Great Article on Healthcare

http://www.washingtonpost.com/wp-dyn/content/article/2009/08/21/AR2009082101778.html?referrer%3Dfacebook

-ER Doc

Anonymous said...

I am a "green" R.N and just pulled a 36 hour shift in a very understaffed hospital. I was tired, emotionally spent and considering my career choice. After reading your blog and seeing the way you use humor to deal with the day to day happenings it rekindled my faith and reminded me that I wasn't alone. Thank you.

Re Anonymous: I really appreciate your comments. In medicine, we see a lot of sick things...and even more sad things. It is emotionally and physically grueling. This is especially true for the young docs (residents) and "green" nurses b/c we start out in understaffed and county type places. We really don't help people as much as we would like. There are many reasons for this. One is b/c of things that are out of our hands...like social and financial constraints or the resources available. Other reasons are as simple as the people who flood us who "aren't sick" and have secondary gain usually outnumber those that truly need help. That being said...in psychology humor is regarded as a mature defense mechanism. Sometimes the only way to get through a situation is to laugh at it. Humor as a defense mechanism takes feelings that are uncomfortable to talk about "straight up" and allows us to express them in ways that don't hurt others and at the same time help us. (Albeit I tend to do this sometimes in sick ways and go too far, but that's me and my problem, not most peoples.)

The patient you are referrering to was a good example of this. She was horribly sick in the head, smelled terrible, high maintenance, had been in the ER daily for 4 days, and drained ALL of our staff. She made me mad at her, mad at society, and just mad in general. I honestly didn't want to take care of her again. But I found something funny about it and knew I could share it with you guys. All of a sudden I wasn't as mad anymore.....

Thanks for your understanding anonymous.

-ER Doc

Chief Complaint: My Cat's Burning

Here is a direct copy of a chart I saw when looking up a patient's past history:

Chief Complaint:
Patient presents with

• "My Cat's Burning"

HPI: Patient very difficult to interview and giving strange inappropriate responses to questions. Shouts, "AIDS!" long pause "Gonorrhea!" long pause "you want to see my penis?" long pause "My cat's burning and I need someone to look up under me." Finally interpreted to mean that she has burning when urinating for several days. Also complaining of vaginal pain and burning. Unsure if she's had any discharge. No abdominal pain, nausea, or vomiting.

-You can't make this stuff up!

-ER Doc

Misconceptions

It seems that some people out there have misconceptions of what psychiatrists can do. One of my attendings warned me about this last year, but now that I'm in clinics, I believe him. For some reason (probably Hollywood), a lot of the public believe that psychiatrists can read minds. Several recent events, including the gun post by my colleague, bring this to light.

I was at the mechanic the other day. I knew I needed some work done on my brakes, and I was getting a quote. Meanwhile, I made small talk with the brake guy while he was telling me all that I needed. Of course, I felt like he was trying to sell me more than I needed. I went with the minimum service. He said something like, "I bet that your psychiatry training helps you out with negotiations like this," implying that somehow I knew that he was trying to scam me. I did, but it had nothing to do with my psych training.

Another example is when someone recently mentioned that a way to keep guns out of the hands of suicidal/homocidal people is to make them undergo a psychiatric evaluation. Of course there would be a lot of logistic concerns (which psychiatrists would do it, who would pay, etc.) But what I want to make clear is that Psychiatrists can NOT read minds. I can only help you if you want help. If you are lying to me, maybe I can figure it out, but I probably can't. Sure, I may be able to tell if you're depressed or hearing voices. I can obviously tell if you're manic. But I can't tell if you're going to kill unless:
1. You tell me you're going to or
2. Your family/friends/police heard you make those statements or
3. Other aspects of your personal history (which you can lie about anyway) send up a red flag.

The third aspect of all this is what really hits home. I recently found out that the father of one of my daughter's classmates died. It made me confront my own mortality; I had seen him a few days before. He was fairly young and appeared happy and healthy. He did NOT look depressed. I figured he had a heart attack or car accident. Then I checked the medical examiner's website. He committed suicide. This was a person who on the surface had a loving family, a successful career, wealth, you name it. These are all protective factors for suicide that almost none of the patients that I treat at a county hospital possess. Who knows what his own personal demons were. But the point is: I'm sure nobody saw this coming.

I can't stop thinking about the hole that he left for his wife, kids, and friends. My initial sympathy turned to anger due to the selfishness of this action. That night, I told my family I loved all of them and promised to never do such a thing. It has been haunting me for a week now. Even though I didn't really know him, it touched me deeply. I am a mental health professional. I am supposed to help people like him.

Please, if you are having thoughts of suicide, or know someone who may be, please get them the help they need.

