirely true. Everyone asks that question, but everyone follows it up with, "It's very low yield, but we might as well do it to rule X out," or "It's not necessary, but it is standard of care, so. . ." Clinical judgement is a dying art and we, as medical professionals, need to revive it if health care reform is going to stick.
Sunday, February 28, 2010
Diet Coke
First night shift tonight. The switch to night shift? Brutal. . This is probably not helped by the fact that last night was Purim and, despite my attempts to not drink too much, I drank too much. I wouldn't call it a full blown hangover that I woke up with this morning, but the drinks were certainly saying, "hello, remember me?" My plan was this. . go out, stay up as late as I could, sleep today. Parts 1 and 2 went well. Part three hasn't gone so well. Turns out despite being tired, sleeping during the day is hard. Also turns out "waking up" at 5:30 pm to get ready for work is even harder.
You know what this calls for? It calls for diet coke - first one in months. Sigh, ER, you may beat me down yet.
I do have some stories for y'all, but didn't get to writing them tonight. Hopefully soon.
You know what this calls for? It calls for diet coke - first one in months. Sigh, ER, you may beat me down yet.
I do have some stories for y'all, but didn't get to writing them tonight. Hopefully soon.
Tuesday, February 23, 2010
Coming to America
The 67 year-old Ethiopian man did not speak a word of English. Well, that's not entirely true. At various times in the conversation, he would interject with, "And what is your name?" (I had already told him about 5 times).
He also knew thank you. And although he used it appropriately, it was a bit uncomfortable when he said, "Thank you," after I finished doing a rectal exam. In my fluster of not knowing what to say, I said "thank you" back, which compounded the awkwardness (for me, not for him). I slowly exited stage left.
With the interpreter on hand, things got a bit easier, but not as much as one would expect. When I asked him if there was anything else that was bothering him, he grabbed his belly with his hands. "This," he said (through the interpreter), shaking his belly furiously. "This is wrong. This was not here 3 months ago. This came on since I moved here. Now I do nothing and my belly has gotten big. The doctors tell me to lose weight, but I don't even eat that much. Like today, I have eaten nothing." The interpreter giggled a little, "I want this to go away; can you make this go away?"
Sigh. . welcome to America, I suppose.
He also knew thank you. And although he used it appropriately, it was a bit uncomfortable when he said, "Thank you," after I finished doing a rectal exam. In my fluster of not knowing what to say, I said "thank you" back, which compounded the awkwardness (for me, not for him). I slowly exited stage left.
With the interpreter on hand, things got a bit easier, but not as much as one would expect. When I asked him if there was anything else that was bothering him, he grabbed his belly with his hands. "This," he said (through the interpreter), shaking his belly furiously. "This is wrong. This was not here 3 months ago. This came on since I moved here. Now I do nothing and my belly has gotten big. The doctors tell me to lose weight, but I don't even eat that much. Like today, I have eaten nothing." The interpreter giggled a little, "I want this to go away; can you make this go away?"
Sigh. . welcome to America, I suppose.
Tuesday, February 16, 2010
A few days ago I was speaking with someone I had just met who asked me what I do. The conversation went something like this:
Her: And what do you do?
Me: I am in school.
Her: What kind of school?
Me: Graduate school.
Her: What are you studying?
Me: Medicine.
Her: Oh. . nursing school?
Me: No, medical school - I am studying to become a doctor.
This is a common conversation. I have it frequently and it made me think that, in a bit over a year, the conversation will be different:
Her: And what do you do?
Me: I am a resident. I am a doctor.
That's a big difference. . "becoming" versus "am."
This is going to happen to me very soon. In one day, I will walk up to the podium and receive a diploma and suddenly "I am becoming a doctor" will change into "I am a doctor." And yet it won't. Because getting the MD after my name won't make me any more skilled, competent, secure in my knowledge, or successful at healing patients. It's experience that does that (or so I am told). And skilled, competent, secure, and successful aren't points that you reach like mountain peaks. Instead they are paths that you travel on. Through experience you become more skilled, competent, secure, and successful.
