Trauma Bay: Airway, Blog...

Sugar

2009-11-04T13:20:00.003-06:00

I don't know what the role of hypoglycemia in resuscitation is; all I know for sure is that both patients I've taken care of with an initial FSG reading of 'lo' that had an associated cardiac arrest didn't survive, even if the problem was addressed. Ideas? Maybe there's something to candy, after all.

"Let grief be your sister, she will whether or not"

2009-11-04T12:58:00.003-06:00

The paramedics call to base for support for a PNB, which is run-of-the-mill, two or three times a shift. Either they have brought the patient back, or they want to stop, or they want to keep going, and they need our OK.

They called from the middle of a basketball court, doing CPR in the center circle on the son, cousin, and uncle of the well-dressed audience, watching and holding each other. A twenty-year old who collapsed stone-cold dead between the second and third free throw, falling backwards.

Round three of the typical three is already done when they call, asking for transport, for continuation; reaching for the refuge of hope that drugs like bicarb and lidocaine after amiodarone represent, some extra tool to throw at death when you're not ready to give up yet.

Everyone there did everything right. The coach started CPR, the EMT basic delivered one shock before the paramedics got there, they placed a combitube rather than an ET tube and ran the show. IV was placed on arrival. By the time they called me, though, it had been almost thirty minutes. Move to the rig. Move to the rig, out of the gym, away from the people all around. I ask one or two times, are you comfortable going 1099. Negative, they say. The mom is with us in the rig. OK, then. Come to the hospital.

The team knows this is theatre, to some extent. That doesn't mean we try any less hard, or that our compressions are too shallow, or that we breathe at the wrong rate. It means as soon as he rolls in, CPR still going, sadness rises in place of hope.

At the head, I see his fixed and dilated pupils; the c-collar in place because he fell backwards and maybe it's trauma, I take off, because it's not trauma, it's a heart that got too big for itself. With the first pulse check the tube is placed and confirmed. We do three rounds of drugs, CPR all the time, switching every two minutes, stomach decompressed. I can see mom ten feet from the foot, being held, eyes fixed on her son that an hour ago was running up and down the court. Not prowling the street selling drugs, not driving drunk, not stabbed by some dude while minding his own business; not doing the things so many of our other visitors do.

Our staff gives the warning shot. I'm going to tell mom it's not going well, he says, and one more round.

The nurse keeps the alarms off. Only the sound of 100 a minute compressions and 10 a minute bag-valve-mask ventilation. It's a soft sound. Rhythmic. The sound of our best tool, our best way to keep someone alive in the short term. The sound of failure.

We stop. A door shuts for the others in the room and mom drops to the floor, wailing and gasping for air. We help her to a cot to support the weight she cannot support herself. She breathes underwater, eyes on nothing.

There is no question of why. I know why this happened, the story is the classic presentation of this. No, there's no 'why'. There's just the next patient, and a sensation over the back of the head as if a window were just opened on a winter's evening, as the stickers are taken off and our patient is covered with clean white blankets.

Holy Crap It's Been ForEVER

2009-10-09T08:47:00.006-05:00

...since I last posted. Sorry!

I've been at ACEP and looking for jobs and generally trying to live life while also remodeling a flooded basement and just being a resident. Somehow that interferes with posting. I'll try to post the best nuggets from the conference as I go through all the syllabi.

A large, large man came in the second to last shift before I flew out with chest pain. He was a mountain. Chest pain, of course, is our most common complaint, so I went in to talk to him without thinking much about the differential.

Where do you have pain?

Right here, he says, indicating his ICD which is so new he has only a partially healed surgical scar over it.

Did something happen to it?

Well, yes, my girlfriend punched me in the implantable cardioverter-defibrillator (ICD), two times. Like, hard. And I think it went off and now it hurts.

Um, OK. I walk back out of the room and pull out the algorithm for people punched in the ICD by their girlfriend, which we have filed right behind the STEMI protocol. Interestingly, all pathways end with 'get a new girlfriend'. And, admit them to the hospital for an ICD interrogation and cardiac rule-out. You never know. Maybe he was having ischemia at the same time he got punched twice in the ICD. God I love my job. The hardest part was not laughing. I think I actually did. I think I might have also told him to get a new girlfriend, a vital part of my patient education.

A What Scratched You?

2009-09-15T15:23:00.012-05:00

I officially have a new favorite chief complaint by ambulance. Mouse scratch.

Paged out as such, I didn't know what to expect but at 3 am I was ready for the worst...not really. I was ready for what I got.

There were tons of mice in my house, one ran over the covers or over the bed, I freaked out, and while I was scrubbing myself down with alcohol solution and soap my leg stung and I noticed this tiny l'il scratch about 5 cm long that barely broke the skin. Oh yeah, I'm wearing a finger splint with a sharp edge on it. But I was worried it was the mouse that got me and maybe I need rabies or tetanus.

Um, tetanus OK. Rabies no. More importantly, since it's three in the morning and you're the only to be seen, how many mice exactly?

Mice on the curtains, mice in the kitchen, in the closet, in the bedroom, kids screamin', can't do their homework, traps out catch ten at a time. OK, so, um, you don't really need me. You need some dude with bad chemicals that has to wear rubber gloves that'll fix your problem. Needing a tetanus shot is, well, the least of your very disturbing, disgusting worries.

Third world at home, folks. Third world at home. Instead of the taxpayers picking up the am-boo-lance ride, perhaps we should pay for the exterminator.

FYI, CDC tetanus recs: booster if more than five years from past tetanus booster. Immune globulin for those who have not received their normal immunizations, or who are unknown. So-called 'clean, minor wounds' can wait up to 10 years and should never get immune globulin, but I rarely see that happening.

CDC recs for rabies are more compliated. First, what animal. If a dog, cat, or ferret--i.e., pets--no treatment is needed unless the pet is thought to be rabid, so if you have the pet, you can watch it. If wild--i.e., scary furry critters like racoons, skunks, foxes, or, notably, bats--immunize as below. If livestock, call public health. Gerbils are probably OK.

Treatment is irrigation with povidone-iodine or the like, rabies immune globulin at the site of the wound AND at a distant site if you can't infiltrate all of it, in addition to the rabies vaccine at 0, 3, 7, 14, and 28 days, in the shoulder, not in the tummy like I was afraid of when I was a kid. Apparently according to another blogger this just changed with ACIP but not with CDC; perhaps we'll be able to skip the last dose.

photo credit

Thanks

2009-09-11T16:33:00.002-05:00

Multi-Tasking

2009-09-11T15:54:00.003-05:00

Finally, got a real night shift.

At one point, I was gowned up holding direct pressure on a spurting radial artery wound after some dude had punched his way through a window. My headset (yes, we wear headsets, and they're only slightly metrosexual) goes off asking me to come to the trauma bay to supervise an airway as we do for any trauma during our second year. I get someone to take over for me and walk down towards the bay, talking on the phone to hand surgery. I don't even know the name of the radial artery bleed, only the room, since I walked in on the heels of EMS. I re-gown for the airway, check the tube and end-tidal CO2, manage vent settings, and while I'm placing an OG tube the radiologist calls me, also on my headset, to tell me about a new cerebellar stroke found on the patient right next to the radial artery bleed.

Despite myself, I smile. This is EM. I realize deep down that it all makes sense. It was the right choice.

Also ran my first PNB over the EMS radio and tubed a drunk lady with a huge laceration of her posterior while wading through the headaches and abdominal pains and two decompensated cirrhotics.

picture credit, an interesting blog on communication found by an image search for 'multitasking'.

Why My Daughters Are Going to Have the HPV Vaccine Strongly Suggested To Them

2009-08-25T15:17:00.003-05:00

A beautiful little cherub sits on the stretcher. Not as cute as my kids, of course, but close. She's reading to herself. Groomed. Haircut is stylish. She's a vision of Nordic charm. Then you ask her how she likes her book. 'Good', she says, 'it's called Who Rang the Doorbell'. Hmmm. Voice is all raspy and soft. I can barely hear her.

That's because she's had genital warts lasered or chopped off her larynx like sixty gajillion times (aka, once every four to six weeks for a year or two). How did she get them? Her mom had asymptomatic HPV at the time of her vaginal delivery that was either missed or tested for and not caught. Now this little girl has to come in and get put under general anesthesia all the time. Today she has re-growth that's 'not too bad' according to the ENT doc. The clusters of new HPV growth are only occluding about 30% of her tracheal opening after six weeks. You can't even see her vocal cords anymore. Her larynx is a tube of scar tissue and virus. There's enough bleeding and swelling after the treatments that she's been hypoxic a few times from acute obstruction, and of course, if she didn't have the surgeries the virus would just keep growing until it blocked her airway and she died.

Compare that to some local injection reactions from the vaccine. Damn those pharmaceutical companies coercing young women into getting a shot just for profit, and forcing their immoral opinions on our young women.

Set-Up For Success

2009-08-25T15:08:00.003-05:00

Normally, intubating children produces angst because we're worried if we miss, but overall they tend to be straightforward as long as you do a few simple things. For young kids, you should have their ear at the level of their anterior shoulder, perhaps put a towel under their shoulder to compensate for their giant heeds, use a straight blade, look up, and you're home free.

So when the anesthesiologist brings in a wee laddie in a crib in traction, meaning their legs are up in the air, their chin is slouched into their chest, there's no way to approach them straight from above like we normally do, and then he says, "let's intubate him on the crib", and, "I normally don't use a paralytic", that's an awesome set up. Sterling. Perfect.

We ended up using a paralytic. Then I got it the second time. Gives me a lot of respect for paramedics intubating with less than ideal conditions, including in cars, in fields, and so on. However, when you have time, it seems silly to me not to use every advantage the first time, every time. Ironic, since usually the anesthesiologists call us cowboys, not the other way around.

Healthcare Reform

2009-08-22T16:03:00.005-05:00

Sigh. I guess it's time to finally say something about this circus. About this distraction. About healthcare 'reform'.

The biggest thing I can say is that we're missing the point completely. The death panel debate is inane and shockingly uninformed and offensive, but it's really a shell game in front of closed-door deals that signal the true agenda of this bill and 'reform': window dressing for business as usual.

Obama, for all his rhetoric, looks to have sold the public down the river in order to mollify the big contributors, including for-profit hospitals, the insurance agency, and big pharma. How can I say this? Well, it seems obvious that he's agreed to limit contributions from the big players as covered by the NY Times and others. Now, conveniently the dialogue has shifted to co-ops instead of a public option; the 'death panel' idea has been dropped. The talk is about taxing health benefits, requiring people to buy insurance, and avoiding forcing drug companies into concessions on what they charge Medicare, all in the name of 'personal freedom'. These are all shifts away from what he said on the campaign trail, and away from meaningful reform.

The real show is going on behind closed doors. And if you're not outraged at that as a citizen you're missing the point. The big dogs are off making the real deal while we're busy yelling at each other like morons in 'town hall meetings'.

The real discussion needs to occur about the possibility of a single-payer, government run system. Unfortunately, with so much money and profit wrapped up in both politics and all aspects of media, it'll never happen. Does that help me as a doctor? Sort of. I'll keep making a higher salary, but I'll also be little more than a profit engine for corporations providing health care struggling to actually take care of patients. We'll still have uneven distribution of outcomes based on socioeconomic status, the CEOs of insurance companies and pharmaceutical companies and hospitals will still make enormous profits, and the president will get his speech. But, overall, very, very little will actually change except you'll be forced to buy crappy insurance.

What actually needs to happen is to get the monied interests out of the back conference rooms of the white house, and out of congress, and out of politics. When John Adams made his way to the continental congress before we were even a country, he had to do it for free, and he had to close down his law practice to do it. He did it because he loved his country, not for the bennies (which, for current congressmen and women, includes a great health care plan. Notice how they're not talking about giving that up). It's all about campaign finance reform and lobby reform, not health insurance.

Life-saving skills

2009-08-22T14:04:00.002-05:00

Stuff that saves people is cool. We can all accept that. The things that really save people, though, are usually not what we expect. Helicopter transport, hypothermia with a cool machine that self-regulates, ICU care, monitors that beep and whistle, recombinant clotting factors that cost more than an SUV per ounce, those save people, right?

Um, maybe; but things that actually do are often eerily simple. Good chest compressions. Needles in the mid-clavicular line. And airway management--with a mask and a chin lift.

Terrifyingly recently, anesthesiologists would do a suprising number of cases without intubation and without a machine, just bagging the patient with an ambu bag. You breathe for the patient, literally.

On peds anesthesia this week, the best cases were the ear tubes, becuase for five minutes or so it'd just be me and the bag and the patient not breathing. This skill, as much as intubation, saves lives. Just a bag. No big fiber-optic scope, no fancy stainless steel LED-lit laryngoscope or, as my trauma surgeon called it, 'dog and pony show'.

It's all well and good to talk about lifting the jaw up into the mask with your pinkie, ring and middle finger spread from behind the jaw to the chin, but like any motor memory task, it takes time to learn it. Once you do, there's no feeling like holding the jaw up, squeezing the bag, and watching that little chest rise just enough to avoid inflating the stomach while still giving them oxygen. And to think we walk around normally breathing without even thinking about it. Want to manage a person's airway? Learn to bag. Don't know what to do with a failed airway? Learn to bag. Save a life.

/sermon.

FMOE: What do I do with this rhythm?

2009-08-22T13:40:00.002-05:00

Gimme an M! Gimme an A! Gimme a G! What's that spell? That's right, the electrolyte that's also a code drug. Let's hear it for magnesium. 1 to 2 grams IV like, stat.

And for all the med students out there? Want an obscure cause of Torsdes? Try cardiac sarcoidosis. We had a woman with a strip like the above who we loaded with mag after a self-limited run who had just been diagnosed with sarcoidosis. The cardiac MRI was negative, unfortunately for science, but fortunately for her.

Rat Poison

2009-08-22T13:17:00.006-05:00

He finishes dinner with his wife, the first they've had in weeks as he's recovered from hospitalization. Both feel better. Renewed. Maybe a bit hopeful. His balance isn't what it used to be, he's still tired, unsteady at times. Weaker than he was. She finishes the dishes while he, complaining of being tired, heads for bed upstairs.

On the third step, he remembers something and, naturally, turns to go back down. His balance, though. Not what it used to be. He falls the three steps, foreward into the foyer. And weak; doesn't catch himself. His nose bleeds. And bleeds. Bleeds even after she holds pressure and calls 911, bleeds to the hospital. Bleeds with anterior packing.

By the time he stops bleeding with a postieror pack, he's intubated; mental status, airway protection, and all that. Multiple facial fractures are found. He's admitted to the ICU for a hopefully swift recovery. Opacity at the base of his lung is watched; perhaps he breathed blood. Hard to say.

By day 3 or 4, it's not hard to say. The lung fills in, the tube stays after the packing does. He spikes fevers. He doesn't wake up. Now 4 to 5 days without nutrition, fractured, infected, a tired body, issues layering on each other.

His wife knows that he wouldn't want all of this. Wouldn't want the tracheostomy, the feeding tube, the supportive care to see if he comes out of it. That's were we were. Stuck. Or, not stuck, because the family was sure of his wishes, and all of them agreed.

The Navy man who drove the boats for the landing on Guadalcanal had care withdrawn on the 4th of July. How terrible, you may opine. How macabre. But. The monitors were shut off. The tubes removed. His sons and daughter were there. His wife was there. They held his yellowed, bruised cool hands. Draped in a home blanket. They spoke to him, and we shut the door and the curtains, watching the monitor still on outside slow, and become more and more shallow until they stopped.

This is the situation the supposed 'death panels' were for. It was as good a death as we could offer for a good man. No bureaucrat showed up and told us we had to let grandpa die, nor would they if we had kept the 'death panels'. The family happened to know what he wanted, and because of that, we could let him go. What if they had been gone? What if they had disagreed? Weeks and months could pass, hooked up to machines and tubes, sustained, exactly as he didn't want to be maintained.

It's terrible when anyone dies. It's worse when they are treated with guesses as to their wishes. No one deserves guesses like that. The family is often asked to 'guess' what they might have wanted. Imagine, having to feel as though your decision will either end the person's life or lead to a full code and then the end of their life, not knowing if they wanted to leave quietly, or fighting to the last.

brownout

2009-08-13T08:15:00.000-05:00

The concept of burnout isn't new; the pre-game is brownout, and it feels like it sounds. There's no crack, no explosion, no drama. Just a slow fade. The exams of patients get a bit shorter, the reliance on data higher because it's emotionally easier to look at a scan or a lab. The morning is harder.

Empathy starts to slip and is replaced by pity and sarcasm. Families aren't comforted or updated as often. It's not terminal. Your work doesn't slip to poor, just from excellent to good, or good enough.

Time to leave the ICU. Time to leave the one long hallway lined with an ever-changing but remarkably similar parade of random victims, the drug dealer next to the teenage model UN attendee struck by the drunk driver. Time to leave the purring ventilators and whispering pumps and step into the sunlight. Three days. Thirty-six hours, give or take. Not that I'm counting.

I am not who I was.

Strike One

2009-07-26T11:48:00.000-05:00

Sorry to all for the long layoff. It's been unavoidable on the ICU, which has been a 'rich' learning environment to say the least.

We had a summer weekend night at the beginning of the month not too far outside the normal with fifteen or so traumas that came in, one of whom was a three hundered pound diabetic with hip fractures and rib fractures and a blood sugar of 850. She got blood in the truama bay because she was tachycardic and no pne could feel her pulses; after the resuscitation, she went to thr OR for an open femur. I was at the head of the bed in case there was an airway issue. In retrospect, it's hard to see the detail we could've caught to avoid amputating her leg three days later.

In the ICU, she kept failing to meet her resuscitation goals; too acidotic, not enough urine output, poor perfusion and cold extremities all around, remained intubated. She made all of us uneasy but we didn't quite know why, and we scratched our heads every morning and every afternoon and tinkered with her drips and fluids.

She gradually accrued orthopedic splints and rods sticking out of her leg and pelvis and arterial lines and venous lines and tubes, and on the morning of the third day the nurse said hey her foot looks dusky and it's really cold. The attending looked at it and agreed; she was going to the OR again and we told the ortho docs that the nureses were worried about her foot and that she had no pulse we could find but didn't call vascular specifically.

She came back four or five hours later and they said, you should call vascular, we can't find a pulse. By the time vascular came her foot had been cold for eight or nine hours and they, shocker, said nothing to do. An angio showed loss of the popliteal artery, which supplies the whole lower leg, just above the knee.

The amputation rate for injuries like this eight or more hours out is 86%. Even within six, the rate is about 20% if there is a femur injury. After we found out I remember sitting on the toilet in the room becuase it was the only place to sit and looking at her now purple toes sticking out of the splint. That may have been why she kept missing her goals all along. The reasons to miss the injury were legion, yet sitting there staring at her dead toes they all sounded like excuses.

That's the other part of the whole cost debate. Becuase of those purple toes I'll be more likely to order angios for the rest of my life, but not to somehow line my own pockets and not to avoid lawsuits. To avoid purple toes.

Gauze

2009-07-07T13:47:00.006-05:00

In the midst of the busiest call night in memory, I stand for twenty minutes, still, and watch the end of a baseball game.

I hold pressure to the wound that has soaked the bedsheet and is drying from the outside in. It soaked his shirt before he arrived. My hand protests and numbs after I wedge my elbow against the bed.

I have stacks of consults to finish. The pagers hum, heedless of each other, while I hold pressure, unable to answer. Traumas are stacked in rooms to go upstairs. Ribs, open legs, head injuries. Splintered livers. The detritus of a sticky summer night. Scanned, diagnosed, improved, ready to move.