Sometimes they don't seek help on their own.

And don't expect a random psychiatrist walking down the street to read their mind.

Anyone can fake it.

Anyone can lie.

And I wouldn't know.

-Psych Doc

Daddy's Little Girl??

Interesting shift in the "Children's" ER the other day.

Patient 1: Fifteen year old female presented with a sore throat. She also wanted a pregnancy test b/c she was late on her period. When I walked in the room....I saw a young female with tattoos on her neck and arms that said "bad ass." + nose and lip ring. Overall she was a sweet girl. She was concerned about being pregnant (which she wasn't...thank goodness). She did, though, have gonorrhea in her throat. The kicker...her t shirt said in big letters "Daddy's Little Girl." Having daughters myself, this saddened me. Let's just say we had a little heart to heart.

Patient 2: Fourteen year old female presented with abdominal pain. She was with her FOUR MONTH OLD child. She had been pregnant 2 times before, one resulting in an ectopic pregnancy. Again... this girl was fourteen years old!! She admitted to doing cocaine, marijuana, and "occasional" alcohol. Her last period was 4 months ago. Long story short...pregnancy test was positive, and she was transferred to the adult ER for another ectopic pregnancy workup. We consulted social work b/c she just didn't seem fit to be caring for her four month old.

-ER Doc

More Fun With Guns

Latest victim of a gun shot wound was a 46 year old male who was shot by his...FOUR YEAR OLD SON!!!

Story was that an 18 year old was teaching his 4 year old brother how to "target shoot" from the back of his pick up truck. When dad came outside, the 4 year old turned to show him what he could do and accidently fired a bullet through his dad's spleen and esophagus.

Who's to blame in this one??

-ER Doc

Wall of Saddness

A 22 yo male arrived via EMS after being in a head on collision at highway speed. There were already 2 fatalities on the scene. According to the paramedics, the patient was found 30 feet away face down with agonal breathing. He was intubated at the scene and brought into the ER as a Level I trauma activation under the code name of Alpha. The patient was in bad shape. He had a large skull defect, cerebral spinal fluid coming out of his right ear, & unequal pupils. These are signs of SEVERE brain injury...but he was being kept alive by residual brain stem function and the ventilator.

After we stablized him, three sets of parents arrived and were put into the family waiting room. I called the chaplain because none of the parents knew about the fatalities. We had no way to identify our patient besides his personal belongings. Our patient, the last alive and barely holding on, had a unique belt on.

I went into the family room to talk to the parents. I said "I am sorry to break the bad news but we had two deaths at the scene. The one survivor is here and is in very critical condition."

All I could hear was screaming and sadness. One family member asked, "Who is the young man alive?" I said, "Sir, we have no way to identify him except that he has a unique belt on." Then one hopeful set of parents started crying and said "Does it have a nickname and silver trim?" I said, "Yes." The parents then shouted "That's out son!"

The other parents were crying in agony. It was probably the worst night of my medical career. Trying to maintain composureI said, "You can come back to see him in 5 minutes, but he is in critical conditon with a serious brain injury."
The parents soon came back and identified him. Unfortunately the CT Scan illustrated irreversible brain injury with a cervical spine fracture. Again, I had to break the sad news to the family.

With more strength and courage than I could ever imagine, the mother said "I want to donate his organs so someone else can live. He wouldn't want to live like this." I was shocked b/c so far in my career, I've seen most make end of life decisions that maintain someone on a ventilator, prolonging the inevitable. I made the call to the transplant center and he became an organ donor. I left the hospital that day with a wall around my heart to seperate my emotions from reality.

I eventually forgot about Alpha until I received a letter in the mail one day from the transplant center. It said the following: "Dear Dr. Sensitive, Although Alpha died on June 1, 2008, we were able to harvest his liver, eyes, kidneys, & tendons. Because of your referral, 12 people were either saved or helped by Alpha's tissues. We are extremely grateful, and on behalf of our patients we thank you."

My wall came down and my emotions came back. Thus far I dealt with that night by building a wall, but now Alpha was a real person to me. I went home that night and googled his name. I found out that he was 2 minutes from his house, his girlfriend was following behind him, and she saw the entire accident. I discovered that he had a My Space Page and looked through it. It was strange to see him as a person, and I was saddened that his life was cut so short. However, through his death and his courageous mother, he saved the lives of 12 others.

-Doc Sensitive

Fact Check

Nice article I found on misconceptions with the Health Care bill. Link is provided if you are interested.

http://www.newsweek.com/id/211981?GT1=43002

-ER Doc

Allergies

Below is a copy of a "allergy list" from a recent patient, with only the hospital name taken out. It goes with one of my rules that "the more allergies the patient has the less likely the said patient is sick. " Also, the spelling is priceless. The only pain med this guy wasn't allergic to was demerol. Uh huh....