Becoming. It may seem like a silly, or even obvious point to harp on, but I think it's an important one. Except in a few fields (the trades being some of them), in our modern-day society, we seem to have a binary approach to professions and careers. What I mean by this is that you aren't something, then you go to school to learn about becoming something, and then you get a degree and you are something. In many areas, we have lost the idea of apprenticeship. Without a doubt, school (especially the long road to the Ph.d. or the shorter road to becoming a teacher or therapist) serves as a sort of apprenticeship, but it seems like we have lost a structure for learning on the job. Everyone says that the most important learning occurs when you actually do something, so why don't we have any formalized structure for that?
Once you get your teaching degree and land a job, you are a teacher who is given as much responsibility and evaluated with the same criteria as a teacher who has been teaching for 30 years. No one expects you to be as successful as the teacher with more experience, but there is no allowance for that built into the system (except perhaps through pay). We suffer from the absence of mentorship. Pretty much everyone would benefit from a mentor, especially one who can evaluate your skills and say, yeah. . I think you are ready to try this.
One of the things that is often criticized in medicine is it's hierarchical nature. I am not 100% convinced that it is a bad thing. Doctors with more experience have seniority and are treated as such. Younger doctors should be able to speak up (and they are with more volume with the changing times), but in a field like medicine, experience should carry significant weight. It's a field where hierarchy appropriately refuses to die. It's a field that that seems to acknowledge that one is eternally becoming a doctor.
Her: And what do you do?
Me: I am in school.
Her: What kind of school?
Me: Graduate school.
Her: What are you studying?
Me: Medicine.
Her: Oh. . nursing school?
Me: No, medical school - I am studying to become a doctor.
This is a common conversation. I have it frequently and it made me think that, in a bit over a year, the conversation will be different:
Her: And what do you do?
Me: I am a resident. I am a doctor.
That's a big difference. . "becoming" versus "am."
This is going to happen to me very soon. In one day, I will walk up to the podium and receive a diploma and suddenly "I am becoming a doctor" will change into "I am a doctor." And yet it won't. Because getting the MD after my name won't make me any more skilled, competent, secure in my knowledge, or successful at healing patients. It's experience that does that (or so I am told). And skilled, competent, secure, and successful aren't points that you reach like mountain peaks. Instead they are paths that you travel on. Through experience you become more skilled, competent, secure, and successful.
Becoming. It may seem like a silly, or even obvious point to harp on, but I think it's an important one. Except in a few fields (the trades being some of them), in our modern-day society, we seem to have a binary approach to professions and careers. What I mean by this is that you aren't something, then you go to school to learn about becoming something, and then you get a degree and you are something. In many areas, we have lost the idea of apprenticeship. Without a doubt, school (especially the long road to the Ph.d. or the shorter road to becoming a teacher or therapist) serves as a sort of apprenticeship, but it seems like we have lost a structure for learning on the job. Everyone says that the most important learning occurs when you actually do something, so why don't we have any formalized structure for that?
Once you get your teaching degree and land a job, you are a teacher who is given as much responsibility and evaluated with the same criteria as a teacher who has been teaching for 30 years. No one expects you to be as successful as the teacher with more experience, but there is no allowance for that built into the system (except perhaps through pay). We suffer from the absence of mentorship. Pretty much everyone would benefit from a mentor, especially one who can evaluate your skills and say, yeah. . I think you are ready to try this.
One of the things that is often criticized in medicine is it's hierarchical nature. I am not 100% convinced that it is a bad thing. Doctors with more experience have seniority and are treated as such. Younger doctors should be able to speak up (and they are with more volume with the changing times), but in a field like medicine, experience should carry significant weight. It's a field where hierarchy appropriately refuses to die. It's a field that that seems to acknowledge that one is eternally becoming a doctor.