I try to switch hands but position dictates my left is better, so I switch back. The chief had held pressure before me but she was too busy. Go get someone to do this, she said. This is what he needs. He needs a human being to hold pressure for thirty minutes.

Thirty minutes. From 9:25 to 9:55 PM on a weekend night in June, after the summer heat has arrived.

I ask for the med student first. He is too busy learning, I am told. My own staff tells me this, an attending who has taught me how to read EKGs, how to diagnose vertigo. My own staff who should be on my side except this month I am an interloper, I am a surgeon, I am an other, a 'consultant'. Get a tech.

I go and talk to the charge nurse, perhaps even more important than the staff physician. She is washing a bed. I do not take that as a good omen. I need help, I say. Someone needs to hold pressure on this poor man's wound, and right now the overnight chief of trauma surgery, the grand poobah of weekend nights, is holding pressure. She laughs a short laugh. We have no help, she says. They are too busy. She does not recognize my so-called authority. I am but a mendicant.

I return. I will hold it, I say to the chief. Perhaps you would like to argue our cause. She leaves, the curtain rustles. The nurse, who is giving an IV medication over the course of ten minutes, cannot leave her post, either. We are together. The patient is silent. He watches the game.

The bleeding stops. The bandage is taped. The patient is treated. Anyone could have held it there. The choice of who holds the gauze, though. That is how I know where power lies, and where it does not.

And what was gained? The patient was treated. A task was completed that the charge nurse, the staff doctor, the chief of surgery, and the medical student did not want to complete. Will this matter, I wonder. Will it matter that I did that task rather than order someone to do so? I could have, with my authority, so-called. But authority and power are not the same.

Photo Credit

A New Era

2009-06-16T18:47:00.000-05:00

This is the first post from a phone I've ever written, and that sure is amazing if you think about it. Of course, the fact that I think it's amazing rather than normal tells you what a dinosaur I really am. Pretty soon my phone will intubate my patients and place central lines while it brews my coffee. Perhaps now I will actually be able to post again, busy as we are on truma. Sorry to all for the layoff.

We sent a lady wothy of buckeye surgeon, another blogger on the sidebar, to the OR today for a small bowel obstruction, and now I get what the surgical emegency is all about. Her belly was like a drum. Fourteen prior surgeries. Tiny little lady with a buddha belly, criss-crossed with scars that she clutched with both hands, fluid pouring out of her NG tube. She would surely be vomiting up a storm without it. I guess those surgeon-type people do some good after all.

Irony

2009-06-08T17:34:00.003-05:00

Here's a knee-slapper. What if the very Harley that you rode to traumatic brain injury land without a helmet also technically kept you from qualifying for federal insurance to pay for the nursing home you needed? What if it made you 'over assets' because it was so nice on paper, but really was a twisted heap of metal that no one had officially listed as totaled yet?

Hmmmm.

Trauma Time

2009-05-31T14:14:00.005-05:00

Photo Credit

Last day of cardiology call; starting trauma surgery tomorrow.

An article about South Africa's hosting of the 2010 World Cup made me think about the context of penetrating trauma. Johannesberg in particular is an infamous center for trauma research, and one of the most dangerous places in the world, prompting all the concerns about tourists visiting.

Looking around, it certainly seems that the risk of getting shot or stabbed is, ahem, not quite equal. The rates where I train are in the neighborhood of 20 per 100,000 or so, putting us outside the top 25 most dangerous cities in the US in favor of places like Detroit and Compton; on a country averaged rate, though, it puts us between Puerto Rico and Kasakhstan, which is not great. With a stated death rate from intentional trauma of 20, we get more than a gunshot wound a day on average (they do tend to come in groups).

Of course, it gets worse; South Africa has a rate of 38 per 100,000, as high as almost 50 in the last decade. Iraq wins--or loses, whichever. But that's an active war zone; the one that makes me wonder in this list is Jamaica, which people run off to all the time. Imagine if Apple tourism started selling getaway packages to Iraq.

These statistics face the same problems as any public health measure. Any country with a functioning public health system will do a better job of tracking statistics, and the statistics in Sierra Leone or Somalia are likely not quite reliable, whereas ours should be quite reliable. I'm guessing the rates in countries like Somalia, Angola, or Colombia are unreliable to say the least. I'm not sure how a country with no infrastructure deals with such a trauma load, except as depicted in the pictures linked above from Somalia.

According to the Boston Globe article with the photo above, Somalia has lost 17,000 civilians to trauma in the last 2.5 years, or 6,800 a year; if the population is counted right, that's a death rate of 680 a year from penetrating trauma. 680! Makes that picture above seem a bit more poignant. Makes me think I'll take trauma more seriously. Makes me happy I'm not in Somalia. Makes me just overall confused about the state of the world and what we're missing on a daily basis if we don't go looking for it. Imagine the apocolypse we would be filling our airwaves with if our penetrating trauma death rate was thirty times greater than it is now. And yet, it's happening. Just not here.

That's The Difference Between Us...

2009-05-25T12:29:00.011-05:00

Rotating on cardiology, I've had the opportunity to see some of the, ahem, differences in how we approach patients. It was accentuated this morning when my staff said, 'your notes are so ER', which I took as a compliment--she said that because my entire written plan in the daily progress note was 'pt to CABG tomorrow'. I hadn't commented that we were replacing the potassium at the low end of normal, keeping the patient on a cardiac diet, monitoring the patient on telemetry, and so on. I just wanted to say what was happening and how they were leaving. Well, what more is really needed?

Although EM grew from medicine or surgery based on which hospital was covering the ED in the sixties and seventies, I would argue that we are now our own full-grown speciality. We're hyper and have the attention span of a caffeinated meerkat compared to the other services, we're the only ones to seriously consider things like toxicology, we think about disposition like no one else, but the real, real difference is one of mindset, and it all goes back to the teaching I got as a 4th year medical student.

My attending said, what do you think is happening, and, at the same time, what are you doing? You're in the ED, buddy, dispo is everything, and you can't sit there and scratch your head forever. 18 in the waiting room, let's go.

We 'diagnose' our patients, although that's a loose term and really an ED diagnosis is more like, are you going to die a) 5 minutes ago b) in the next 5 minutes c) maybe in the next few hours d) in the next 30 days or e) someday, but I don't know when and I bet you'll see another doctor before you do therefore relieving my liability.

If the answer is a or b, then we're at our best, and we DO diagnose to the extent of determining the pathophysiology of the shock present and the subtypes of life-threatening presentations we see, including poly-terrible situations like the 85 year old who either had a heart attack and hit a tree or hit a tree and had a heart attack.

If the answer is c or d, then our 'diagnosis' is not really a diagnosis but rather risk stratification for really bad things that might lead you to be in category a or b. Yes you have chest pain and it might be mantle-cell lymphoma (which if I weren't on a medicine service I wouldn't even know was a disease) but really what I care about is how likely are you to die soon? This is really, really tough and I'm still learning it. It's hard. And it always presents patients that don't fit the mold.

Medicine, god love them, and by that I mean internal medicine, is a vital adjunct to Emergency Medicine. They take all the patients in category c and d that we risk stratify to scary or at least a little bit scary and then they do something called rounding, which involves terribly long and inexorable walking conversations about patients to agonizing detail. They address changes of less than 5% in electrolyte levels over the course of days; they draw crazy tests like trans-thyretin antibodies, ceruloplasmin levels, anti-double stranded DNA antibody tests, dexamethasone supression tests, and so on and on. They get really excited by complicated patients with multi-system disease that affects multiple organ systems and they love the unifying diagnosis that ties all of this together.

This drives me bonkers. I can't concentrate. I pray for lines and codes and then feel bad because that means patients are sick. I go talk to the crazy withdrawing person because it reminds me of the ED.

A discussion the other day epitomized this divide. I wanted to start our sarcoid patient on steroids because we knew she had sarcoid and probably she had cardiac and GI sarcoid and she felt sick, so why not give her steroids and see if she feels better? What am I doing for this patient?

The med resident, who's very good, was all, we don't know for sure that it's cardiac sarcoid.

So?

Well, what are we treating then?

Um, sick person? Hope she feels better?

But that's undisciplined, she meant to say; that's untidy, that's not targeted therapy.

Sigh.

I love them because I admit to them. I'll stick to my version of diagnosis, though. Not sure what the point of this post was, other than to say, we all have a place, and the best way is to figure out how we complement each other.

Thank You

2009-05-25T12:17:00.002-05:00

When my girls see the flag outside the window, they go, 'look, the flag!' and they both burst into song: "it's a grand old flag, it's a high-flying flag..." through all the verses.

Happy Memorial Day, and thanks to all of those who put their lives on the line for all of us. Your service is appreciated, your sacrifices noticed.

Um, Silly?

2009-05-19T12:44:00.006-05:00

When I admit a patient, I ask them what they are taking. The nurse asks them what they are taking, and the pharmacist does, too. In the ED (happy, WhiteCoat?) we have a little section where we can mark their medications and enter new ones.

Then, when they go upstairs, I copy the medications from a computer onto an order sheet by hand with a ball point pen, making sure to press hard so it goes through the carbon paper. I then copy it again, still by hand, into a history and physical. Three lists and counting.

I then am supposed to copy it onto the daily progress note by hand with doses and frequencies every day even though we round with a pharmacist with a computer (who, you guessed it, has access to the computer list). I don't do this out of protest. Four lists, and counting.

When the patient gets transferred from the ICU to the floor, or from one floor unit to another, there is a transfer medication list that also gets copied onto a triplicate paper order sheet with a ball point pen, because there is no way to just, oh I dunno, transfer the list. So that's five and counting if there's a transfer.

Upon discharge, the nurse prints a form that has their before admission meds and their inpatient meds as well as a new place to write discharge meds, so we'll call that six. The nurse is then supposed to copy, by hand, that list onto another so-called 'RN discharge'. That's seven. I then dicatate, hopefully from one of these reliable lists, into a discharge summary that is on a different system and not automatically correlated with anything. We'll call that eight.

Eight medication lists for every hospital admission, seven if there's no discharge or transfer. If someone comes out of the ICU and then transfers at all it's up to nine. They all live in different spots. There is no automated updating except at that first step, when there's an EMR.

I know White Coat just posted about a place that uninstalled it's EMR because, admittedly, garbage in is garbage out. But what is garbage copied eight different times, with lists as long as 30? That's, hmmm, 240 chances for error. All in the name of reducing errors.

And we chide our patients for not knowing what medications they're on. We probably don't know, either.

Gassed Out

2009-05-19T12:07:00.002-05:00

I have any number of ideas about what to write but I am truly spent, good hearts. I am browning out. It's slower than burnout. I walk slower. The coffee isn't as good at 5 am in a nurse's unit as it is at 7 am on a beautiful morning on the patio with the kids. The iPod works but I get tired of walking the hospital stairs as my only workout, and listening to lectures while filling out forms as my only mental stimulation.

It could be worse, mind you. I have my health. We have running water, plumbing, heat, and food. There's no nearby war. I haven't lost my job or my house. But...

All of us on the current service have our own short-timer's calendar. Somehow we're all looking forward to the 20th because the 20th seems a manageable amount of days away from the end of the month, but that's only half-time, and then it's on to another month of call and scut, then another.

I'm tired of having my family and my relationship come 5th of 5 on the priority list so we can walk around and discuss oral versus IV magnesium supplementation and when to make so-and-so NPO for the cath I won't see except to document normal pedal pulses four hours after return.

This isn't a sarcastic hate the world post, a lot of patients are decent and I'll try to post about them, it's just that I'm 'all done', thanks, as my son would say. All done.

Jaded, Redux

2009-05-15T07:21:00.002-05:00

A confidante noted that I've gotten sarcastic. It's a weakness of mine, brought out by paperwork, long hours, and stress. On the way in from the parking garage, though, the birds were chirping, the sun was shining, and the helicopter landed right overhead, which, call me crazy, has always reminded me why I love this job.

Intern year, I will yet conquer thee and remain at least somewhat compassionate. But thanks for the reminder, I need it.

Pearls Before Swine

2009-05-11T11:01:00.005-05:00

Which is more--twenty or thirty thousand, or fifty-nine?

The first is the approximate number of deaths over the last few years, per year, from 'influenza and pneumonia', one of the top ten killers in the country. The second, of course, is the number of deaths from the virus formerly known as swine flu, now known as H1N1 flu, which, though unreported, is also the antigen configuration that makes up a goodly portion of the seasonal flu. Now, I'm no public health guru, I'm just a simple resident. Somehow, though, those numbers call recent calls for global action into question just a tad.

We all love a crisis. Me more than most, apparently, since I picked a job where 'crisis' is part of the daily routine. We're good at it; we can pick a discrete enemy to fight.

I must say, though, that the reaction to this pandemic has been just a trifle ludicrous. Fifty-nine deaths? Really? Schools closed, flights diverted, billions of dollars, for fifty-nine deaths?

Not to mention the ED overload with people spreading whatever other gunk they had to each other in order to get tested for swine flu. Awesome. Sterling.

The public health departments actually did the job they were supposed to. They performed surveillance on a new threat and quickly tried to characterize it's mortality rate and epidemiologic characteristics. This work has to, by nature, be paranoid. It's the job of those of us watching and interpreting to avoid mass hysteria, and in this, we failed. I blame mostly the media, frankly, and Joe Biden for good measure as a proxy for elected leaders.

Oh, there's a new virus? Let's cover it for ten minutes of every hour of every day for weeks on end, close schools with no cases, and generally freak out as if the world is ending and make sure people know it COULD HAPPEN TO YOU AT ANY SECOND, especially if you happen to have Mexicans in your neighborhood or even in your time zone. Oh, wait, that's all of us.

Where are all these people for the ongoing threats we have to face on a daily basis? Where's the call for clean water worldwide? Where's the call for increased flu vaccination coverage, which is almost always woefully abysmal? Where's the call to stop diarrhea? Where's the call to actually, shock, have a helmet law or make drunk driving illegal to reduce accidents (no, it really isn't illegal, first time, in some midwestern states. It's a citation). Hmmm, must be too busy spraying down the playground equipment with powerful cleansing agents, because that will somehow stop the kids from sneezing on each other when they come back.

Seriously. Hissy-fit extraordinaire.

Non-Compliance

2009-05-11T10:35:00.006-05:00

We have a guy right now that's got it all figured out. He has heart failure, and some sort of cardiomyopathy that keeps his heart from pumping well, and in order to treat this, we need to help him remove more fluid than he takes in, preferably rather quickly so he can re-equilabrate. Simple, right? So why does he roam the halls at night drinking tons of water from outside his room and stealing other people's food?

On the surface, it would seem mad, but deep down it displays the hallmarks not of madness but of mad genius. Each time someone tells him to be compliant, he says, oh, yes, I know, bless you, I'll do better. And then each night he goes and drinks more. A styrofoam cup filled with hospital ice here, someone's leftover milk carton there.

You see, if he's in the hospital, he has free TV, a comfortable bed with housekeeping, a nurse to help him take care of everything, and he gets to stay away from work because he has a decompensation of a serious medical problem. It's a five-star hotel with a craftmatic adjustable bed and an on-demand minibar of narcs.

The team this morning noted, accurately, that even if we discharge him he'll be back in the ED in a couple days 'feeling puffy' and wanting admission, so if we kick him out, he just becomes a problem a few days later for someone else.

Where's our out? Here's the mad genius part. He never openly defies anyone, and he never asks to leave. He says he wants to get better. This takes away the option of letting him leave against medical advice, one out for a troublesome patient. But he doesn't want to leave.

He's always pleasant to the attending and usually to the resident, and always agrees that his health is important, and that he has to save his urine so we can measure it and comply with the fluid restrictions ordered. Thus, we have no options we normally have with a defiant patient. We have no way to restrain or sedate him, or put a catheter in him to measure the urine output he refuses to save. We literally cannot force someone to get treatment unless it's an 'emergency', which, currently, it's not. Further insight can be gained through his one persistent request: a disability letter so he can get out of work. He knows the hospital gig is limited, even in the current climate. He has to have a long-term retirement plan. He's found the gravy train, and it's us. He's playing us. The team knows it.

Our system, for all it's good intention, facilitates this cycle. He has to be seen if he comes back to the ED even if we kick him out. We know if he leaves he'll just drink, do cocaine, and eat salty foods until he 'decompensates' again. I suggest a sitter to make sure he stays in his room, and I'm told that we don't have the staffing for it, because apparently it's better to just have him in the hospital for an endless amount of time. He's totally non-compliant but pleasant, thus we continue, night after night, him wandering the halls undoing everything done during the day. He's been here for almost 2 weeks, and another hospital before that, working on getting his disability in air-condintioned comfort, with top notch nursing staff and a team of dedicated doctors.

It's good to know that if we kicked him out and he got really sick again, there would be a wealth of potential legal advocates to represent his interests. It's great to know that our system supports this poor gentleman in such dire need. God bless America.

Twitter

2009-05-09T14:35:00.001-05:00

As you can see by my sidebar, I'm not too sure about what to do with Twitter. My phone is too old to work with it, and me sending updates would be mind-numbingly boring, i.e., going to work, coming home from work, going to work, eating, and so on. If anything actually interesting is going on, I'd better not be twittering, but standing somewhere trying not to pee my pants, remaining outwardly calm, and running the ACLS algorigthms best I know how. So for now, I'm going to try and set a record for longest time between Twitter posts. If I ever get a new phone and a life, we'll see. Sorry. New post below.

Too Many Acronyms

2009-05-09T11:49:00.004-05:00

AF w/RVR + AS.

One of our staff calls up from the ED to the floor (gag) where I have to work for three more long weeks with an 'interesting case'. A fib with RVR is common; my first week, we had, like, seven of them, old people with underachieving, scatter-brained atria fibrillating away and ventricles that responded too quickly, leading to usually mild badness like relative hypotension, shortness of breath, weakness, and so on. This one, though...

He came in as a trauma, having fallen off of his bike. EMS did CPR for 'a minute or two' with a stated GCS of 4 initially, and then 9. He was hypotensive with an irregularly irregular pulse, and a harsh, mechanical murmur over the right and left chest. He had old, old fistulas on his right arm for dialysis.

Now A fib doesn't seem so benign. The irregularity keeps the ventricles from being able to pump well; first, they're chaotic, and second, they lose the 'atrial kick' that is often needed to fill them. This gentleman's murmur sounded like aortic stenosis, adding one more problem; the same ventricle that lost it's sidekick atrium also has to push against a tiny, hardened valve.

He comes to the ICU with a rate of 150 or so, and a pressure of 70/48. He won't answer me. He won't open his eyes. He won't do anything. He also doesn't respond to pain. But he's breathing. Thank goodness my ED staff from the department had warned me that he's got mental retardation, too; and thank goodness his mom was there to tell me that he hates hospitals, and ignores everyone. If I hold his eyes open, he looks at me. Cautiously, I decide that he's wide awake, just faking it. Usually this doesn't bother me to assume, but when his pressure is now, hmm, 72/50, it makes me nervous.

What to do? He gets a fluid bolus. He gets pads put on. Now I'm stuck. If I give him too much fluid, that floppy heart pushing against the valve will get filled like a water balloon and lose it's strength from being stretched. The rhythm I can try to fix with a shock, but I don't know if he has a clot in there that could shoot up into his scon-box and infarct a bunch of brain. Even if I shock him, he has a fixed outflow obstruction from the valve--a class of problems that can cause shock because blood is blocked. Other similar lesions include massive PEs, and tension pneumothorax, although the obstructing mechanisms are vastly different. He has two IVs, so we just watch him. Watch him, and worry.

I start explaining to his mother how he'll probably need surgery, and he yells 'no!' from the bed, then 'no, no, no!' just to make sure. Ironically, he looks strikingly like a bald Dustin Hoffman, making the comparison to Rain Man complete. I feel much better with my retarded, hypotensive, irregularly irregular, stenotic, and syncopal patient who is now vociferously negative. Thank you for your lack of cooperation, sir. Keep it up.