-ER Doc

Healthcare Reform and a Scary Fact

We haven't broached the politics subject yet....but figured now is as good of a time as any.

The US Securities and Exchange Commission Filings reported that profits for the 10 largest insurance companies increased from 2.4 billion to 12.7 billion from 2000-2007, while the number of uninsured increased 19%. Kind of hard to explain that one. And we are supposed to believe the rhetoric that if a public option exists the private insurers wont survive. Come on. Not to mention that the average salary for the CEOs of these insurance companies is 11.4 million!

Here is a link from a fellow blogger that has lots of the most up to date information and videos on the health care debate. View if your interested.

http://gardnersgate.blogspot.com/2009/08/white-house-responds-to-health-care.html

-ER Doc

Tough Love

A 32 yo male arrived via EMS in full cardiac arrest without a pulse. Despite our best efforts, and despite us coding him for over an hour, we pronounced him dead in the wee hours of the morning.

We all scratched our heads because this young man looked healthy, clean cut, and didn't appear to be an IV drug user. We went to the family waiting room and broke the bad news. It was tragic to all, including the nurses and doctors because its always hard to have a young person die.

Later in the evening, the hospital chaplin spoke with the girlfriend regarding their last moments. The girlfriend stated : "He had been looking at girls all night long and pissing me off. When we went to leave the bar he did it again, and I punched him in the chest and he took two steps and fell over."

When I heard the story I was shocked because I didn't believe someone could die from one punch! After some research, however, the condition is called "commotio cordis," results in V-tach, and can cause immediate death. Everyone should think twice before checking out girls in a bar!!!!

-Doc Sensitive

A Strange Case of Indigestion

This is a case that goes back to my intern year, where a portion of my Internal Medicine rotations were at an outpatient clinic. A 60-year old male came in for a routine checkup. He had most of the usual problems: hypertension, GERD, T2DM, etc. It seemed like a routine med-refill visit, until he asked, "Doc, I think I need some of that Mylanta."

Like a good little intern, I had already reviewed his med list. This seemed easy enough. "Sir, you're already prescribed Nexium. That should take care of everything."

"But I really think I need Mylanta," he said.

"Okay, if you really want it, I can't stop you. If your reflux acts up, feel free to buy some over the counter," I replied.

"But Doc, you don't understand. I have a new lady friend who's 20 years younger than me. I don't have the ability to give it to her as much as she wants."

"Oh, you must mean Viagra."

- Psych Doc

Rural Medicine

It's my 3rd year of residency. One of the perks about 3rd year is you are allowed to moonlight. Moonlighting is basically working outside of your residency part time and earning some semi-real cash. I actually started the last few months of my 2nd year at an urgent care....but this weekend I started at an Emergency Department in a rural hospital. The shifts are generally 24-48 hours b/c you can get some sleep since the volume is low at night. I was the only doc in the whole hospital all weekend...kinda scary

I'm a city guy...so this weekend was kind of an eye opener. I enjoyed the greenery on my drive in with all the cows and horses in the pasture. I quickly learned that not having a truck made me out of place....and the "Yes We Can" Obama sticker didn't go over well. The patients were generally very friendly and nice....which

was a pleasant change.

One patient was a bipolar manic gentleman off his meds. In the city, this kind of case is very easy to admit. In the country, it was a big ordeal... even involving the "sheriff." This guy was very agitated and wanted to smoke. The nurses refused to let him go outside since it was a non smoking hospital and he was under a medical warrant. I felt bad for him and wanted to keep him calm, so I volunteered to break the rules and accompany him while he smoked outside. He sat on the curb....but didn't pull out a pack of cigarettes. Instead he pulled out a bag of home grown green stuff and a white wrap. He rolled it and smoked a joint right in front of me! For some reason I was shocked weed is smoked in rural communities.

Next an old man came in after hitting his head. The story behind it was much more interesting: He was getting up in the middle of the night to get a drink when he walked into his "hanging bull skull!" Yes...a skull of a bull hanging in the living room. He passed out. When he woke up he tried to wake up his son to take him to the hospital. He kept banging on his son's locked door...but he couldn't get him to wake up. So he decided to go outside with his shotgun and fire it outside his son's bedroom window. That seemed to wake him up!

Speaking of guns....we got a heads up call from the local authorities that some kids were driving up and down their street firing a rifle repeatedly. They wanted us to know just in case someone got hurt. What's with country folk and guns? I've never even held a gun.

Overall....I had fun. I surprisingly like the outskirts and look forward to what's next. Only in the country.....

-ER Doc