Monday, February 15, 2010
Day One
So here I am. the ER. The ER and I. It's been six weeks since I've talked to a patient, 10 weeks since I've been invested in a patient's care (and that was a psych rotation), 5 months since I've really touched a patient, and over a year since I've been expected to manage a patient. In other words, it's been a damn long time since I've felt like a doctor, or even a student doctor.
I've been told that rotation through the Hospital X (HX) ER* will cure even the most reluctant medical student. There is no shallow end there, it's all deep. It is a "kick you out of the nest, watch you hit the ground, then roll you to a cliff and push you off again" sort of rotation. Fly dammit, now.
The anticipation - horrible. I've been fretting about this rotation since I signed up for it. And the fretting became physical about a week ago. . culminating with my last 2 days of "freedom" being spent mourning the fast encroching loss of my freedom and worrying about how may days into the rotation I will be kicked out of medical school for my lack of knowledge, skill, and all-round un-doctorlyness. Needless to say, I was spinning a wee bit the night before. For example, at 10:00 at night I decided it would be a great idea to make not some not-so-important cheat sheets I've been meaning to make for a year. It shouldn't be a surprise to anyone that I did not sleep so hot that night.
The introductory lecture of the rotation only added to my anxiety. I thought the rotation director would be gentle and smiley and welcome us to HX with big hugs and words of reassurance. Instead she was more than a little manic (tip to SR) and spoke so fast that I'm still not really sure of about half of what she said. I left the room even more wide-eyed and petrified. I ran through the list of probable alternative jobs in my head: teacher, sign language interpreter, singer, farmer, lab rat, dog trainer, whale tank cleaner, balloon animal maker .. . really, anything. ANYTHING would have been less stressful than this, I thought. What the F was I thinking? If I could go back to that 23 year old and talk to her, I would shake her. . . a lot. . and say you stupid, naive girl. Stress. . .it sucks, I promise you that by 29, you will realize it's not even close to what it's cut out to be. That's what I was thinking as I speed walked across the street to the ED, trying desperately to keep up with the clerkship director who apparently also walks manically.
So day 1 started, and day 1 continued, and then day 1 ended and I didn't die OR cry once. (Of course with 17 days left, there is plenty of time left for that).
The ED Green (where the less acute patients are seen - think urgent care) has a fast pace and you tick away your time there by patients rather than hours. We work "12 hour" shifts, but they end up being more than that since you have to tack time on for the patients that are essentially ready to go, but not out the door, when your shift ends. The responsible doctor and med student doesn't just hand those patients off to his/her replacement. . nope, he/she finishes what he/she started. You discharge those patients, and that's a lot of paperwork and a bit of time. Plus you have to finish any and all charts that you might not have had time to complete during the day. This took me 2 extra hours my first day. . .I'm hoping I can trim that time down a bit.
Somehow, in an ED that sees few to no pelvic exams, I ended up doing 2 today. This morning during our tour, we walked by the pelvic exam room and the clerkship director pointed at the room and said. . "There's the pelvic exam room, but you probably won't ever see it. We really don't do pelvics here." (On a side note, I found this statement rather odd. . really, any woman coming into the ED with abdominal pain and/or vaginal bleeding should probably get a pelvic exam). But despite that statement, it was like the Gods of irony and the Gods of Gentle Introductions to Scary Rotations were holding hands and blessing me today. Female problems and pelvic exams are a homecoming from me. I'm not saying I was perfect, but at least I can understand the gynecological language.
The high point of the day was the young female (from jail) who presented with abdominal pain and thought she was 3 months pregnant. Her uterus was just too big for her reported gestational age so I thought, she has to be further along. Turns out we were both right. A quick bedside ultrasound showed us a head, an arm, a leg, a heart. . then we moved the ultra sound probe and saw the heart again. . but then we also saw a different heart. . and then the first heart. . and then the 2 hearts side -by-side. Twins, with a gestational age of about 4 months! An exciting moment for the ED.
And the look of surprise, fear, and joy on the girl's face was, well, heart warming and heart wrenching. She flashed the first smile I'd seen on her face all day.