Review his labs; the EKG is irregularly irregular but no ST elevations; the chest x-ray, unfortunately, has a hugely wide mediastinum, but 'no!' is also the answer to my inquiry about chest pain, so perhaps this can wait. His troponin is 0.5, which is elevated but not yet in the NSTEMI territory (that is, he doesn't have a heart attack, yet).

As the Fat Man says, the delivery of good medical care is to do as much nothing as possible. So we do nothing. We watch. We wait. And at 7 am, when the team arrives, and the post-call sigh of relief occurs, my retarded, stenotic, hypotensive, irregular, contrarian friend is in a regular rhythm (on his own), has a pressure of 94/62, and still shouts 'no!' whenever surgery is mentioned, now opening his eyes and sticking out his bottom lip to make the point. More to come. I want to see that valve when it gets hacked out (he NEEDS it).

Communists

2009-05-04T20:35:00.003-05:00

The old demented Lithuanian is upset because I wanted to get an EKG for his heart block and bradycardia. He gets upset. He gets ornery. He raises his voice.

'Ah, you,' he says, 'you're a communist, aren't you?'

'You forgot your Red Star.' 'Where are we?' I ask.

'Where are we? Hah! You know! Where are we!?' OK, so it wasn't the most delicate way to ask about orientation. I think I know where he is; thirty years ago, in some Gulag. It dawns on me that this may be very real for him, and the EKG pads, Lord knows what he thinks those are.

I go sit next to him. 'How can I make this easier for you?' I ask, since he's been roaming the halls, and since we can't give haldol to someone in heart block.

'I don't have to talk to you,' he says. 'You're nothing.' It makes me wonder about his story. But since I don't have my Red Star with me, I suppose I can't very well interrogate him.

Like Butter

2009-04-29T08:11:00.000-05:00

So far, I've had three really sick people this month--one sepsis, one status, and one angioedema. At the end of each, the staff has said it went smoothly. The last one even said, 'from my perspective, that was like butter'.

Which reinforces my sense that, if an Emergency Doc knows exactly what's wrong with you and knows exactly what to do, you're a sick, sick puppy.

All those other folks that confuse the heck out of me with wierd shooting pains in their foot and some shortness of breath and a headache and oh, yeah, I'm sleepy--nothing too terrible seems to happen to them.

"Then You'll Get One Case..."

2009-04-27T08:38:00.002-05:00

Staff and I were sitting at the tracking board when a new patient popped up, that I signed up for. The chief complaint was 'allergic reaction'.

"That should worry you," he said. "You'll get all these people with rashes and minor stuff and you might get cavalier, and then you'll get one that's true anaphylaxis, or true angioedema, and from then on that chief complaint will cause a lot of sphincter tone." We walk to the room.

He draws back the curtain and the lady's lips are HUGE, both of them. He turns and says to the nurse, benadryl, cimetidine, and solumedrol, please...no audible stridor but she is uncomfortable, worried.

0.4 mg of epinephrine, 1:1000, IM, is given. The language phone reveals nothing--no known allergies, no medications, no recent changes. Her hands are swollen, as well, and she has hives on her chest. No wheezing. Still no stridor. At the end of the phone call with the translator, through which she has said nothing as her cousin translates because she can't talk, she says, 'my throat feels tight'.

She is wheeled back to the trauma bay, where we do all our airways and lines, nurses hurrying, which is often a great predictor of how sick someone is. Surgery is there with three other traumas but the trauma chief is very intent on this lady. Another predictor of how sick someone is.

I am tempted to ask if this is a 'learner airway', but it's assumed that I will take it. I've seen her posterior pharynx, it's not swollen, she's young, it should be easy, but the impact of lips the thickness of two fingers across each is daunting. The trauma chief has the cric kit and is gowned.

Etomidate, sux, and I walk the mac blade down the center of the tongue, posterior pharynx, epiglottis, and a grade I view of the cords at which point I know she's safe because if I can't get it someone will, then the tube is passed gently, and she's truly safe. All over but the sedation, and the workup. No labs ever drawn. Under it all, she was an easy airway--which means we did it at the right time.

These are rare. I remember those prophetic words--you'll get cavalier, and then you'll have one...

Poor Predictors

2009-04-18T09:54:00.004-05:00

There are probably plenty of healthy people out there who don't take medications and don't see doctors. If, however, this is you, and you end up in the ED, and you're over the age when people normally start taking meds and seeing the doctor--say, forty--then these are bad signs.

Any other major medical problems? No? Any medications? No? Next question, always--do you see a doctor regularly or are you just in denial?

Alternative health nuts would say the western system is based on ilness not health blah blah dangerous medications blah spirit healing and so on, and for some, sure. If it works, great. But...

If you come in with a smoking history, painful lumps in your groin, axilla, and on your shoulder, and you have a cough, and you've lost twenty pounds since february, and you wake up soaking the sheets...sorry, dude. Giant, metastatic lung cancer for you. Now granted, lung cancer has no accepted screening. But maybe, just maybe, a family doc actively trying to get him to quit smoking might've made a difference. I sure didn't--outside of delivering the news as compassionately as I could.

He has a nine month old daughter. Damn, damn, damn. Add not smoking to helmets, please.

And to highlight why we get so paranoid--he had been to two EDs prior to this, and had never gotten a chest x-ray. Of course, he hadn't had four weeks of illness at that point, either. The last doc ALWAYS looks the smartest, but they have the easiest job. Catching it on the first go round? Now that's genius.

A Stye? Oh, wait, a hordeolum...That's an Emergency!

2009-04-12T19:56:00.003-05:00

If you come in at 01:30 by ambulance into our ED with two months of eye pain that you just couldn't take anymore with no redness/swelling/discharge/eyeballpain/changesinvision/headache/fever/chills/nausea/vomiting and bumps on both eyelids that you haven't tried anything for, well, OK...no, please, tell your son who just got home from work that he doesn't have to come get you because we can call you a cab right after we dispense your tube of erythromycin ointment. Sure, no problem.

Oh, no, don't worry, we won't bill you for the cab or the ambulance ride or the visit or the eval or the ointment or the tissues. No, no. Thanks, taxpayers. You got this one.

Six shifts, I lasted, before I got mad about misuse of the ED. Not too bad. And remember, folks...85% of patients believe they have a true emergency, even if only 5% of MDs think so.

Super Bowl

2009-04-11T07:36:00.004-05:00

There are a few people that lay claim to the airway in medicine. EM docs are a big one, and we usually spar with anesthesia. Paramedics handle tubes in the field in many systems, and then ICU docs are a third. Before my last airway, I had done anesthesia tubes, and ICU tubes, but the ED tube--that's a different ballgame. One of our lecturers calls it the 'super bowl' of airways.

When I heard that the first time, I thought it was a bit over the top, until I had a truly sick airway.

Sixty-something obese, small-jawed alcoholic with a bicarb of 3, Kussmall respirations, yet somehow still oriented, needs a tube. We positioned him ear to sternal notch as we were supposed to. First pass, and I saw cords but the mouth was tiny and I couldn't pass the tube. Terrible feeling. Someone holding pressure on the trachea was also less than ideal, moving it while I was looking--but still.

Bag with a nasal airway. Staff takes a look, 2nd pass with a bougie, tubes him blind and blood sprays out the tube all over (yay for gowns and masks!) and no color change. We place a King LT to bag him back up from the low nineties, which is not too bad, but he was dropping. "This is exciting", says my staff, who is a sharp, smart young doc we all love to work with.

Third staff comes in and looks, all smiles, like he's at the coffee shop chatting about donuts. Next pass, bougie again, downsize the blade to a 3 because the airway is anterior--always changing something, and this time bougie through cords visualized and the tube passes. More blood and no breath sounds on the left, so pull the tube back.

All good.

This was my first ED tube but not my first tube; a previous post talked about my anesthesia rotation where I was up to 13, then I had an ICU month with 6 and hit them all, so I was at 78% first pass success and about ten in a row on the trot, which is to say, nowhere near proficient, but not a total newbie. But this one was terrible. Sick, sick, sick. I see now why they call it the super bowl of airways. I see now why my attending said when I was setting up, 'got your bougie?', and 'got your King LT?' Up to 1% of ED airways are not tube-able. That's a lot. Many, many more are like this...badness. And it will go down as a procedure with no hypoxia, no hypotension, and no perceived adverse event.

I Say, Leave the Darn Thing Alone

2009-04-04T13:34:00.002-05:00

The teaching about nailbed injuries is that if you have a crush injury or any sort of injury involving the proximal matrix of the nail it has to be removed, the matrix, or nailbed, repaired, and the nail replaced to keep the matrix open for the new nail. The worry is subungual hematomas.

A pregnant lady came in who had cut her nail and fingertip with a breadknife. She was on lovenox because it was a high-risk pregnancy. She had a linear laceration through her nail but it was three quarters of the way towards the tip. My staff indicated we should explore the nail bed and pry the nail up to see if there was damage underneath it.

I did that; her finger was numb, so I pryed up the end of the nail and it started bleeding like crazy. Surprise, surprise. Before, there was no visible hematoma, no bleeding from the nail. But the nailbed is so friable in a normal person, let alone someone anticoagulated, that it's a mess to reveal. This lady did have a laceration; I had to trim off maybe 3-4 millimeters of her nail to get to it, and then we repaired it with absorbable sutures.

But, before we started messing with it, it was FINE. According to Tintanelli, nailbed repair is required for open fracture underneath, disruption of the proximal matrix, and subungual hematoma. Some recent lectures on EM podcasts have disputed the subungual hematoma thing; the others I buy. Otherwise, I say LEAVE THE NAILBED ALONE. It bleeds, I don't think it helps proximally. Thoughts?

Oh--to take the nail off, gently dissect along the bed from the front with drivers, grip and pull away from the matrix along the axis of the finger, then repair, then suture the nail back in place through the nail itself with simple or matress sutures.

Bardos

2009-03-27T01:28:00.003-05:00

Buddhism has this concept of transitions, or bardos, transitions between one state and the next. When a practitioner is prepared, they can be opportunities for enlightenment; for the unprepared, they can be terrifying. Buddhism captures the same fears and opportunities many religions do about death, just in a different framework. The picture is the 'big buddha' on Lantau island off of Hong Kong, which I saw in college--although my favorite was the tiny stone buddha in an alleyway in Kathmandu.

When I saw those buddhas and read about bardos I had never seen people die. From my perspective they really do withdraw; wikipedia above describes all these stages of the bardo of death--final breath, lucidity after the final breath, then the space until the next life. I feel as though my whole service right now is in that state--some stage on their way out. Three brain-dead patients between yesterday and today, two donating organs, preserved for now. I joked I was the angel of death. Now, I think not so much. That's too stereotyped, co-opted by the halloween crowd. Bardos are more my style. They're more real, too. Death can be terrifying, but maybe, if we prepare ourselves, it might be a transition to something else? I hope?

Old School

2009-03-22T01:50:00.002-05:00

When my hands ache from four central lines and an arterial line, and I laugh inappropriately at the MRSA swab on the brain dead 20-year old overdose admission because I'm too tired to care about hiding my derision...

When my boss tells me to go upstairs and talk to the overdose girl's family and it's just me and two parents who have lost a daughter and the nurse...

When it gets to be one in the morning and I haven't even started my documentation for the three afternoon transfers...

When these shifts come along, they make us doctors.

For The Love of God, Wear a HELMET

2009-03-19T14:29:00.007-05:00

Natasha Richardson's death is tragic and sad. No one is prepared for such an event, and the mysteries surrouding her case have prompted a rash of articles on traumatic brain injury on CNN and in the New York Times.

With the exception, finally, of this article on CNN, which actually advises people to wear helmets, gasp, everyone has been discussing imaging and neurosurgery. It was noted that the initial hospital didn't have an MRI scanner, as if that would've been used. It was noted that she could've had a carotid or vertebral artery dissection that would've required special imaging, and then 'months' in the NICU, as if the best imaging and the best critical care was what she was missing. Perhaps she needed a craniotomy, or better yet, a hemicraniectomy where half her skull was removed. Then, in a one-liner at the bottom of the article, we get, 'it might've helped to wear a helmet'. Maybe.

The autopsy report showed an epidural hematoma according to the AP. The ONLY WAY to get an epidural hematoma is by TRAUMA. Not some rare neck artery dissection, not some wierd syndrome, or Moya Moya, or an aneurysm.

I have some bad news for the public. If you get this injury, we can do virtually nothing to reverse the damage to your actual grey matter if it has already occured. Yes, you can get a CT scan and then a hole in your skull or your skull removed and we can reverse any coagulopathy and we can monitor you in a beautiful ICU and control your blood pressure to within strict parameters and monitor your blood sugar and correct your electrolytes and prevent clots and use new, fancy drugs, and protect your airway and eat for you and pee for you and poop for you and then give you the best in long, slow, painful rehabilitation...

Or you can WEAR A HELMET!!!

This post does not in any way disrespect the tragedy that befell Ms. Richardson. But, why, by all that is holy, in that aftermath, wouldn't you advise people to wear helmets strongly? Another ABC article starts with a debate over whether acute care would've made a difference, and on page 3 says, well, she should wear a helmet but 'there's little evidence' that a helmet would've helped. Well, shoot, let me go out and conduct a randomized controlled trial on helmet use. We'll put half our people in helmets, half not, and then ram them all into a snowbank and see what happens. Heaven forbid we advise safety precautions before we have 'good evidence'.

Everyone should wear helmets. They're warm, they're stylish, they have ports for headphones, and, contrary to some asinine contentions on CNN and other major media outlets, they don't restrict your peripheral vision or encourage reckless skiing. Please. Please. Wear one.

End of Life Care

2009-03-12T06:53:00.002-05:00

I morbidly joke, usually on my ICU months, that when my time has come, I'm taking my morphine and going on a long hike.

The way we treat end of life care in this country bespeaks a discomfort with death that is bad for the dying. My jokes aside, ICU patients are often there for unexpected catastrophes: muggings, subarachnoid hemorrhages like time bombs in people's skulls, car accidents. That these people are alive is a medical achievement of high order.

However, as Buckeye Surgeon notes, the return on our investment is somewhat less than miraculous. After these catastrophes, despite our ability to image the smallest blood vessels in the brain, and measure a gazillion-and-one physiologic parameters, we rarely are able to restore full or even almost full function. As a pediatrician I was shadowing once said to a patient, 'we can fix some things, but if you fall on your head or neck, we can't always fix it'.

For families, this presents a problem. Some don't care; they bring the social security benefits form in for their comatose relative to 'sign' with an X so they can collect a check. Others are in the ICU room for days and days, monitoring tiny changes in progress. My wife blinked. My mom moved her toe when the doctor yelled in her ear.

I think we need a frank discussion in our society that makes it OK to transition to comfort cares. Hospice docs have long held that allowing a failing body to expire on its own is more comfortable than prolonging life. Gradually failing lungs raise CO2 levels and essentially sedate the dying patient. Procedures to monitor ICU patients, on the other hand, are often painful--bladder catheters, arterial catheters, needles, ventilators.

Don't get me wrong--these are life-saving advances. But when it becomes clear that the prognosis is poor, it should be easier to say, 'enough'. We need to face death and accept it, not hide it behind sliding glass doors and curtains.

Damn it all

2009-03-11T03:26:00.003-05:00

Just had to intubate the Marlboro man, in room 3. Stubborn bastard wouldn't keep his sats up. Second time in a week.

This tube didn't feel like saving a life, it felt like ending it. He'll never come off the vent.

Scary

2009-03-10T23:51:00.002-05:00

Room 1 is an 84-year old stroke, clotted off her whole left carotid. We had to place a central line. Her BP is supposed to be like, 220.

Room 2 is a forty-something with c-spine surgery that lead to fulminant meningitis on the ventilator.

Room 3 is a COPD-er who is breathing 30-40 and dropping his saturations to the low nineties on BiPAP who we are giving one last shot at breathing because if we tube him he will never breathe without help again.

Room 4 is an intubated subarachnoid hemorrhage who moves her feet, sometimes, and blinks.

Room 5 got tPA today and was bleeding from her IV, her ET tube, her NG tube, and her eyeballs when she arrived. Her blood pressure is supposed to be low. Pray I don't mix room 1 and 5 up.

Room 7 is a poor guy who got mugged for three dollars after his car skidded into a ditch and the person who offered to help him beat him up. He only moves half his body.

Room 8 is bleeding from her tracheostomy, has renal failure, and can't move because she's been here so long. She's having trouble breathing.

I'm the only white coat here.

Only six more hours until the others return.

Only five hours, fifty-nine minutes until the others return.

And so on.

Callous

2009-02-28T16:52:00.008-06:00

The EMS call comes over the phone to us in the ED, ambulance in the field needs assistance. 5 month old, found down, not breathing for an unknown time, be advised CPR in progress. 1 round of epi through an intraosseous line, asystole is the presenting heart rhythm.

The three of us--intern, senior resident who answered the phone, and pediatric EM staff--calm down when we hear the story. This is not a rush, not a challenge, not a moment to shine. This is a moment to let death quietly come in. The chance of success bringing back a dead baby with no heart activity is near zero, and the chance of having a baby recognizable as a baby who smiles and coos is even smaller than that. But we are in a quiet, carpeted control room, not in a cramped ambulance performing CPR on a tiny infant with family looking on. It's easy for us to assess the situation at a distance. Easy for us to be 'objective'.

More details are relayed--impaired status at baseline, crack mom, baby now living with grandma who wants everything done. 2 rounds of epi, aystole in three leads. Intubation fails. Bagging, doing compressions. As I listen, the paramedics relay updates in brief chunks of speech with long pauses.

The senior resident asks for signs of lividity or prolonged downtime. A long pause. We're dealing with an african-american baby, hard to tell, comes the answer. One sign of lividity is pooling of blood by gravity, which is easier to see in a caucasian baby, but that's not why they answer that way.

Third round of epi. Asysto--wait, one beat. Another beat. Long pauses.

The pediatric staff puts her hand to the bridge of her nose, squeezing. I hate the third round of epi, she says. You can get a beat from a stone with enough epi, the senior resident says.

Ask them if there's a pulse. Cajole them. Push them to call off their efforts, it's the right thing to do. We're in the carpeted room. The situation is clear to us. We're not the ones compressing the tiny chest, feeling the ribs recoil, suctioning out the mouth, bagging, watching the limbs jump with the compressions. We're not the ones willing return of circulation. Not the ones chasing the fairy tale ending.

No pulse. Asystole. Stop.

I Will Never Diagnose Constipation

2009-02-27T17:54:00.005-06:00

I will never diagnose constipation. I will never diagnose gastroenteritis. You have abdominal pain. You have nausea and vomiting. I may have to diagnose viral syndrome, due to the overwhelming crush of well-appearing sniffly children, but I draw the line after that.

To say 'constipation' or 'gastroenteritis' is to say 'there is no chance that you have badness currently occurring'. That is NOT how I have learned to think. This was reinforced a few days ago.

A 14-yo boy w/hx of constipation written suggestively in the nursing notes comes in with RLQ pain for only 2 hours that came on suddenly. I went to see him. His story was correct in sequence for an appy--pain first, central migrating to RLQ, with nausea. One tiny loose stool that did not relieve the pain. His exam was correct; he was tender maximally over McBurney's point, the magic spot for the appy. There was one more detail; there was something behind his eyes that told me he was sick. This is not scientific. It isn't always there. When it is, I have found it very reliable.

I went to staff the patient, told the story, and the attending, who is quite good, said, if you told a surgeon this story, they would laugh at you. No way appendicitis starts and progresses in only 2 hours. But, you're right, he's hooked us with his exam.

We tried a KUB which showed some stool. We tried a fleets enema, and it initially seemed to work. I actually filled out the paperwork for constipation before I went back in to re-examine him on my own, because the nurse said it made him feel better. Just before I went in, my staff went in, and came out. His exam was unchanged. CT showed a 1 cm dilated appendix with peri-appendiceal fat stranding (inflammation) and I called surgery for an acute appy, put in a line, gave him some morphine.

Constipation is a sign and a symptom, not a diagnosis. Yes, there are LOLs who come in with impaction, but it is due to something--inactivity, opioids, or, scary terrible inflammation in the gut that is waiting to kill them.

Gastroenteritis and constipation are dangerous, dangerous diagnoses--moreso becuase they are so common, and usually we will get away with these diagnoses if we are confident, or maybe foolhardy, enough to use them. The author of RENT, 3 days before he died in his apartment of a ruptured aortic aneurysm, was diagnosed with gastroenteritis. Is that common? No, or people would be dying in droves. But COMMON isn't what I'm looking for. I'm looking for 'zebras', what we call rare diseases. For a medicine doc or a pediatrician, that's usually some obscure genetic disorder. I look for enormous zebras with big teeth waiting to kill you--the aortic dissection, the coronary artery aneurysm from KD, the inferior MI that shows up as weakness.

It felt good to be right about this kid. He got helped. But how many have I sent? How many will I send? Only paranoia can save me from the abyss.

Heroes

2009-02-27T17:45:00.003-06:00

At the program I train with, we are required to do EMS ride-alongs, and we have the option to do helicopter medicine. I am all in on the flying, but I learned the most real-world perspective from two or three ride-alongs. EMS folks live in a different world than anyone else. They take the fight to save the patient from themselves into the erstwhile lair of the patient themselves, and all their crack-addled neighbors.

Imagine intubating on the kitchen floor while your partner stomps the roaches to keep them from crawling into your field of view. Or starting an IV in a moving truck.

ER docs do good. But we work as a team. Next time EMS rolls in, whether they've done a banner job or not, I think we should keep in mind where they were and what they do on a daily basis. Coffee's always around for y'all, you do good work.

Why this post? Good new EMS blog here.

Respect the SS

2009-02-27T05:50:00.003-06:00

Sickle-cell anemia comes in a couple of forms, but in general SC disease is more trait-like, and SS disease is more severe, with pain crises, strokes at young ages, autoinfarction of the spleen, and so on. So, typically we're more careful with SS patients than with others.

A 13 year old girl with SS comes in with a sore throat for about six hours and feeling a bit tired. She has friends who have strep. Her exam isn't scary; she does have a fever, and a bit of a fast heart rate (116), but otherwise, her throat isn't bad, she's not in respiratory distress, she's appropriately alert. This is not like a normal crisis. She's having absolutely no chest pain or shortness of breath. Her neuro exam is normal. By protocol we sent off CBC, reticulocyte count, and blood cultures, but only by protocol.

Her anemia was so profound that her count of new blood cells being created in order to make up for her losses was almost higher than her blood count. Her hematocrit was 18 (normal is above 35) and her reticulocyte count was 17 (normal is, like 2). Oh, and her O2 saturation was 80.

We only got an oxygen saturation because she had sickle cell disease.

This kid scared me good. Respect the SS disease. She looked fine! No respiratory distress! Yes, she had a murmur--but a hematocrit of 18?!? And a pulse ox of 80%?!?

Oh, by the way, the strep was negative.

Is a Missing Lip an Emergency Condition?

2009-02-25T19:40:00.003-06:00

The medblogs are buzzing about University of Chicago's decision to treat a boy attacked by a pitbull without surgery.

Shadowfax has posted multiple times, most recently here; WhiteCoat has picked up on it here; and Scalpel has replied with a vigorous, bracingly conservative ripost here.

These three and others have framed the question as an EMTALA violation; is this a patient dump, or not? Is it illegal, or not? I'm more interested in how it framed the plight of modern EDs. I don't think, from what I've read, that there was an EMTALA violation. The boy was 'treated', and although his cosmetic outcome may well have been better, according to Dr. Grevious (no joke) once mom carted him across Chicago for immediate surgery, I think UCMC has a case.

More interestingly, the question is how can overwhelmed EDs possibly respond to crushing patient loads, the loss of subspecialty coverage, the mandate to see any and all regardless of pay, and all of this increasing as more and more EDs close and the federal government that forces us to see everyone subsidizes less and less? This on top of California's recent court decision that legally prevents EM groups from seeking additional compensation for services rendered from the patient. From our perspective, what exactly are we supposed to do? Chicago was trying to dispo out people who don't need emergency care. That's OK with me; tons of people abuse the ED although they are overall the minority. I think they picked a horrible time to do it with this kid--but, then, maybe they did it on purpose. No plastics available? Fine. No subspecialty care? Fine. America, this is what you get from us, they are (possibly) saying. You get the care you pay for. And when co-pays in the ED are zero, medicare reduces payments towards zero, states disallow collection of fees, we all end up with...well, zero happy stakeholders.

It's easy for me to say I care about cosmesis and wound outcomes and I'll fix a lot. I didn't see the kid, it might well have been beyond me, and besides, I work in a pediatric ED sometimes with triple attending coverage and three or four residents for twenty rooms, and we still have visit times up around four or five hours. I can see UCMC's side, easy--even if I also feel for that poor kid who couldn't get his lip sewn after he was a chew toy for a pit bull. If we can't take care of that, we're in trouble. Maybe UCMC is just pointing that out to society.

Undue Influence?

2009-02-25T11:34:00.003-06:00

Thought this was a great shot. On anesthesia at the VA, one of the retiring PAs brought in his pen mug from his office and these were my top choices for classics. Interesting how long big pharma has been plying MDs with free pens--not that we should be interested, it seems like we could afford our own pens. I still don't understand why MDs are interested in these. The trip to Hawaii I understand.

I've taken an oath here to avoid pharma influence. So far it's been easy. The county where I went to medical school outlawed drug reps, and my residency program has a policy of not taking any money or gifts from pharma. Just wait for the community, right?

I think the Versed pen is my favorite. I was tempted to take it, I admit.

Rant

2009-02-24T09:07:00.006-06:00

This is a rant. Fair warning.

OK. Reasons NOT to bring your kid into the spanking new high-quality 20 bed pediatric only ED with 6 resuscitation rooms and triple attending coverage.

Number 1. My kid's foot jerks in his sleep sometimes. I videotaped it. It happens, like, every five minutes. He keeps sleeping but he, oh my GOD, like rolls over. I brought him in here, not so you ED docs could look at him because you don't know what seizures are, but so he could get an MRI and a STAT Neurology consult (I didn't tell her that was an oxymoron). Yes he has a fever. Yes he has a cold. Yes he's 18 months. So, A, that's not a seizure, it's sleep myoclonus, and B, even if it were a seizure and it were generalized, even up to 3 or four minutes, it would be a febrile seizure and he wouldn't need an MR. Let's say you're right and he is having focal seizures, just for the sake of argument; if that were the case, he has a fever so I have to 1, CT him, which is radiation which you don't want, and 2,tap him which you obviously won't like if it bothers you that his itty bitty widdle foot twitches in his sleep. Honestly. I'm not trying to deprive you of your God-given right to a stat MR for sleep myoclonus. I'm trying to avoid giving your kid leukemia (now thought to be perhaps as high as 1 in 1000 for early CT exposure). Sigh.

Number 2. My otherwise well kid really didn't sleep well last night and he has a runny nose. Guess what? My kid didn't sleep last night either, because despite stripping at the door and sprinting to the bathroom to wash my hands, I still am covered with stinky-germ-goo from people like you and all my kids, my wife, and I, are sick. I still came to work. My kid is at home. He woke up ten times too. My wife, who feels sick, is at home taking care of three sick kids so I can have the joy of telling you it's a virus and you should, like, suction his nose and let him rest. Christ.

Number 3. On to annoying primary docs (many are good, I'm not yelling at them). My patient is totally fine, but she has a bump on the back of her leg that doesn't hurt at all. She fell a MONTH ago on her shin and couldn't walk for a day and now is better. She has NO feverchillseasybruisinglossofappetitenauseavomitingdiarrheacoughheadachemalaise. You, smart PMD, told this poor lady and her two kids to come DIRECTLY to the ED for EMERGENCY hematology consult and EMERGENCY orthopedic consult. Apparently small, painless, barely noticeable calf bumps are outside the scope of practice for this particular generalist pediatrician.

Number 4, a special shout out to the receptionist. Thank you, oh thank you, for telling the chronic abdominal pain patient who, to their credit, is not requesting drugs or mega work-up, to come DIRECTLY to the EMERGENCY DEPARTMENT (so named because it is for emergencies, not clinic visits) so that we EM docs can arrange for your doctor to see you in the ED because he's over at the hospital today. Please, please don't tell the patient they can be seen in clinic by one of the doc's colleagues. Please, please don't tell them to make an appointment, God forbid, tomorrow when the doc is back in clinic. No, no. Send them directly here. I'll see them right after the runny nose, the calf bump, and the jerking foot kid.

Airway Tip O' The Day

2009-02-19T20:01:00.004-06:00

A colleague on flight had a horrendous trip the other day to a blast site. One victim was talking, had normal vital signs, but was hoarse and covered in black soot from the neck up due to the blast.

An indication for a tube if ever there was one; it had only been sixty minutes or so from the time of the blast and already she was unable to pass a tube a full size smaller than needed, and saved his life with a rescue device instead (a King LT). Which leads to the airway tip o' the day.

A bougie is a long, flexible plastic thingee used to find the trachea by feel and by the bend at its end, over which you can then pass a tube. Usually I think of it as a means to improve an airway with a bad view. She had a great view; he was just too swollen.

The tip is to use a bougie even with a great view in the setting of airway edema; if you can't pass a tube over the bougie, leave it in place, go one size down, continuing until you pass something.

Of course, this being the great frozen north, it was seven degrees where she was trying to intubate without the windchill, so the bougie probably would've snapped. The O2 tubing had already frozen. Sweet. Can't wait to start flying.

GCS of Seven

2009-02-10T14:09:00.003-06:00

Most kids aren't that sick in the ED. Some are downright well. After working there for a while, you're sicker than most of them because they've given you GI junk and URI junk and maybe some rash junk, too.

When they ARE sick, good God, it's scary. We had an ambulance call, not a trauma call, come in the other day, of a 3 year old, head versus TV, and 'altered'.

To prepare in my head, though I would never be the one to do it as an Intern, I reviewed RSI doses--0.2 mg/kg etomidate, 2 mg/kg succinylcholine, estimate for a 3 year old about 15 Kg, so 3 mg and 30 mg.

He came in moaning, not in a C-collar, his right arm flexed, eyes closed. GCS? 1 for eyes, 3 for pediatric moaning, 3 for flexion posture--seven. Needed a tube.

We took him into the trauma bay, and held C-spine precautions while I realized I didn't know how to work the C-collars we have at children's because I've never done it. Having never done a peds trauma resuscitation, I was sort of useless--I could hold the bag on and do the ATLS algorithm in my head, but so what?

IV in 2 minutes, intubated in 5, CT scanner in 10. Pretty good. The kids are so small and everyone is so intense, pediatric traumas are frenetic. Everyone is close together. The sphincter tone in the room is incredible.

His CT scan showed a skull fracture and air all over, with 2 mm of midline shift. Hopefully he'll do better.

That's Peds EM this month--95% BS snot and wheezing or their leg looks funny but doesn't hurt, and 5% holy crap.

I'm Sorry, Man

2009-01-30T21:09:00.004-06:00

The picture here is from the first page of Beowulf--not the CGI version that was produced with Angelina Jolie but the oldest surviving piece of English literature. It's a testament to how important words are, and for how long we've struggled as people to get our meaning across.

Imagine, then, not being able to find your words. Imagine speaking in truncated sentences, stopping in the middle, fumbling. This is a finding called non-fluent aphasia. Sudden onset of speech difficulty is often listed as 'slurred speech' in stroke education, but that is actually dysarthria and comes from loss of control of the muscles of the mouth and tongue to some extent. Aphasia is a stroke that somehow involves the higher cortical functions of language, and patients literally cannot find the words they need.

A gentleman came in with this last week. It had first happened in Mexico, on vacation, and then resolved somewhat; it had returned four hours before arrival and it was his only presenting symptom. Histories like this make me sad. It was no doubt what he had. There was an upside--he had very few deficits. But imagine not being able to find words anymore.

Imagine being mute not from some physical ailment but from literally not being able to get to that word or phrase that is dying to come out. It happens to all of us (ironically, for me the other day when I was trying to remember the word 'dysarthria')--but this is different. He stopped in the middle of almost every sentence, and he made grammatical mistakes normally heard in an ESL class.

His main question? When can I go back to work? He worked in business, had meetings all day. Not soon, dude. Not soon.

Shaken or Stirred?

2009-01-15T08:53:00.003-06:00

When James Bond says how he wants his martinis, both choices are refined, the choice is a test of internal character, of dashing charm. In the ED, though, it never seems to work out that way...

Part 1: 'Stirred'

A middle eastern fellow comes in complaining of 'twitching' and a funny feeling in his chest, and, sitting on the gurney, shakes his extremities violently and spasmodically, going red in the face. He still responds, asking, 'what is it, what is it' that makes him do this between episodes, and even throws up a couple times. He gets pads, monitors, a non-rebreather, and serum and urine tox.

History reveals that he's had 3 full-size Red Bulls that morning alone (it's about 10:30). He also says 'someone blew smoke in his face' and he didn't know what it was, right before he started jerking all the time. Riiight. U Tox comes back with...hmmm...cannabinoids. I go to tell him and have to excuse his father and older brother; his mother, covered head to toe in a hijab (they're Jordanian) doesn't speak English and just looks at me with a smile while I tell her son he's a pothead (which he denies, must have been that guy blowing smoke at him) and it doesn't mix with Red Bull. His father wants to know if he's doing drugs. I said, "I can't tell you, but as a father, you should parent him as you would based on your own impressions". The dood (thanks Nurse K) denied any pot use. Right.

Part 2: 'Shaken'

I'm walking down the hallway minding my own business when an uptight lady standing next to a gurney says, 'Are you an attending?' then before I answer, says 'I'm doctor so-and-so from the Children's hospital ICU, and I need to talk to you right now.' The Children's hospital is adjoining ours, and corridors connect us. She then gives me sign out about this guy who started having 'a seizure' in the cafeteria of Children's. Later the nurses said she was totally rude and I wish that I had told her something about EMTALA violations (since he was on Children's premesis) but I didn't. The guy is still shaking all over but looking at us.

'Sir, can you hear me?' He can. 'Can you stop?' He can. Sweet! Cured.

I start examining him briefly and tell him we're going to get a few tests--and he refuses blood draw. My staff comes in, and says--'Hi, Howard. We're not going to play these games today, OK? You give us blood and let us evaluate you, or you leave now'.

Howard starts shaking again, this time on his feet--miraculous how he can do that--then pretends to fall. Refuses blood draws. He gets put in a wheelchair, and says, 'I'm going right back to the cafeteria to have a seizure!' 'Go ahead', the attending says. He starts shaking in his chair again. 'Knock it off, Howard', says the tech, and he does. To myself, I'm thinking, did that ICU doc even look at this guy? Probably not. Way too old.

So the ED shaken or stirred question, not so glamorous. But way, way more fun.

How Much Does She Drink?

2009-01-15T08:52:00.003-06:00

Sometimes, I'm a dodo and it's good that I'm supervised.

Sixty-ish African-American lady who came in seeing mean white bugs on the walls, and colored squares on her body that came and went, as well as a new tremor, shortness of breath, and minimal chest pain, BP 210/120, HR 130, SOB. She was diaphoretic, tremulous, anxious. She had been seen at another ED and diagnosed with anxiety.

I did a careful history and physical. She was seeing squares at the time. 'Are they friendly?' I asked. I can't help but mess with psychotic people. 'I'm not sure', she said. My differential included thyroid storm, encephalopathy 2/2 the hypertension. The attending asked, 'does she drink?'

Well, @&*%$#!, I didn't ask. Back to the room.

Ma'am, do you drink alcohol?

Oh, yes.

How much, would you say, on average?

Oh, four or five drinks a day.

When did you drink last?

Well, New Year's Eve; that was five days ago.

Peak for DTs. I'm an idiot. 2 mg ativan IV and dispo done. Sheesh. Thyroid storm.

FMOE: Toxicology Case Answers

2009-01-15T08:18:00.007-06:00

Case 1. 21 year old genius shows up in the ED. His girlfriend is concerned because he seems weak, acts like he's drunk, and is unsteady on his feet as well as slow in his responses. She is holding a plastic bag with what smells like model glue in it. Afebrile, RR 23, HR 80, BP 120/68.

1. What chemical element was this genius probably exposed to, given the odor?

Toluene is desired by high-seekers for its rapid CNS absorption and quick high; the toxicity here is obtundation, which usually clears quickly. Chronic users kill brain cells and become demented. Hydrocarbon ingestions typically damage the lungs more, but toluene goes straight for the CNS.

2. What secondary disturbance is likely causing his symptoms, especially the weakness?

Toluene can simulate a renal tubular acidosis and lead to hypokalemia and hypophosphatemia.

Case 2. A 25 year old sportsman was golfing when he felt a prick in his finger with some scant bleeding after searching for his golf ball in long grass. He finished the round, and now has increasing pain and swelling in his hand. He is starting to feel a bit weak. Temp 99.5, BP 85/50; right hand is tender, swollen, and bruised.

1. What happened? What are you worried about next?

This case best fits the effects of a snake bite; rattlesnakes are most common, and local tissue necrosis is common to most varieties. Some rattler varieties, specifically the Mojave rattler, will cause neurotoxicity, but only in the SW US, where you also find plague, hantavirus, and various other sundry complaints like coccidiodomycosis.

2. What is the treatment?

Crofab, so named because it affects crotalid venom, the main genus of snakes in the US.

Case 3. A 4 year old girl is brought to the ED by her worried grandmother (mothers always let grandma take over these days). She has not been her self; she is sleepy, and vomited once earlier. She found an empty bottle in the girl's room. She gives it to you; it smells like Icy Hot (NO USING GOOGLE!) There isn't a label. Temp 38.2, HR 130, RR 36. Exam reveals a drowsy, slightly diaphoretic child, with coarse rhonchi bilaterally.

Basic labs: sodium 142, chloride 104, potassium 3.4, bicarb 15, glucose 78, creatinine 0.8, BUN 12.

1. What did the kid drink?

Although med students all know that aspirin overdose gives a classic metabolic picture, I didn't know until I smelled oil of wintergreen that the oil is chock full of salicylates. In fact if you look it up on wikipedia, it's the main ingredient. So don't keep it in your medicine cabinet where your kids can get to it.

2. Med students, what is the disturbance seen in the labs and vitals? What can you do to treat her?

Med Students will be able to tell you better, but salicylates create a mixed metabolic acidosis and respiratory alkalosis through direct stimulation of central breathing centers beyond physiologic compensation. There's some computations to do...maybe later. As far as treatment, you can start patients on a bicarbonate drip to alkalinize the urine and trap the acid in an ionic form. ASA is also dialyzable.

Case 4. Three sixteen and seventeen year old males (automatic geniuses, I was never stupid when I was that age) arrive in the ED, combative, mumbling, and completely incoherent. Found by the fuzz drinking funky tea. A representative exam on genius 1, temp 102.5, HR 140, BP 140/70; agitated, small pupils, with red, warm, dry skin.

1. What is the toxidrome (for non-medical readers, mostly my parents, a recognizable set of symptoms that identify a specific toxin)?