*In order to keep these posts somewhat confidential, I will be changing identifying characteristics of patients, including the name of the hospital, which I have changed to Hospital X, or HX for short.
I've been told that rotation through the Hospital X (HX) ER* will cure even the most reluctant medical student. There is no shallow end there, it's all deep. It is a "kick you out of the nest, watch you hit the ground, then roll you to a cliff and push you off again" sort of rotation. Fly dammit, now.
The anticipation - horrible. I've been fretting about this rotation since I signed up for it. And the fretting became physical about a week ago. . culminating with my last 2 days of "freedom" being spent mourning the fast encroching loss of my freedom and worrying about how may days into the rotation I will be kicked out of medical school for my lack of knowledge, skill, and all-round un-doctorlyness. Needless to say, I was spinning a wee bit the night before. For example, at 10:00 at night I decided it would be a great idea to make not some not-so-important cheat sheets I've been meaning to make for a year. It shouldn't be a surprise to anyone that I did not sleep so hot that night.
The introductory lecture of the rotation only added to my anxiety. I thought the rotation director would be gentle and smiley and welcome us to HX with big hugs and words of reassurance. Instead she was more than a little manic (tip to SR) and spoke so fast that I'm still not really sure of about half of what she said. I left the room even more wide-eyed and petrified. I ran through the list of probable alternative jobs in my head: teacher, sign language interpreter, singer, farmer, lab rat, dog trainer, whale tank cleaner, balloon animal maker .. . really, anything. ANYTHING would have been less stressful than this, I thought. What the F was I thinking? If I could go back to that 23 year old and talk to her, I would shake her. . . a lot. . and say you stupid, naive girl. Stress. . .it sucks, I promise you that by 29, you will realize it's not even close to what it's cut out to be. That's what I was thinking as I speed walked across the street to the ED, trying desperately to keep up with the clerkship director who apparently also walks manically.
So day 1 started, and day 1 continued, and then day 1 ended and I didn't die OR cry once. (Of course with 17 days left, there is plenty of time left for that).
The ED Green (where the less acute patients are seen - think urgent care) has a fast pace and you tick away your time there by patients rather than hours. We work "12 hour" shifts, but they end up being more than that since you have to tack time on for the patients that are essentially ready to go, but not out the door, when your shift ends. The responsible doctor and med student doesn't just hand those patients off to his/her replacement. . nope, he/she finishes what he/she started. You discharge those patients, and that's a lot of paperwork and a bit of time. Plus you have to finish any and all charts that you might not have had time to complete during the day. This took me 2 extra hours my first day. . .I'm hoping I can trim that time down a bit.
Somehow, in an ED that sees few to no pelvic exams, I ended up doing 2 today. This morning during our tour, we walked by the pelvic exam room and the clerkship director pointed at the room and said. . "There's the pelvic exam room, but you probably won't ever see it. We really don't do pelvics here." (On a side note, I found this statement rather odd. . really, any woman coming into the ED with abdominal pain and/or vaginal bleeding should probably get a pelvic exam). But despite that statement, it was like the Gods of irony and the Gods of Gentle Introductions to Scary Rotations were holding hands and blessing me today. Female problems and pelvic exams are a homecoming from me. I'm not saying I was perfect, but at least I can understand the gynecological language.
The high point of the day was the young female (from jail) who presented with abdominal pain and thought she was 3 months pregnant. Her uterus was just too big for her reported gestational age so I thought, she has to be further along. Turns out we were both right. A quick bedside ultrasound showed us a head, an arm, a leg, a heart. . then we moved the ultra sound probe and saw the heart again. . but then we also saw a different heart. . and then the first heart. . and then the 2 hearts side -by-side. Twins, with a gestational age of about 4 months! An exciting moment for the ED.
And the look of surprise, fear, and joy on the girl's face was, well, heart warming and heart wrenching. She flashed the first smile I'd seen on her face all day.
*In order to keep these posts somewhat confidential, I will be changing identifying characteristics of patients, including the name of the hospital, which I have changed to Hospital X, or HX for short.
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