This is a classic case of jimson weed ingestion. This plant, believe it or not, grows all over the US and, when boiled, is a mild hallucinogen and a strong anticholinergic. The toxidrome is dry, flushed skin, tachycardia, dry mucous membranes, fever, slurred speech, hallucinations, tiny pupils, urinary retention, consipation.

2. What is the antidote? When you would you use it? When would you NOT use it? What else can you give them?

Physostigmine is a direct cholinesterase inhibitor, thus increasing the level of acetylcholine and reversing the 'anti' choliergic effects. It does, however, prolong the QT interval and precipitate VT, I think, in cases of TCA overdose, a class which has anticholinergic effects. So, in a kid who got into the cabinet, it's not a good choice unless you like coding little kids. You can also use benzodiazepines and bicarb. I'll have to look up why bicarb works.

Case 5. 3 year old Max is brought in by his father reeking of garlic, vomiting garlic, and not acting like his usual self. Temp 37.4, HR 145 and regular, RR 42. Hyperactive bowel sounds, coarse rhonchi, constricted pupils.

1. What did Max ingest? Why is it not illegal?

The garlic odor is characteristic of carbamate insecticides which reversibly bind to cholinesterase and cause the opposite of jimson weed--or DUMBBELS, defacation, urination, miosis, bronchorrhea, bradycardia, CNS excitement, lacrimation, salivation. Atropine works (see below), and so does benadryl in large doses theoretically. The other toxins in this class are organophospate insecticides, which are irreversible but take time to convert, and Sarin gas, which is irreversible and converts almost right away. I think these should be illegal. They're poison.

What is the treatment? Hint: he should talk to the geniuses above and get some of their tea.

Electrolyte Emergencies

2009-01-13T11:21:00.008-06:00

The Cancun congress on EM had a great lecture available for download on electrolyte emergencies. I had wanted to look at these when I was on medicine, but they had a, well, different approach that took forever. This is much more EM specific.

Hyperkalemia is the most dangerous abnormality; the most common cause is 'not', that is, a lab draw error, hemolysis with the draw, and so on. An EKG guides how we treat the patient, so the first step in a work-up is re-draw and get an EKG.

Causes: Not; renal failure with acidosis; drugs over weeks or months (ACEI and ARBs, NSAIDs; and cell death (burns, tumor lysis). There are other causes, but these are the big ones.

EKG changes: tall T, loss of P, QRS widening, PR lengthening, sine wave (um, bad).

Treatment: calcium is only used in an emergency, defined by a widened QRS on EKG. Calcium for QRS (calcium chloride, it's faster), 2 amps of d50 and 10 U insulin, bicarb if acidotic but only if acidotic, albuterol nebs, fluid if hypovolemic.

hypokalemia=prolonged QT with U waves.

hypokalemia=hypomagnesemia, and K always goes with mag. We must replete both. If you don't give mag the K will stay intravascular and be excreted. The deficit is always worse than you think.

So, if you give K, give mag. Treat with EKG changes.

Hyponatremic emergencies manifest as altered mental status. Causes include runners drinking too much, women more than men, X use with dancing all night--water intoxication and hyponatremia. The big worry with hyponatremia is seizures and the AMS; the big worry with repletion is central pontine myelinolysis, or the so called 'locked-in syndrome', which is truly awful. Never correct a patient with symptomatic hyponatremia faster than 0.5 an hour or 10-12 a day. Seizures with Na below 120, like 100 or 110; intial 3% NaCl MAX 200 cc total, start with 100 cc bolus over 10 minutes. Must be previously healthy. So, the gorked out nursing home resident on diuretics and who knows what else who comes in 'just not themselves' with a sodium of 118 should not get 3% NaCl. The 19-year-old clubbing person with an empty water bottle seizing at 5 am with a sodium of 105 should, in two boluses, as above.

See? Much easier than the old hypovolemic-euvolemic-hypervolemic triad just for sodium and so on for each electrolyte...see this post.

My Pet Peeve

2008-12-30T22:09:00.001-06:00

OK, so I can understand when the giant billboard in the side of the road in BFE Nebraska that says 'Abortion Stops a Beating Heart' uses some crazy EKG tracing that looks like V Tach, ironically, but I really can't stand it when people just sort of draw a squiggly line and call it an EKG tracing. And this one is on a book I got in the mail from a resident group. Really? Is that a tracing or not? I suppose perhaps a bit of a widenend QRS with a prominent R wave that might be in one of the precordial leads, but still? No P? And what's that squiggle where the ST segment should be? Is that some transient flutter wave? Gah! Please! Couldn't any med student after the first year draw a decent lead II P-QRS-T? For the love of Pete.

FMOE: Toxicology Cases

2008-12-30T21:20:00.003-06:00

Here are some tox cases, one or two liners with vitals and questions. Pipe up if you think you know the answer. Answers will be posted within a week or so. When we did these stations, they provided a scent in a bottle. I'll try and describe them for you.

1. What chemical element was this genius probably exposed to, given the odor?

2. What secondary disturbance is likely causing his symptoms, especially the weakness?

1. What happened? What are you worried about next?

2. What is the treatment?

Basic labs: sodium 142, chloride 104, potassium 3.4, bicarb 15, glucose 78, creatinine 0.8, BUN 12.

1. What did the kid drink?

2. Med students, what is the disturbance seen in the labs and vitals? What can you do to treat her?

1. What is the toxidrome (for non-medical readers, mostly my parents, a recognizable set of symptoms that identify a specific toxin)?

2. What is the antidote? When you would you use it? When would you NOT use it? What else can you give them?

1. What did Max ingest? Why is it not illegal?

What is the treatment? Hint: he should talk to the geniuses above and get some of their tea.

More next week, with the answers! I love my job!

Learning a Craft, Revised

2008-12-26T17:22:00.007-06:00

So I suppose to prove I'm not a total grinch I should mention that my favorite Christmas moment is a 3-way tie between watching my one-year old play with his toys before moving on to the next one, building a snow fort and then sheltering from the wind with my middle daughter on Christmas Eve, and playing chess with my oldest daughter for the first time.

But the post is about learning the craft of intubation. Everyone talks about the art of medicine, but the craft is just as important--and, if you look at how we learn procedures, it sure mirrors an apprenticeship. We start off watching, then do it under close supervision for years.

The skill of intubation is by far the most important of all EM procedures. It saves lives and no one else does them like we do; anesthesia has far more repetition but under ideal circumstances (no eating cookies or you wait another six hours for your surgery). This post is about learning the craft with a record of my first attempts, for what it's worth.

I'm in the OR this month learning the craft. Here's a list of my first attempts. DL stands for direct laryngoscopy, which is the way it's done almost all the time. ASA scores range from 1 to 5, with 1 being healthy, 2 being stable minor problems, 3 major problems but controlled, 4 major with threat to life, and 5 not expected to live for 24 hours. By definition all airways in the ED should be 4 or 5. All attempts are first pass only; if I missed, someone else took over.

1st attempt DL: miss, ASA 2, no predicted airway difficulty. Didn't position patient properly.

2nd attempt DL: success, ASA 3, no predicted difficulty.

3rd attempt DL: success, ASA 3, no predicted difficuly. At this point I feel pretty good about myself.

4th attempt DL: miss, ASA 1, great view, couldn't pass tube, no predicted difficulty.

5th attempt DL: miss, grade 4 view, had to change blades, no predicted difficulty. Now not feeling so good.

6th attempt DL: success, ASA 2, no predicted difficulty.

7th attempt DL: miss, no predicted difficulty.

8th attempt DL: success, no predicted difficulty.

9th attempt DL: success, no predicted difficulty.

10th attempt DL: success, no predicted difficulty.

1st attempt glidescope: success, predicted difficult airway secondary to morbid obesity, poor jaw opening, short neck length.

11th attempt DL: success, no predicted difficulty.

12th attempt DL: success, no predicted difficulty.

Tally: 13 attempts, 1 difficult; 4 misses, 9 successes. Rate: 69.3%. An experienced operator in the ED should hit more than 98 or 99% of attempts, but I don't have numbers for first pass success; I think I'd be higher if I had to get the airway and there were no one to back me up. It's a difficult skill.

This is the new world of accountability; you really want to know what your doc knows and can do? There it is. Best I can say is I'm improving, right?

About attempt 8, my body started to know what to do, and I've been successful since. You can describe the procedure in words and it doesn't help--you have to do it. It DOES help to know what you're trying to do so you can, in retrospect, figure out what you did wrong. But in the true sense of a craft, the only way to truly learn it is to do it over and over again.

Before I intubated, there was a sequence to memorize: apart from preparation (which is arguably most important) the motor skill itself involves positioning the head in a 'sniffing' position, scissoring open the lower jaw, placing the laryngoscope just off the midline to the right and slowly advancing down the tongue, sweeping to the left. As I do this I verbalize what I see for the supervisor to know whether I'm lost or found; posterior pharynx with uvula, epiglottis, then, after the blade is placed above the epiglottis and it pulls on the hyoepiglottic ligament, I should see arytenoid cartilage, posterior, and anterior vocal cords. Once in the correct area the laryngoscope, hand, wrist, and elbow are raised 45 degrees towards the feet as a unit without torquing the scope to move the tongue and jaw out of the way of the view. If I'm lost, it comes out as I verbalize; perhaps I only see soft tissue, perhaps I can see epiglottis but not cords. If I can't see at least the posterior portion of the cords, my chance of successfully passing the tube drops to below 1 in 2.

Now that I've done it, even as I type this, I have visual memories for each step and it is much easier to remember. We must read about procedures before we do them but initially it is a memorized scaffold for knowledge; then, the first time the task is performed correctly, there is a sense of recognition as you realize what it feels like to raise the epiglottis. The above paragraph is long and unwieldy; the motion itself, for even a relative novice on an easy airway, is a fluid progression at best, so I'm trying with a thousand words to describe a motion that is best described by doing it.

Language is a poor substitute for the experience but it's a necessary starting point and the best we have to try and get someone ready for 'the show'.

The same is true of confirmation; to carefully watch the tube pass between the cords is the best way and you can look after placement. Before it was memorized; now, when I've passed the tube and that tube stands in the way of hypoxia and death for the patient, looking for fog in the tube, chest rise, CO2 return, listening for breath sounds on both sides--all are almost reflex already.

Now for the long years of solidifying and refining the skill; working with more and more difficult airways, worse situations, even cementing the initial knowledge.

How this is learned is an ethical question these days--is it OK to learn on patients? After these few weeks, I would ask, how can I not? If I were to be intubated, I would not want someone who had only learned on simulators. It's different. Simulators are great and they help make rote the preparation, the scaffold of knowledge I was speaking of above that is required for analysis and learning of the skill. But there's no substitute for actually doing it live.

L'il D

2008-11-28T21:52:00.005-06:00

L'il D is a 2 month old. For reasons unknown, his soul was born to pain. His parents' story is that they were having a party and had too much to drink. L'il D was left on an ottoman, fell, and somehow acquired massive subdurals of different ages.

The human brainstem takes care of life for months. Early eating, sucking, and regulation rely on so-called 'primitive' reflexes but it's probably more fair to think of an operating system out of the box that takes care of basic tasks. After 2 to 3 months, the cortex should take over.

For this guy, his cortex can't take over. It's gone. He's cortically blind and deaf. He probably will never eat correctly. He's sort of all done.

For both of my last call shifts I've had to deal with him spiking temps or heart rates or both, and fussing. Babies fuss, that's OK, but they don't normally spike to a BP that would be hypertensive for a fifty-year-old smoking vet. And they don't fuss like D.

Last night, I held him. Now I have three kids, so I have the part of my brain that knows how to hold babies and wants them to feel better. Because I held him, I think, I now cry more for L'il D than almost any of the other remarkable patients I've had. You should see him. His head is a bit lopsided from all the swelling. His pupils are too big and usually lazily unequal. He has a tiny little NG tube in one nostril. All of his limbs are stiff and tonic because they don't have a brain to guide them. Despite all of it, he is, somehow, consolable. He likes to be held. His rates go down. He fusses but not as hard. His cries are miniature convulsions, eyes closed, bundled.

I don't know what happened to him. It may be his parents got drunk and he was hurt by someone else, he fell somehow. It doesn't matter. There is no justice for him. He's already gone, and yet still so vulnerable for the tail of soul he left behind when he was devestated.

Here's to him, and to the foster parents taking care of him when he goes home. L'il D, we love you. I hope your soul is more at rest the next time around.

Photo Credit: Not L'il D, of course, due to HIPAA.

See Below

2008-11-26T20:00:00.001-06:00

There's been a lag, see below for two or three new posts that have been percolating for a while.

FMOE: Cope's Appendicitis

2008-11-26T18:24:00.007-06:00

Ah, the appy. Every second-year med student can diagnose the acute onset of periumbilical pain that then localizes to the right lower quadrant. My first appy was a teenage girl who presented with pain, loss of appetite, fever, and dysuria for about twelve hours. Exam showed right lower quadrant tenderness. Labs were negative except for sterile pyuria. Even an obvious case like this one, where I walked out of the room and felt pretty sure, had a wrinkle, but sterile pyuria is a known associate, perhaps because the appendix can irritate either the ureter or the bladder.

But it's not until I read Cope that I look back on the appendicitis I missed in every single abdominal pain patient I've ever seen. Cope, incedentally, is the surgical bible of the acute abdomen. My surgery attending told us all to sit down and read it in a night, an 'easy read'. Perhaps, but to really absorb it...it's the book that keeps on giving. The following are some pearls to flesh out what we were taught in medical school.

History.

The 'march' of symptoms should be carefully sought, and is as follows: pain, followed by anorexia, nausea, or vomiting, followed by tenderness that is localizable but could be, according to Cope--and I love this--'somewhere in the abdomen or pelvis', followed by fever, followed by leukocytosis.

Put that in the context of what we think of as appendicitis. RLQ abdominal pain with a white count and fever. But a white count is the last finding. This march should be acute. Diagnosis of appendicitis should happen within 24 to 48 hours of onset, to avoid perforation. Fever first, nausea before pain, fifteen years of abdominal pain--these can make appendicitis less likely. Also, sudden onset of severe localizable pain, especially if it occurs in a 65-year old hypotensive veteran...perhaps not an appy.

Physical Exam.

This is the part of the reading that terrified me. The appendix can go anywhere in the abdominal cavity. Sweet. Frickin' awesome. I love that kind of a problem. If any localizable tenderness is found in the setting of a history that shows the above march, appendicitis should be on the list.

Of course McBurney's point must be palpated, and is perhaps the earliest localizable site of tenderness. Cope mentions light percussion as a very sensitive sign of parietal peritoneal irritation, which is what causes the tenderness--the switch from pain carried by the visceral peritoneal nerves to that carried by the parietal nerves. This can also cause hyperesthesia over the right lower quadrant to light touch. Test the psoas by rolling the patient to the left and extending the hip. Rovsing's sign is pain in the right with deep pressure on the left.

Perforation.

If the appendix does perforate, it can do so in a dizzying variety of ways. It can be localized or generalized, depending on whether it happens to be walled off or not. The most interesting difference, though, comes with rupture of an 'iliac' appendix versus the rupture of a 'pelvic' appendix.

The iliac appendix sits in the abdomen nestled against the pelvic girdle, while the pelvic appendix has dropped down behind the pelvic brim.

The iliac appendix should show a degree of guarding in the area we would expect, though, as in the case I started with, it can also produce urinary symptoms due to the proximity to the ureters. Overall, iliac appendiceal rupture should be found with a rudimentary exam of McBurney's point, which is reassuring since most people do that at least even when completing the intern's morning rounding exam (run in, stick stethoscope in the middle of the chest, push on tum, run out).

The pelvic appendix, though. Ah, the pelvic appendix. Much more terrifying. 'One of the most easily overlooked and therefore one of the most dangerous conditions that may occur in the abdomen'. Now that's saying a lot. A lot of badness can happen in one's abdomen. It's like a black box of poop-filled terror.

A perforated pelvic appendix may actually improve symptoms; the pain of distention is relieved (usually felt epigastrically) and the pus soup that was inside spills down deep in the pelvis, into the Pouch of Douglas.

So? SO, there will be little or no rigidity in the abdomen because the giant pus ball is in the pelvis. In fact, appendicitis can be misdiagnosed as PID, thereby lending insult--literally, if you're wrong and it's a young woman who is not sexually active--to injury. Things to watch for include pain with micturition, tenesmus, or diarrhea from inflammation. The cool maneuver here would be to rotate the hip internally to check for hypogastric pain, which would be wierd, right? Now, what if this is missed? It can go three or four days before the pus ball extends into the abdomen, and it tends to go to, wait for it, not the right, but the left side due to anatomy. Awesome.

See how I get paranoid? Now anyone who has abdominal pain in any location, with or without a fever, with our without nausea and vomiting, who may have diarrhea, pain with urination, pain with defacation, that has or has not been constant, probably has either early, late, missed, or atypical appendicitis and a giant collection of bacteria waiting to make them toxic and die.

This is how I think.

The Thirty

2008-11-26T12:58:00.006-06:00

The thirty hour shift. The reason I didn't pick medicine other than, as stated before, endless metabolic work-ups, intact PTH draws, and anemia work-ups that make me want to stick a pen run dry from hand-written six page H&Ps in my eye. The reason we're losing so many primary care folks to specialization. The reason your primary won't come and see you in the hospital. Also, to listen to some of the old hands, one of the best learning experiences ever. What-everr, old dudes.

Hour 10. The normal work day is over. The rest of the team leaves. Have a good night, they say. See you tomorrow morning. They leave. The sunlight from the window kisses them hello as they escape into the world. The shadows in the hallway for the call taker lengthen, distort. The sounds of the hospital are eerily calm.

Hour 16.One or two admissions have occured by this time, perhaps accompanied by a hurried supper. It's past the kids' bedtime but still when a normal person might be awake. A bit of fatigue starts at this point but not too much. You can still assess a patient somewhat well. Skills are maintained at probably about 85% of normal. Cross-cover gets worse as the night nurses come on and re-evaluate sloppy day orders--this isn't a slam, just a point. Each nurse has their own style just as each doc does. We get better at writing PRN tylenol on peds, or 'beer at bedside' on trauma.

Hour 20. This was about when I got my favorite page of all time, from a senior I actually like. "Your night is about to blow up. Call me about the first of the admits." I'm now up way past my bedtime--I'm old, after all--and any hope of sleep is squashed, although it's best to assume it won't happen anyway. Total coffee--approaching 32 ounces for the day. Taking a history, now at about 2 or 3 am, I find myself pausing between questions, getting glassy-eyed. How many histories? I don't know. Three asthmatics. Two adrenal insufficiencies, one from CAH on cross-cover, one no one knows why. I close my eyes to listen to the heart sounds better and sway. One night, getting a kid at this time that was really sick with what we thought was Stevens-Johnson Syndrome, I was shocked awake by a six-month old pussing from his eyes and crying through secretions. The sick ones wake you up. Still, probably about 70% capacity.

Hour 24.One falls asleep finishing notes. The sun rises again. Somehow, that makes it better. I usually have time to spread out my admissions and finish up details around this time, as the morning team comes in. It takes me a minute to write a tylenol order without dropping a decimal point. Maybe 30% capacity. Differentials down to dead or not. What's wrong with them? I dunno. Can we figure it out tomorrow? Or at least later, when I'm gone?

Hour...um...the best is trying to be coherent on rounds. Usually I save a cup of coffee for this time, first to walk to the stall as a some sort of break, and second to be able to form sentences. It's just survival for the last hours.

Home, for recovery. This is the cruel part. It's the middle of the day. My kids are cute, my wife is gorgeous, the crock pot is aromatic, the sun is out and beaming across the kitchen. Despite that, despite all the reasons to stay up, all I can think of is bed. I sleep for 2 to 3 hours so hard that, per report, I'm sideways on the bed and I don't even notice getting moved.

The evening brings some post-nap attempt to stay awake in order to reset the clock. So I can go to bed, and get up early, and do it all again. The rounding. The anemai work-ups. And the pen in the eye. Suh-weeeet.

Photo Credit

FMOE: The Apathetic Adrenal

2008-11-26T12:20:00.003-06:00

4-yo female, african-american with big bushy pigtails and a vacant stare, presented to an outside hospital today after mom noticed that she was unresponsive. Initial exam notable for altered mental status, hypothermia to 35.2, decreased respirations, bradycardia. Her blood sugar was urecordable; she got glucagon IM by EMS, then more glucagon in the ED, then D25, then a dose of 20 mg hydrocortisone with subsequent return to baseline.

Mom is present with the child and notable for flat affect and a poor recollection of when she was seen last, by whom, or the name of any of the specialists that take care of her. She knows her PMD who is an NP at a free clinic.

Her past medical history is notable for a stroke at the age of 3 with persistent right lower extremity weakness and some speech delay, adrenal insufficiency of unknown etiology, and multiple seizure episodes accompanied by hypoglycemia.

The differential for shock that presents as above includes adrenal crisis but also sepsis and dehydration. The prodrome, if history is obtained, may often include a recent illness. This girl, g-tube dependent from her stroke, had vomited twice over the last two days and had generally been 'tired'. Check.

Physical exam findings may support CAH--abnormal genitalia, vitiglio, or the like, which I've never seen. She had no such findings.

The most interesting part of the case is, first, the appeal of a 'fix-it' intervention for a shocky patient--the hydrocortisone brought her back to baseline relatively quickly--and the oddity of such an apathetic parent and child. Their main question on rounds has been 'when can I go home?' A genogram reveals lots of hypoglycemia and stillbirths in first-degree relatives but mom didn't really care. I mean, I know you are a primary care giver for a sick kid and that can be tough but sheesh.

The other part of it is home management. Like asthma, if a kid with known AI starts to get sick, or get fatigued, parents should give them a stress dose of steroids--2 to 3 times their normal dose of supplemental meds. Mom HAD that at home. Although it's easy to use the retrospectoscope on her, it would've saved her kid a lot of possible harm to just treat early. And she's had a STROKE at the age of FOUR in the past! I would think that would catch her attention.

The other explanation is that she's very aware just tired of residents. That's possible.

Still, good to keep on the differential for a cold, slow, shocky kid, especially with a non-specific, malaise-and-angst-laden prodrome or some flu-like illness.

Photo Credit.

Numbers

2008-11-01T20:05:00.002-05:00

I saw 155 patients this month, in 21 shifts.

Shifts averaged about 11 hours, so 11 x 21 = 231 hours, give or take, in the department.

That's 0.67 patients per hour.

Slow things are beautiful, too. Turtles, for example. Gorgeous shells. No one complains about how slow the turtles are. They still manage to do everything they need to, right?

Hemoptysizizer

2008-10-18T22:08:00.004-05:00

Actually had a sick patient the other day. 40-ish female coughing blood every minute or so, about a teaspoon each time, breathing in the 40s, sats in the 70s. The picture of respiratory distress: retracting, scalene muscles pulling the whole rib cage up, abdomen tensing with each expiration, retracting--the whole body working to move air.

They always teach to go through the ABCs; the patient could say her name, and had an obvious B problem. No tracheal deviation, breath sounds equal but 'wet'. Good periperhal pulses and her pressure was 147/86.

History? Gosh darn if she didn't have a history of asthma, COPD as well, tuberculosis (the MAI kind, not the typical TB), pseudomonal pneumonia, and aspergillosis, a fungal infection that can grow in old TB cavities. Well, at least it wasn't unprovoked hemoptysis.

She did well, actually. A non-rebreather got her sats up, duonebs times 2 and then a continuous neb decreased her work of breathing. Her CXR showed new opacity where an old cavitary lesion in the upper lobe had been. Who knows. Those cavities can erode into the bronchial arteries without warning; massive bleeding can occur and we transfuse, specialists embolize.

Her follow up is revealing. Her lung history started with an exposure to tricholoroethylene, which, oddly enough, doesn't mention anything about lung injury, but this poor lady needed a VATS procedure--laparoscopic resection of part of her lung. Wonder what it did to her kidneys. Come to think of it, that was the main reason we couldn't get a CT scan. She underwent embolization because she wasn't a surgical candidate, and recovered well.

Cases of the Priviledged

2008-10-17T14:24:00.003-05:00

She parks her wheelchair in the hallway, glowering at the nurses. We're all watching the board; new 'red' (needs to be seen') in 13, and the chief complaint is a post-op leg infection, started bothering her today, normal vital signs. We try and see everyone within ten or fifteen minutes of coming back, and sick ones of course right away. By the time I get in there, Mrs. not sick and her husband are irate. Why did they have to come to the ED? Can I call Mr. Bones and have him come in and see her personally to avoid the wait? No, you have to see the resident. Well, what's taking them so long?

The ortho resident that night was awesome. We gave her sandwiches out of the patient fridge, she was doing so much. I had first-attempted a reduction of a complicated ankle fracture dislocation that literally had no solid structure connecting the leg to the foot, and that was one of four of her cases currently in the department.

I'm sorry for your inconvenience, ma'am, but we have to see people here based on how sick they are and I know of at least four other serious fractures right now.

Still didn't work; they backed off but passively kept trying to see how they could jump the line.

Last night, a guy came in with decreased sensation to bowel movements, buttock numbness, thigh numbness, and new erectile dysfunction. He got an MRI for possible early cauda equina syndrome. His question? How long will this take? I can always come back. I was like, dood, you're getting a stat MRI. Do you know how hard that is to do?

Also affluent, he had been told to get an MRI by his golfing buddy who was, you guessed it, a doctor.

I don't disagree with the call, I advocated it. He did have anesthesia and decreased rectal tone (although, ahem, there were 'other' reasons for that in retrospect and on full social history), and the new ED was alarming. But his status led him to expect certain things. Quick emergent service by the best, and full answers, and the best scans.

Over at M.D.O.D., God love them, they discuss the entitlement of the freeloaders. I'm as scared of the entitlement of the upper classes.

Some days you eat the bear...

2008-10-16T23:32:00.002-05:00

Some days, the bear eats you. I only saw eight patients in ten hours, couldn't get a fem stick on one guy to save my life, was slow to order meds that had to be ordered from the pharmacy, blah, blah, blah.

About my only victory was guessing Radon for environmental contaminant that is a degredation product of uranium during toxicology jeopardy during grand rounds. I got the next one wrong, though. We lost.

Sigh.

You got an MRI for a stress fracture?

2008-10-15T19:29:00.002-05:00

There's a new article in the NYTimes that talks about the error rate in MRIs. The article is written fairly well, but totally misses the mark. Why?

The story says that MRIs have variable quality based on who reads them--sure--and that if your MRI is read by someone inexperienced it might miss something. OK. Then it quotes someone from U Mass who says 'we don't miss things because we have a 3 tesla MRI and radiologists who only read musculoskeltal MRIs', essentially. I'm guessing on the 3 tesla thing but I'm sure U Mass has at least one, probably more.

So? So, the author had a new stress fracture. OMG! Get an MRI! Have it read by a specialist at an academic medical center! Or, take a plain film to ensure adequate alignment, and put your foot in a boot with close primary care follow-up. Good God. To be fair, she finally gets around to the idea that we rely on scans too much and should just talk to the patient, but it's buried at the end. No wonder we spend trillions.

Meanwhile people living on Indian reservations in New Mexico don't even have an ambulance within 30 minutes, let alone an Emergency Room.

The scariest part? It was the number 1 e-mailed article of the day. I guess I'll brace for MRI requests.

WTF?

2008-10-11T11:05:00.002-05:00

No joke, the chief complaints of the previous night.

I have a bruise. Of course, by ambulance.

I have a cold. For 3 whole days. Nyquil just isn't cutting it, but the Tylenol I had in triage cured me.

My doctor saw that I have a hemoglobin of 9.3 (we transfuse in the ICU below 8) and thinks I need an emergent transfusion. I have NO SYMPTOMS. AT ALL. This one was great. I called the doc and they actually suggested I do a rectal exam for an occult GI bleed on a 24 year old woman who was having heavy menstrual periods, even though she had been in her doc's office ONE DAY AGO.

And the really sad one; I'm having weakness in both legs, bowel and bladder incontinence, I can't feel my groin...and it started a week ago. True neurologic emergency. Too late.

Sigh.

True

2008-10-09T09:33:00.002-05:00

'By the way,' says the attending, 'she doesn't have guarding. So in your note, no guarding, no rebound. Got it?'

'But she did have guarding', I said.

'What's guarding?'

'Involuntary contraction of the abdominal muscles with palpation', I said without hesitating. I had felt it, although it was brief.

'She didn't have guarding. If you distracted her, she didn't do it. It's a peritoneal sign. Maybe you're just a such a terrible brute,' he said, in fun.

'True guarding is rare', said the other resident, a year ahead of me.

This is why we have residencies. This is why Osler said that seeing patients without reading was going to sea without a rudder, and reading without seeing patients was like never going to sea at all. The 'true' signs we read about are dramatic and real. Guarding is a peritoneal sign; that is, some abdominal catastrophe is occurring. This lady either had reflux or gallstones. Neither one is a catastrophe. Annoying, painful. Not a full-blown catastrophe. I got schooled, but I can take it easily from that attending. He was taking night call on the floors at Beth Israel when I was still eating crayons and pureed carrots.

Is That What I Think It Is?

2008-10-06T17:39:00.002-05:00

Guy came in the other night, older, with MS, very anxious and cachectic but claimed he had been injured since Vietnam, was just fine, let me go home. The story was that he had aspirated a bit of pork chop, coughed it up, and was being evaluated for aspiration.

In acute aspiration pneumonitis a patient should present with respiratory distress if they've really aspirated something caustic like gastric contents; this guy was breathing normally, had emphysematous lungs, but otherwise was OK. So I staffed him, and the doc was all, fine, but where is the pork chop now? Are you sure it's out? Where could it be? Hmmm. Lungs, or, esophagus. So get a chest x-ray, and do a bedside swallow study. If he swallows and has a normal CXR, he can go.

So I go back in the room with a cup of water. "I can drink fine", he says. Takes a drink, 'swallows', then spits it back in the cup. Three times we try. I get new water each time because he doesn't want to drink his own spit. The third time he's all, 'I'm fine', but I can hear the gurgling because the water won't go down. Note to self: ALWAYS check swallowing on an aspiration risk.

But it gets better. We pull up the x-ray and I start going through my system-A for airway and lungfields, B for bones, C for cardiac, D for diaphragm and OH LOOK THERE'S A RAZOR BLADE FLOATING IN SPACE. Actually probably stuck in the GE junction, but still. Not supposed to be there. We get his clothes off and gown him and re-shoot. Still there. Call the scope monkeys (hey, my father-in-law is a GI doc, it's a term of affection).

Meanwhile, the dood's sister arrives and says no he doesn't live at home he lives at the mental health complex (and I slapped my forehead internally for not reading the documents that were on the chart) and WE CAN'T FIND A RAZOR BLADE we had there. I didn't even ask why they had a razor blade. The poor guy ended up getting a consult from surg and going upstairs. He looked so sad. And so earnest when he was saying 'I'm fine'. Poor dood.

FMOE: How To Not To Screw Up Headache Patients

2008-10-04T16:53:00.008-05:00

Headaches are a very common complaint in the ED--3 to 5%--and only about 1% of those have a serious underlying cause such as meningitis, subarachnoid or intracranial hemorrhage, mass effect, carbon monoxide poisoning, or hypertensive encephalopathy, according to Rosen's, the bible of EM I'm working my way through.

This morning I had a oh crap in retrospect moment wondering if I missed something, so I'm going to use a case to illustrate how to go after this problem.

48-yo african-american female with hypertension, comes in with a BP of 202/104, a dull HA on the top of her head with no focal neurologic deficit for 2 days. How do I decide if this is a scary headache or not? My gut says not. So?

Red Flags:
1: sudden onset.
2. "The worst headache of my life."
3. altered mental status.
4. true meningismus. See this post for what 'true' means.
5. unexplained abnormal vital signs.
6. focal neurological deficits.
7. worsening under observation.
8. new onset of headache with exertion.
9. history of HIV.

She didn't have any of these, although the hypertension was a bit worrisome. Still, it's in her history so not 'unexplained'. So I have a textbook backing me up. That helps me avoid badness. Now, are there signs that she's all clear?

All Clear Signals:
1. previous identical headaches.
2. normal alertness and cognition for exam and for history.
3. normal neck exam. Our Brit attending does this well. Patient actively ranges chin to chest and looks up, looks side to side. Then, he supports the neck and asks the patient to go all floppy. He then gently but quickly turns the head side to side, for so-called 'jolt accentuation'.
4. normal vital signs.
5. normal or nonfocal neurologic exam.
6. improvement under observation.

The trick is that the patient gets flagged if they have any one of the red flags, and cleared only if they have all of the all clear signs, and she doesn't have normal vitals. So we observed this patient, and worked her up for hypertensive emergency--hypertension with evidence of end-organ damage by altered mental status, EKG changes, or elevated creatinine. Three hours later, after diltiazem, which she had not been taking for four days, and a gram of tylenol (which by the way is a wonder drug), she was better. Bye bye. The only thing bugging me was an EKG finding--she had mildly inverted T-waves in V4, V5, and V6 in the setting of left ventricular hypertrophy--enlargement of the heart due to the increased pressure it has to push against in the setting of hypertension. Why would that bug me? Because a web search of EKG findings in sub-arachnoid hemorrhage, the kind of headache I was worried about in her, showed inverted T-waves in V4, V5, and V6! Oh no, right?

Not really. This is like that 'true' meningismus or 'true' guarding. Inverted T-waves occur after major neurological events that should manifest themselves on exam, and are more impressive--see this example at a great ECG wiki site. Plus, these changes can even be seen during migraine headaches, a common and NOT life threatening presentation in the ED. Last but not least, the wiki site mentions deep T iversion in the precordial leads, i.e., V1 and V2, which correspond to the septum of the heart. This lady's EKG finding was in the leads corresponding to the anteriolateral portion.

So does LVH cause inverted T's? Sure does. See this link, first example. Phew. Fare well, nice headache lady. PLEASE take your diltiazem as instructed by your primary doc. Next time I might see inverted T's in you with altered mental status and severe, thunderclap headache, seeing as how you have hypertension too...sometimes I feel like I'm a pappa bird watching tiny little baby birds jump out of the nest when I discharge. I'll have to get over that, I suppose. Get jaded for my own protection. We'll see how it goes.

Polypharmacy

2008-09-23T13:09:00.008-05:00

I had to pronounce a patient the other night at 3 am. I could feel my own pulse in her arm which freaked me out until I felt my own carotid pulse at the same time. She was very, very dead. I didn't know the patient. There was no explanation for her death; apparently, she was getting more feisty, not less over the past few days. She was a nursing home resident on twenty or more medications.

Scheduled diazepam, as needed lorazepam, geodon (an atypical anti-psychotic), depakote sprinkles, effexor, propranolol, cipro, reglan.

The picture is of ecstacy pills and they would probably give you a less durable high than that cocktail. I would be OUT like a trashbag full of poopy diapers on that cocktail. What did she die of? Hmmmm.

One of our teaching attendings summed it up thus: 'you've had a nice life, grandma, now please go and die'.

So what did she die of? Polypharmacy. Epocrates multi-check lists QT-prolongation and arrhythmias with both cipro and effexor combined with geodon; depakote impairs excretion of lorazepam leading to higher levels; and all of them have additive effects that lead to CNS depression. Pick one.

The crazy thing is that three days later I discharged a woman back to the nursing home on a similar list. What's wrong with grandma? She's agitated, we're giving her more medications. Why is she agitated? Never mind hypoxia, it's probably her baseline dementia. She's talking to people that aren't there, she must be nuts and sundowning. Besides, she's DNR/DNI. More drugs, more drugs, more drugs.

When I talked to my sweet LOL (little old lady) and asked her who else was in the room, she listed off about ten names; Oh yes, there's Mr. McSo-and-So, and Mrs. Whozit, and Mr. Horton, and Mrs. Who, and the baby...

But who's to say that's not normal? It's psychosis, certainly, even though she knew who she was, where she was, and what year it was (thus, she was 'oriented'), but does it need treatment with multiple sedating medications?

You Know You're on Internal Medicine When...

2008-09-23T13:01:00.001-05:00

...the attending hospitalist keeps everyone up for a FULL HOUR discussing the differential diagnosis of hyponatremia at 3:30 AM. 30 hour shifts are the whole reason I stayed away from IM, at least one of them. I just had to laugh, in order to avoid gouging my own eyes out with my pen which was running out of ink anyway since we have to handwrite our dictations.

My other favorite:

Me: the patient in ED bed 9 with the acute asthma exacerbation looks like she'll avoid intubation thanks to continuous nebs and 5 over 10 biPAP plus mag and epi times three from EMS, but she's still tachypnic in the high thirties and speaking in 1-2 word sentences, just FYI.

Admitting doc: Did you get a complete review of systems and family history?

Me: Well, I kinda was worried about treating her and she's, again, only speaking in 1-2 word sentences.

Admitting: just go back and do a complete 12-point review when you're done. Make sure to dictate the ROS by system.

These med folks do some good work and I sure like to admit to them, but jeez...

No Sissies!

2008-09-17T16:10:00.002-05:00

I found an urban mountain bike path the other day. I must admit, that despite my admiration for phat bikes like the Trek Fuel, I'm but a resident, and I have to tackle mtb trails on my, ahem, 'fitness hybrid' with l'il skinny knobby tires. The picture here shows what a real trail does to a bike like that. I got faster as soon as I lost that thing. It was still stuck to the crank, though, like clinging to life, after it hit the tree. Gotta love a real workout, not one in the A/C with headphones and a little TV on the front of the elliptical.

FMOE, OB: Shoulder Dystocia

2008-08-30T12:33:00.007-05:00

This is the second in a series called FMOE, which stands for For My Own Edification. Read on, but the post may be boring to anyone past an Intern, as I'm doing these to further my learning.

Coming off of OB, the next few will likely have something to do with pregnant women, who are total rock stars in my book, none more than my wife who has done things I would never have been able to do even if I had been born a woman. Too much of a wimp.

Shoulder dystocia (greek, dys for difficult plus tokos for birth) describes the failure of the shoulder to pass below the pubic symphysis during a spontaneous vaginal delivery with the head already delivered. In practical terms this is terrifying. The largest baby I delivered was 9 pounds, 12 ounces, and I had to pull like, a lot more than I expected to get her out despite excellent work by mom. It's scary when the baby feels stuck and you are hauling on its head. Normal deliveries require much more traction than you expect as a neophyte.

A truly stuck baby can have a severe shoulder injury or can asphyxiate and die. Badness, terrible badness. It's also hard to predict. If I had a 400 pound diabetic primigravid at post-dates in my ER delivering, I could say it's a good bet, but other than that, it can surprise anyone. What, oh what, to do?

Initial maneuvers. Of course, delivering the anterior shoulder requires a great deal of downward traction normally, so as a newbie, I have to remember to have may cardinal movements right; down for the anterior shoulder, up to the ceiling for the posterior. Simple suprapubic pressure from an assistant can help. The Gaskin Maneuver is mentioned on Wikipedia and via Google searches; the laboring mother is repositioned on all fours in order to create more space. I have not seen or heard of this maneuver in my EM textbooks or on the OB floors, but it makes great sense and should work--in a mother with no epidural! A Google search turns up anecdotal evidence, but this is no reason to disbelieve; midwives have been at their job a long time and much of OB is not evidence-based--try doing studies on pregnant women. Difficult.

Other initial options include the McRoberts maneuver, which is achieved by flexing and abducting both hips while laboring on the back. In practice, all deliveries were done in this position on the OB floor. If still stuck, the Woods Corkscrew maneuver is an option; reach in past the head with two fingers behind the stuck shoulder and rotate the baby about 180 degrees. Fingers go behind the shoulder to collapse the torso rather than open it up.

Truly horrible options then ensue. Keep in mind that by this time everyone is likely freaking out and the baby is probably quite literally dying in front of you. You can attempt to push the baby back into mom in order to go for a c-section--the so-called Zavanelli maneuver, which according to the namee was perfectly safe. This one is particularly funny since if you had such immediate access to any OB doc, you wouldn't be trying to push a large baby back into the uterus in the first place.

According to whonamedit.com, this maneuver was invented in the 70's by somebody named Gunn, and Zavanelli heard about it and told it to some other guy while he was volunteer teaching. So, if you want to use it, go ahead. Me, I'll put it in the same category as other things that should've stayed in the 70's, like the Pinto and Fleetwood Mac.

You can also deliver the posterior shoulder, by reaching up and grabbing the hand. Or, you can deliberately fracture the clavicle. Terrible sounding, but better than death. Actually, one of my deliveries had a fractured clavicle, and they heal well if there are no complications at the time.

The last option, a symphysiotomy, should scare everyone, not least because one of the tools needed is a finger guard. The pubic symphysis is the anterior joint of the pelvis and is just above the urethra and vagina. Apparently, in the late 1500's difficult deliveries were relieved with this method--using a scalpel to sever the ligament joining the two sides of the pelvis together anteriorally, allowing it to open so the baby can be delivered. I would have a hard time with this.

May we all have happy, quick but not too quick, ED deliveries, with no lacerations or post-partum hemorrhage.

Reichman and Simon, Emergency Medicine Procedures, McGraw-Hill

Shoot. Can't Vote for McCain.

2008-08-28T15:08:00.004-05:00

And I sort of liked McCain, too. He seems honest, and straight-talking. But his health policy advisor apparently had this to say about the uninsured:

"anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)
"So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.

I can't really even respond to this idea. Those who are mandated to be seen in the ED are not funded, for one, and basically saying that being seen in the ED is akin to insurance is a touch daft. Sigh. If only I had enough energy for a true rant, but alas, I'm too tired already. Too many patients to see. Where could they be coming from? I wonder. See the post on the Movin' Meat blog here.

The MD-patient Relationship

2008-08-26T13:14:00.003-05:00

Intersting post on the doctor-patient relationship on M.D.O.D. here.

Seriously, patients aren't customers! Drives me nuts.

FMOE: Obstetrical Bleeding, >20 Weeks

2008-08-26T13:05:00.009-05:00

This entry is as much for me as for you, since I have to learn and retain information, and somehow putting it on a webpage helps.

So, a 18-yo (just so it's not too depressing, and she's 14) comes to the ED for sharp, constant pain just above the waist of her hipster jeans on the left that doubles her over and came on like a tornado on a midwestern summer night (sorry, can't give a canned case). No nausea, vomiting, or fever. She doesn't remember when her last period was, and she says she's not sexually active.

VS: 98.6, 54, 18, 80/50, 98% RA.

A brief physical exam reveals a rigid abdomen with guarding and rebound tenderness low in the left lower quadrant as awesome life-saving ER nurses place two large-bore IVs and run in liters of normal saline before she gets whisked off to the OR.

Not so common, probably too Grey's Anatomy-like, although if we were on TV then one of the residents would've just splashed betadine on her tummy and opened her up in the parking lot with the help of the nurse who's carrying the baby of her fiancee. Ectopic pregnancy can present as frank shock but is more likely to present unruptured, which means the differential for vaginal bleeding in pregnant women at less than 20 weeks gestation is simple: ectopic pregnancy or some permutation of a spontaneous abortion (threatened, inevitable, possibly missed). Less likely but possible choices include a molar pregnancy or a GU problem masquerading (UTI, pyelo, stone).

Overall, ectopic pregnancies are the second-leading cause of maternal demise in the US and complicate 2% of all pregnancies. For some reason the data is old but in 1986 that meant over 75,000 hospitalizations.

Medicine likes threes, and amenorrhea, abdominal pain, and vaginal bleeding is the ectopic triad but it's not very reliable--the patient may not be amenorrheic--at least not for the most typical six to twelve weeks--and may not be bleeding, at least not visibly. In the case above, the ruptured ectopic causes a bradycardic, hypovolemic picture due to the vagal stimulation caused by blood in the peritoneum. Not sure if it's real but I'm lookin' out for it.

Obviously, in the case above as in every female of child-bearing years plus five in either direction as well as drag queens a urine beta-hcg is the initial test usually done in the parking lot. A quantitative serum beta-hcg can be used but as Tintanelli's is very clear to point out (it's in bold for the idjits like me who skim) there is overlap and no level can reliably exclude an ectopic in favor of an IUP.

Ultrasound! Grand rounds last week, endovaginal U/S can find a gestational sack in the uterus at 5 weeks. Five weeks! That's barely long enough to start wondering and run to Walgreens, even if all our patients leveled with us and told us when they had last been sexually active or had a period.

Ectopic pregnancies can implant in the tubes most often, or interstitially in the uterine wall, or elsewhere; however, if there IS an EP, then the endometrial stripe should be thickened and without a gestational sac. That, along with the story, is likely enough to at least get an OB consult.

Treatment. In the above case, go directly to OR, do not pass GO, I would suppose. But most cases aren't like that. Options are laparoscopy which I would advise or IM methotrexate, which has a success rate quoted at 91%, but can cause a lot of pain as it aborts the EP chemically. The last 'detail' is to type and screen mom, and give her RhoGAM if she is Rh negative to prevent from alloimmunization.

Can't help but wonder how EPs are viewed by people who champion the rights of the unborn. If life begins at conception and this is an abortion would treatment of EPs be legal in the setting of a Roe v. Wade reversal that did not have an exception for the life or health of the mother? Hopefully they'll be smart enough to specify IUP abortions. I actually had a colleague in med school who was very strong in her views and said she would not offer methotrexate as it somehow was more abortion-y than laparascopy in this case.

Sorry for the boring post. I'm on medicine now, I don't have any good stories anyway. Besides, it's not all about you. Sheesh.

Umm, Not Our Fault, So Much

2008-08-22T15:39:00.002-05:00

A colleague is on trauma which is OK except there is one resident who always rips on the ED. Recently he was taking us to task for waiting to call them for an appy in a 3rd trimester pregnant lady--they were called at 4 am for a patient that arrived the previous evening late for a 'classic' presentation.

Ah, the medical record. I must now enumerate with the alphabet and count with my fingers.

A, the patient did'nt have 'classic' symptoms initially. She had vague abdominal pain which, hmm, could be some other things besides an appy in the 3rd trimester, like, oh I don't know, labor or preeclampsia.

B, the OB attending had been consulted and agreed the patient had an appy within an hour or two of the patient showing up which was pretty good, thanks. Then, she spent hours--literally four hours--arguing up and down with radiology about getting a CT, which, frankly, she needed in a 3rd trimester pregnant lady who was about to get filleted for an appy or rupture. Totally the ED's fault, clearly. As if we got a 'classic' case and then waited around for the five or six hours until it was totally inconvenient to call.

C,while we're on the subject, why the heck is a radiologist arguing with an OB of all people about getting a scan on a pregnant lady? Wouldn't the OB know more about pregnant ladies? Perhaps? Sheesh.

Sometimes we absolutely get things wrong, I admit, me more than most since, as an Intern, it takes me six hours to disposition a hangnail or toothache. However, we actually do know what we're doing and we actually do make good decisions. Often. Sigh.

Total Cluster Averted

2008-08-22T15:27:00.004-05:00

Sorry for the long breaks between posts, life is hectic. I'm on OB which was been a great rotation overall. The other day, though, there was an interesting situation that could've turned out badly.

We were called to the post-partum floor for a woman who was having an (air quotes)allergic reaction(air quotes) after having some percocet. She was complaining of trouble breathing and tongue swelling. Her tongue did seem swollen and she did sound a bit stridorous but I could hear her talking from the hallway and she was moving air well. Blood pressures were high, not low as they would be in anaphylactic shock. Her O2 saturation was 100% the whole time. She was given 50 mg of Benadryl.

It got interesting when the OB and the anesthesia resident disagreed. OB didn't think the patient was anaphylactic--neither did I, frankly--but was more concerned about the airway. Anesthesia was worried about an epidural hematoma from the spinal anesthesia. Management differed. Anesthesia wanted an MRI, STAT (ha, I thought at first) which I managed to actually get within 15 minutes, yay me.

So the OB attending asked me to go with the patient to the scanner. Now, I didn't think the patient was in shock, but the MRI was fifteen minutes away through a maze of corridors. So here I was, wheeling this patient through the hallway with nothing but a bag-valve mask and a portable O2 monitor. So?

Well, in retrospect, that could've been a total disaster (especially since we went right past the cafeteria, which has giant glass windows). What's the treatment for anaphylaxis? Epi and airway. Did I have an airway? No. If she were to swell up? Bag-valve mask wouldn't work. I'd be doing impossible CPR on a pregnant lady in front of the whole cafeteria. IF WE THOUGHT SHE HAD AN AIRWAY ISSUE, SHE NEVER SHOULD'VE GONE TO THE SCANNER.

Nothing happened. She could'nt get the scan becuase she was claustrophobic and there wasn't a nurse and the anesthesia attending didn't want the scan anyway, so we just wheeled her back. But the important lesson was to make a decision about the plan and stick to it. The half-assed business of getting a scan but sending an Intern with a bag-valve mask with her--well, that could've been horrific. In the ED with all resources around me, frank shock would be a challenge for me right now. In the hallway?

No Hay Ganadores

2008-08-03T17:33:00.003-05:00

An article in the NY Times today discussed the story of a TBI victim who was repatriated to his Latin American home for care after a stay that cost $1.5 million. Arguments from most people said that the hospital was dumping the patient, since their agreement to accept Medicare and Medicaid obligated them to care for this person.

The other unspoken mandate behind this story is EMTALA, which requires hospitals that have Emergency Departments to treat and stabilize patients with emergency conditions--in this case, two broken femurs, internal injuries, and a head injury. This mandate is poorly funded, as well.

Medicare payed $80,000 of the $1.5 million.

That's why I said no winners. What was the hospital supposed to do? No long-term care facility will take this patient that requires intensive rehab; their hospital, like ours, costs roughly 2K per night for an inpatient. Is that a good use of resources? The hospital shouldn't 'dump', but if emergency care is mandated then all of the downstream consequences must be mandated as well, including follow-up care, and, wait for it...reimbursed.

We have a serious discussion on our hands in this election. Do we change how we care for everyone regardless of insurance coverage in the ED, and continue to have these situations? Or do we stop seeing people without coverage? I vote for funding the current mandate because I love the fact that I see people regardless of who they are based on need. I don't love getting reimbursed at a 5% rate.

Interns Can't Move Meat

2008-07-27T08:02:00.003-05:00

'Moving Meat' is a phrase for quick discharges in the ED. It's a prized skill and one that I, the Intern, do not have. Dear God did I have trouble with dispo last night. We're starting off with an orientation month in our program, and I guess I took 'starting slowly' literally to mean 'wait six to eight hours to dispo your patients'. Horrible.

So what? Well, a recent article in slate pointed out that people who are boarded (kept in a bed) in the ED are 4% more likely to die. There is a mortality effect to keeping patients around when they don't need to be there. Not to mention the experience of angst over discharge ruined my whole shift and probably those of my attendings and the nurses.

Why couldn't I send the quadriplegic with a UTI and no fever home? Root cause? I felt sorry for her. What, compassion bad in an MD? Well, feeling sorry for someone isn't compassion, it's pity. And pity kills. Compassion would've been to see her as a capable human being, and if she said she was OK to go home alone and handle her own follow-up and get her own drugs (as she hadn't last time) I should've probably let her. It sure was simpler watching dispo as a student then doing it. Sigh.

MedFlight Tribute Page

2008-05-12T08:37:00.002-05:00

UW Health has posted a tribute page where anyone can post remembrances, here. It also contains a link to the page itself to read what others have submitted. Thanks to commentators here and to those from around the country who have sent their condolences.

Dear God, No. No, no, no!

2008-05-11T12:59:00.009-05:00

At the risk of losing anonymity, I have to post the passing of one of those docs I most admire, one of the best I've worked with or seen, who will truly be missed. There was a crash last night, just to the west of La Crosse, Wisconsin; one of UW Madison's EC-135 copters went down with few details known yet. As of what I've heard now, there were three crew members lost.

It's covered in this article in the Wisconsin State Journal. I didn't know the other two crew members, who will be sorely missed as everyone I've ever interacted with has been pure class at Med Flight. Dr. Bean was a leading light to me, a mentor, an example of what I want to be. He was a doctor and a teacher I will sorely miss.

The best way I can think to memorialize Dr. Bean is to tell stories about him. He helped me see that EM was the field for me. I never saw him treat anyone badly, patient or colleague. When he talked to a patient, he sat down as if he had all the time in the world for them, but damn if he didn't know how to run trauma, and how to run a department. As with so many EM docs, he was also the local EMS director. At conferences with other services, his was the honest question, the insightful comment, always in the spirit of increasing cooperation, coordinating.

My fourth year rotation on EM was awesome. Dr. Bean would regularly 'hold court' after shifts, even those that ended in the middle of the night. My best memory of teaching in the ED was at 3 am after a 4-1 shift. Patients were all 'purple' (admitted) or 'green' (discharged). The Intern, who was awesome too, decided to run a session on airways because he had just been re-taught. He took me into one of the trauma bays and we picked tubes, discussed doses. The other intern came in and joined in. Dr. Bean came last, and the first thing he did was listen to the interns teaching me. Then, he ran cases for at least half an hour. What induction drug, what dose, what are you worried about. 'If you're worried,' he said, 'take out a pen and write your doses on the gurney while they're bringing the patient in. Better to take the time to be sure than get the dose wrong. Believe me, we all get rattled sometimes.' He said that, but I never saw him be rattled. More than the teaching points, which I loved, I noticed that this attending was there, two and half hours after his shift, teaching. And I also noticed that he carried himself as an example. Confident, not arrogant.

He also took the time to do the little things right. Wound exploration was a great example. It's not enough to clean the wound; explore, look for tendon injury. He would take time to discuss the proper tension on a nailbed repair, for example, along with suture choice. His attention to detail was impressive, and it pointed out that even though we're generalists, that shouldn't prevent us from taking pride in our work.

My father-in-law said, 'not all those that die, deserve to.' Amen to that. So the next time you're drinking, raise one for these folks. The next time you have a moment, make it a moment of silence. I sure will. I'll be lucky if I'm half the doc Dr. Bean was, but I'm damn sure going to try.

I'll try and keep up announcements, if any on this topic.

Entitlement

2008-05-05T13:33:00.008-05:00

150 people in an auditorium, I asked the prof a question, and then pointed out when he responded that his explanation didn't match the book or some such 2nd-year med student snarkiness. I got, in response, a long, loud, diatribe about how we were the most entitled bunch of whining babies he had ever seen come through the school. I achieved enough notoriety that some smart fellow yelled out to tell the doctor, quick, as I went up to read my match day assignment.

I was hurt at the time; I had worked hard to get there--working full-time and completing pre-reqs as well while trying to see my newborn daughter every once and a while--and he was telling me I was entitled?

But now that I've seen more patients, and seen more of the system, I see that I was--admittedly a bit spoiled--but also just the last straw for an ID doc who was sick of people whining about wanting antibiotics, vaccines causing autism, people not doing their jobs and patients wanting more, better, faster, and cheaper.

Over at M.D.O.D., the posters have little, if any, patience left for the people we treat as a community, who think health care is a right, and that anything less than perfect, enjoyable care is not good enough. This goes in line with the 'quality' movement sweeping through health care based loosely on the six-sigma line of thinking.

I don't know yet how much this affects the field. I will note, however, that the ED I'm about to begin training at has all private rooms, with flat screens and cable TV in each one. I'll also note that they hand out consumer satisfaction surveys to patients. In theory, this may sound great. In practice, it worries me.

Patients are not customers. Putting cable TV in the rooms certainly improves the wait, I'm sure, but aren't we sending the wrong message? When we spent trillions on health care with only so-so outcomes, are flat screen TVs really where we should put our money?

I happen to favor national health care a la the system seen in the UK, the NHS. However, I also acknowledge that this is often advocated in a very indignant way, as if it is an injustice that we don't yet have it. I used to feel the same way. How can the US, which is so advanced and spends so much money, not yet have universal care? Being a schizoid combination of realism and idealism, I like the idea of universal health care, but having watched our government screw up a lot of other things--public education, welfare, land management, and so on--I'm pretty sure we'd screw up health care, too. Instead of decreasing ~~idiotic subjective meaningless griping~~ surveys, it would probably increase them, and JCAHO would metastasize, becoming totally inoperable.

We are becoming a nation entitled. They say it's bad parenting now to tell your children that there are starving kids in Africa that would gladly eat those carrot sticks, but isn't it totally true?

We should tell patients that, too. You just waltzed into this ED at 2 am because you need a refill on your Percocet and got seen within an hour while you sat in your private room and watched the Top Chef marathon on the Food Channel. You personally will not be charged for this visit because we won't be able to find you, and because I am totally exhausted you might even get some narcs out of me. Then, you'll complain how I wasn't compassionate enough on the survey the nurse is required to hand you, knowing full well that the parent of the pediatric resuscitation that went perfectly down the hall won't have the time or energy to fill out a survey because they have more important things to worry about. There are patients in Africa who would gladly take this level of health care.

It's nice going into residency being pre-jaded. At least I won't feel the pain of my ideals burning away.

Iron Man = Hypomania

2008-05-03T23:12:00.003-05:00

Had a rare day 'off' today after getting the house ready to sell, and I went to see Iron Man. That guy is totally hypomanic.

First, he's the millionaire playboy who engages in exaggerated risk-taking, especially sexual, and has an exaggerated sense of self (mania, anyone?) After finding his purpose in life, he's able to work for days, perhaps weeks on end, without anything but coffee (lots, makes me feel better) and a nice trinket from his assistant (who happens to be Gweneth Paltrow) to keep him going, in which time he makes a cool suit of flying armor.

The movie was fun and not too bad. Interestingly, though, he's totally symptomatic. Watching the movie, I wondered about the continuum between disease and benefit. In his case, hypomania was totally profitable and benefited those around him--there was no way that anyone normal would've been able to do what he did, and there was a significant amount of risk-taking involved in innovation. The NY Times, if a search is completed on hypomania, notes that there may be an abnormally high amount of hypomania in the U.S. population since we tend to be risk-takers as the descendants of immigrants. So, this is an example of a disease state--acute mania, treated with an IM injection of haldol and lorazepam--that is on a continuum with arguably one of the most important personality traits known, since the hypomanic folks were the ones who likely talked us onto the boat, invented the lightbulb, the atomic bomb, and PopTarts.

Being nerdy ruins everything. I can't even enjoy a good blockbuster without wondering about diseases. The lady who sold me vases this afternoon has Parkinson's, treated, I'm sure after watching her fill out the receipt, which she insisted on doing by hand. It sucks being a med student.

Why I Love My Gal

2008-05-03T22:55:00.003-05:00

A Jeep pulls up next to us, the driver's hand on the wheel with a cigarette between digits 2 and 3.

"How can people smoke? What are they thinking? Why not just wear a T-shirt that says, 'I'm a total f@$*ing idiot?"

That's why I love her. Well...one of the many reasons, actually.

Waxing Poetic

2008-04-28T12:45:00.002-05:00

Well, it's finally arrived. My big transition, the great leap, the fall, tipping into the abyss, the milestone, the ceremony, crossing the rubicon: graduation. Three weeks from now, I'll be more than just tyro (novice), I'll be tyro, MD.

In honor of this occasion, I'd like to try and figure out what the color attributed to each degree means. We all have separate colors, see. My hood should be black with 5 inches of forest green velvet trim. Sweet. I'm wearing it to the gym, I don't care if it's typically only worn to commencement or the encaenia (doubly sweet! Who goes to those things?)

forest green: MD. Obviously, this means we're a loving, caring profession that is a welcoming and nurturing as Gaia, the earth goddess. We continue to grow in our knowledge as we seek to propagate the growth of all. Alternatively, one could comment that the medical profession is like a terrifying forest at night full of hungry wolves waiting to stick tubes down your throat or lines in your subclavian vein. Ask me again after internship.

purple: Law. I wasn't surprised to discover that purple comes from the Latin purpura, as in 'manifestation of a terrible systemic disease that will kill you shortly'. If I see purpura on a patient, I should think of overwhelming sepsis or meningitis. I will leave the fair reader to draw their own conclusions about the similarities and differences between lawyers and dread systemic diseases. Alternatively, I may be a tad unfair. It may just be that purple, associated with royalty from antiquity, represents how lawyers are only available to the wealthy. Oh, sorry--I was supposed to be positive with that one. I suppose everyone has their growing edges.

silver: oratory, speech (i.e., politics).I didn't make this up, from the silver article on wikipedia:

Silver is the most popular color for automobiles because police surveys have shown that because silver is a bright color, silver automobiles are involved in crashes less often than cars of any other color.

Now, if that doesn't describe a politician, I don't know what does.

So I guess our colors do help define us. Good thing we wear those hoods.

The Female of The Species

2008-04-21T08:22:00.005-05:00

In reference to this post:

Rudyard Kipling's Verse By Rudyard Kipling:
"...the Himalayan peasant meets the he bear in his pride
He shouts to scare the monster who will often turn aside
But the she bear thus accosted rends the peasant tooth and nail
For the female of the species is more deadly than the male"

A comment on the momma bear post brought Kipling up as a previous observation that there is something to mother's instinct that defies logic or expectations. Although Kipling's work does wax a bit dated, it bears out the same observation.

For the Dearly Departed

2008-04-20T21:45:00.000-05:00

Worth reading: a post at a great blog about the price some first-responders pay to help out.

White Cloud?

2008-04-20T21:29:00.001-05:00

Crap, it didn't work. I guess fate doesn't listen after all. I'm going to bed now, that'll do it.

White Cloud

2008-04-20T20:01:00.022-05:00

I'm hoping that in writing this I will tempt the fates enough to bring me an admission. I'm a white cloud right now, and I'm stuck on call blogging rather than working. Now, this might seem like a bit of a crazy request; but when my wife is home in bed taking care of three kids, I kind of want my time away to be, oh, I don't know, somehow productive.

The first time I realized that I was actually superstitious was an overnight trauma call. We had seen a penetrating chest wound that didn't survive, a car accident that included a whole family that did, and a five-hundered pound Amyand's hernia, which occurs when a Meckel's diverticulum incarcerates into a hernia sack and then ruptures, causing necrosis and serious badness if not removed. Even the chief, who was amazingly resiliant, was exhausted, breaking between stitches to roll his shoulders back and look at the ceiling. As we finished up the case, I said, 'well, at least it's quiet now, right?'

He looked at me as only med students can be looked at, for we have yet to learn the ways of doctoring that matter. Never, ever, ever, tempt the fates, for they will deliver. We had three more traumas not thirty minutes later, just in time to push morning rounds back by hours. I couldn't feel my feet. And while that night was the night that helped me pick my speciality, I was tired and I wanted to go home. I had made myself into a typhoon cloud.

In contrast, here on my medicine rotation, I'm a white cloud on a breezy blue-sky day, footloose and fancy-free. Life I love you...all is groooovy.

The concept of white and black clouds, well, it's not official until I've actually been the responsible one on call. We'll see yet what my true colors are. Perhaps fate, just like attendings, doesn't really care too much what medical students say. Here's to being productive.

Transition, Part 2

2008-04-20T11:31:00.002-05:00

Seriously, am I that full of myself? Oh well. I guess I really do have what it takes to be an MD.

Transition

2008-04-20T10:59:00.004-05:00

"He saw: this water ran and ran, incessantly it ran, and was nevertheless always there, was always at all times the same and yet new in every moment..." --Siddhartha, Hermann HesseTransition. The day is fast approaching when there will be new initials after my name, when responsibilty for patients is real. And yet that day will be no different than any other day in the particulars. It holds some special significance, but more in the awareness of the destination rather than the steps taken. Haven't I been studying to become a doctor for four years? And will I somehow become a doctor when I start as an intern? Yes, and no. The path is what matters, but the transition points are the source of anxiety.

I have a trick for this. I put myself on the other side in my head, and imagine myself at the end of intern year, a bit more jaded but also more confident, efficient, and still open to learning. Developing my own ideas. The white coat is longer. It is no longer difficult to write a script from lack of practice. Calling in a consult is only occasionally terrifying rather than often or always.

That is the nature of our transitions. We are always who we are and yet always renewing; tomorrow I will be who I am now but I will also be new and what I did today will be gone, yet it will have decided who I am.

The picture above is of the Rio Grande. The river south is flat and placid, often shallow to the point of disappearing, but higher, in the narrow canyons by Taos, it is a deep and raging thing. It is the same river in both places.

Me, MD.

Bookends

2008-04-10T19:33:00.011-05:00

The final week of my 3rd year, I scrubbed in on a hysterectomy for a 500 pound woman. I commented before the case that I had also seen her every morning for my entire internal medicine rotation, prompting my attending to comment to the patient, in the OR, that 'you're almost like a bookend' for my first year of clinical training.

Morbidly obese patients seem to make fantastic bookends. This final month of my clinical 4th year, that same woman is in the ICU with sepsis. Again. And, we had another patient admitted who was over 500 pounds, because he had fallen three times in the last week, and couldn't get up each time. His chief complaint was knee pain. Hmmmm.

As this article in the NY Times illustrates, fire departments and EMS providers around the country are buying 'bariatric' stretchers and 'bariatric' ambulances. Picture here courtesy Stryker on the NY Times website, so I may have to take it down.

Our attending commented that he doesn't think that this type of obesity is common, and that the obesity epidemic is more comprised of the just-barely-obese; I beg to differ. I've seen more morbidly obese patients than I have pancreatitis patients, or hepatitis patients, or AIDS patients (even in Milwaukee), or colon cancer patients.

When I say morbidly obese, it does get, well, morbid. As in, 'suggesting the horror of death and decay', here. It's hard to describe the reaction to someone of this size when they are sick. In my experiences, these patients could not perform any routine hygeine, and were sometimes incontinent not due to any urinary defect but due to an inability to reach the bathroom. One woman died of urosepsis from an indwelling catheter she used for this problem. She died because she couldn't get up and go to the bathroom. Their skin folds were so deep and extensive that they would become infected with yeast, which would allow the entry of bacteria, which often led to sepsis via panniculitis, or infection of the panus, the word for overlying fat rolls. They often had chronic ulcers, which again led to sepsis. And when they were intubated they couldn't breathe because the fat was too heavy for the lungs to expand properly.

The woman above, when she started to recover, didn't want to leave. She was the first patient where I was taught the trick of pushing down on someone's abdomen while listening, thereby hiding the fact that you were testing for pain. I pushed down the stethoscope; nothing. I pushed with my hands; Oh God, terrible pain, 10/10, doc, I can't stand it. I assume that the hospital nursing care was superior to the in-home care she had to receive.

Mountains of illness, geological formations of pestilence, people encased in double or triple the amount of pure protoplasm they should have, decay, stench. I don't describe this to be judgemental; obviously, these patients had reached an apex of obesity beyond that of the occasional trip to McDonald's and a failure to eat enough leafy greens. Everything was more difficult. Rolling them in the OR took five people instead of three. They didn't fit on the gurneys. The instruments weren't long enough. Their tissue died more easily because fat is poorly vascularized. And so on.

An epidemic, indeed. Bookends of illness against which I often feel helpless at the sheer enormity of it all.

The Laying On of Hands

2008-04-03T18:20:00.005-05:00

Today at conference we ended up going around the table and swapping stories like geezers comparing fish. Here, in no particular order, are some of my favorites.

Elderly, gaunt gentleman with a giant sternal scar from a CABG comes in with nausea, vomiting, and a mass pushing up like a grapefruit just below the lower edge of his sternum. I walked in and started to ask questions, nonchalantly examining his abdomen at the same time. He was going along while I noticed a large hernia, probably at the base of his old CABG incision, and gently applied steady pressure for twenty or thirty seconds. Pop! In it went, and his lump was gone. "Cured", I said. He stayed for a couple hours for observation and went home. Priceless.

An elderly granny, cute like only old people are cute, took her morning beta-blocker and promptly 'bradied down' into the thirties, starting to get loopy as her heart rate dropped. We came over to see her, and my intern, having just pimped me on the antidote to beta-blockers--glucagon--proceeded to fix her with one dose. Way, way cooler than atropine. From an intern. Big shoes to fill, big shoes.

One man, having a full-on, strength-sapping, one-sided-weakness-causing, speech-slurring, tragic stroke, sneezed. And was cured. No joke.

Scruffy, unshaven construction worker comes from the bar, not for trauma, or a fist laceration from someone else's tooth, or alcohol poisoning, but for supraventicular tachycardia, narrow peaks of anxiety ticking along regular as clockwork at about 160 or 180 sitting in bed. Joe, the attending from Chicago who's seen everything and works nights as if he's of the undead, walks in, nonchalantly. We prepare the adenosine, get a line. Joe says, head cocked to the side, "try something for me...bear down like you're going to the bathroom." So the scruffy guy valsalvas hard, and beep...beep...right down to about 75 or 80, normal sinus rhythm. He sticks there, too. Beautiful. About 1 in 4 SVT rhythms will break with a valsalva maneuver. Free, easy, all-natural, organic medicine.

Here's to the fun cases.

La Raza, or, Am I Racist?

2008-03-29T19:20:00.007-05:00

I just came back from Step 2, and, no, official oversight committee, this is not a blog entry about any details of the exam; I understand that such postings are forbidden.
At the end of our 4th year all of us now have to take an exam that is practical, called step 2 CS; we line up in our white coats, with our non-augmented stethoscopes, without or accessory brains (PDAs), and go in to see 12 standardized patients. In 15 minutes, we have to take a history, do a physical exam, and present our impression to the patient. Then we have 10 minutes to write a note with what tests we want to order. The whole thing costs over $1,000, which I think is a racket, personally. Who's idea was it to charge 4th year students, those whose loans have most likely run out, over a grand for a required test? At least they supplied lunch--cold cuts and pasta salad. That extra scone was about $450.

It's not a bad test, actually. But what I wanted to talk about today is a bit more interesting than details of cases. For whatever reason, there were four of the twelve standardized patients I had that were African-American. I think, having thought about it, that I treated them differently.

I didn't mean to, certainly. However, in the exam situation, it was with young, African-American standardized patients that I forgot, more than others, to tell them about tests I would consider routine in their situation. Perhaps I'm imagining things; or, perhaps there's something to the finding that minorities get poor health care even when you control for income. What was going on? Did I think them less likely to need the test? Did I consciously want them to have a missed illness? I'm sure not. Rather, it was likely my brain did what it did, distracted by the pressure of the test.

I've spoken about Malcolm Gladwell's books on the blog before, and his idea that there is a whole slew of assessments and judgments that occur the split second after you see or talk to someone is relevant. He calls it 'thin-slicing', and at best, thin-slicing in an experienced physician can allow for quick recognition of major illness versus stability. At its worst, however, it can be distracting.

So, because these folks were black, did I somehow make a snap judgment that caused me to order fewer tests? I think so. I think so because when I left to write the note, it was obvious the work up I wanted to do, and I put down those tests I hadn't described to the patient. For whatever reason, though, there was a gap between whatever initial judgments I made without thinking about it and what amounted to good, thorough care. Of course, now there are a maze of confounders--did I know I wanted the tests, but not explain them well because I was less comfortable on some level? Were they less forthcoming with me and therefore I didn't feel like they were acting as sick? Did differences in question style, language, and non-verbal communication make a difference? Not sure; I do know they had two-way mirrors for 'research', so maybe there's a way to find out.

Obama's candidacy for president has made clear that race is an issue in the US. I give us credit as a country for talking about it; there are lots of racists in the world and they often deny that they are much more than we do, as when a Korean student I met denied that there were any Korean homosexuals (I know that's not race but it's similar). The test makes me wonder just how much I'll have to watch myself for hidden bias. Better, I suppose, to see it for what it is and correct it--which is precisely what everyone has to do when their 'thin-slice' is inaccurate.

I remember a class in Mexico where we discussed race, and the class wanted to know why Americans were racist, why they locked the car door when Hispanic youths walked by, why they were so anti-immigration. I found myself on the block for everyone. It was disconcerting, but also enlightening; we have a constant choice to either ignore our own blind spots, or look into them. Hopefully, by doing so, I become a better doctor for everyone, not just the Scandinavian farmers I know how to relate to.

Respect the Momma Bear

2008-03-21T22:42:00.004-05:00

The NY Times has brought up vaccines again in this article, discussing a measles outbreak that involved nine unvaccinated kids and some others that were vaccinated. The Times is spot-on in its critique of the decision, discussing both sides and rightly pointing out the public health risk.

However, the angle that is always missing is still missing: the angle of benefit for the individual vaccinated. Rarely do people frame it that way, and when they do, they are often successful, in my experience. This is good for YOUR kid. Not the other ones. Not the public. Not the schools, or the government. YOU and YOUR kid. Why? Because, even if you buy the risk of autism (which I personally don't) the chances of having some bacteria or virus eat holes in your kid's brain large enough to park a Tonka truck in are greater than harm from the vaccines.

Vaccines do harm kids; according to VAERS data, the self-reported network, they do cause fevers and irritability, and can also lead to allergic reactions. But these reactions are much less common and much less devastating than the consequences of the admittedly rare sequelae of our major immunizable diseases. When I was on the pediatric wards, one of four kids I took care of was a CP patient that had an MRI that made me cringe, and the damage was from infection.

The whole problem is that we haven't respected the mother instinct. I'm a guy so I'm a bit bigger and probably physically stronger than my wife, but if there were someone or something threatening our kids, she would be the one to rip its trachea out and stomp on it. This instinct is so strong that it defies the laws of Newtonian and quantum physics. Even when I did a google search on 'momma bear' to get a picture for this post, I happened on a good blog where a mom avowed that she would 'rip the heart out' of anyone who attempted to accost her child. We joke about this in our society, but its very real. Just try it sometime. I dare you. Go up to a mom feeding her baby with mashed up bananas and take the food away. See what happens.

So what? So, doctors like to tell people what to do. It's our job; we go to school for a long time so we can do it. Guess what? Moms don't care. They go through labor to get their kid and who the hell are we to tell them what to do? I think they win, even though school is long. As a medical community, we will never be able to change a mom's mind by telling her what to do, and that is evolutionarily appropriate. Thank God for moms. Even though I'm done with mom doing her mom stuff now, I'm sure it saved my life a couple times when I was seven and stupid.

What Momma bears can teach us is that if we are to change the mind of a parent we will not do it by saying, 'you must succumb to our order to stick your kid in the leg with a needle that may or may not have mercury in it'. Instead we might try, 'I understand you are worried. In my opinion, the risk of getting this vaccine is much lower than the risk of getting a terrible disease if you don't get the vaccine. Both risks are small, but the risk of disease is much bigger than the risk of a serious reaction to the vaccine'.

Mommas don't care about other kids when it comes down to danger to their own cubs. They just don't. So we may plan as a profession with public health in mind, but that is no argument to a momma bear.

Why are vaccines so vital? Chicken pox isn't that bad, right? Well, it's not the normal outbreak that the vaccine is aiming to prevent. It's the rare outbreak that eats the child's brain, the rare measles infection that makes them dance like Satan's marionette, the rare meningitis case that kills them before they have a chance to wake up, or the rare HPV infection that progresses to fungating cancer eating into the wall of their vagina. Once you've seen those cases, vaccines aren't so scary. We just have to respect the interests of patients and their parents and let them know the real consequences they face; and, like it or not, I still believe we have to let them make their own choice.

Match Day

2008-03-21T15:20:00.005-05:00

On match day, 4th year students walk to the front of a huge auditorium filled with peers and family and open an envelope that contains their residency appointment. I cheated; I looked at mine before hand, and then had them put it back in the box to read it during the ceremony. People may be mad, but for me, having begun pre-requisite classes for the MCAT seven years ago, I had waited long enough. Someone said, 'can't you wait another hour', and I thought, 'actually, no'. So I'm off to one of the best programs in the midwest, I think. Cincinnati was first, I believe, followed by LA, Pennsylvania, Chicago and Louisville. Many of the other programs in the midwest have also been around for upwards of twenty-five years, and it has a high concentration of well-established programs. There were fewer open spots left in the midwest after intial matching than any other region except the far west, which has the fewest spots and the most extra-curricular attraction.

Although it was probably the toughest program I looked at, that's ultimately what I want. As I said to my wife, 'when someone ultimately dies even though I try and save them, I want it to be because that was what was destined to happen, not because I wasn't prepared'. Whew. Glad that's over. Or, I suppose, just beginning.

Congratulations to all those who matched, good luck to those few that had to postpone, and thanks to those who helped--although I'd like to think I'll thank them a little more personally than this.

The Inadvertent Comment

2008-03-19T11:14:00.003-05:00

The other day a surgeon I actually really like was putting in a G-tube on a patient, which is required when they cannot feed themselves by mouth. The approach involves an incision and dissection down through the upper abdomen to the stomach. As he operated, he said, 'you know, it's really nice to finally have a patient who's thin'. We're in the midwest; most of our patients are over 200 pounds, and it is not uncommon to have someone north of 400 pounds, which makes operating quite difficult, and much more dangerous.

The woman had stage 4 squamous cell cancer which was preventing her from eating by mouth. No wonder she was thin.

Insensitive? These types of comments are the ones that get people all mad. But really, I had ample evidence that this surgeon was, though maybe not warm and fuzzy, compassionate. We're just human. His mind was preoccupied with the task, not the big picture, and when he has a long, curved needle in his hand, that's absolutely for the best.

Without thinking I've asked people with ET tubes down their throat how they are doing, or other questions that require an answer rather than a nod. I've accidentally dropped names in the cafeteria, although I'm getting better at that. I've made jokes or light of injuries that may border on insensitive out of a desire to lighten the atmosphere in a room, even though there is evidence that jokes do not help patients feel better about their conditions.

People are right to point out insensitive comments to health care professionals; we often come to wear callous veils to protect ourselves from the stream of injured humanity we see, especially in the critical care or surgical professions. I don't think that there is a way to consistently re-assemble people without detaching a bit. Some situations become so absurd that we end up laughing because we don't know what else to do, and because if we didn't, we'd instead go slightly bonkers. It doesn't excuse us or decrease the need to remain sensitive to the patient; but if you happen to overhear something to which you object, the context might be helpful. Maybe the doctor who seems callous, is; but it may also be that they are distracted or have a point of view that differs from your own.

"You're going to find that many of the truths we cling to depend greatly on our point of view". --Obi-Wan Kenobi.