Stolen Material

Here are a couple of things I read that I had to share. The first is from a blog call "The Central Line." It is a blog done by the American College of Emergency Medicine. The second is a comment from one of our readers Bubba. Again...not my material.

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#1
Non-Clinical Clinical Prognostic Indicators

Good Prognosis:
-Your doctor hasn’t seen you yet, and you’ve been waiting for (insert average wait time) hours.
-You’re in a bed in the hallway.
-Your complaint consists of “months” or “years” of pain/nausea/headache/X Y Z.
-You’ve come to the emergency department for a second opinion, despite multiple subspecialist evaluations.
-You answer yes to every symptom the doctor asks you about.
-You get a blood draw, but no IV.
-The only medication you’re given is tylenol.
-Your doctor says the words “probably” and “virus” in the same sentence.
-You are talking on your cellphone, playing a game, or chit-chatting.
-You are talking on your cellphone, playing a game, or chit-chatting and the doctor has to ask you to stop.
-You “just wanted to get it checked out.”
-Your primary care doctor sighs on the phone when the emergency physician calls him or her.

Bad Prognosis:
-You get not one, but two IVs.
-You remark, as my GI bleeder did last night, “Boy, I’ve never been to a hospital so attentive and efficient!”
-You get your own personal doctor to take you to the CT scanner.
-Multiple doctors, nurses, and staff greet you in your room.
-The triage nurse walks you to your room and points at you while speaking to the doctor.
-You get a room all to yourself.
-You get a monitor.
-Your monitor keeps beeping, even though you’re not doing anything.
-Your doctor keeps checking on you.
-Your doctor sticks a finger in your bottom.
-You don’t argue with the doctor about getting this treatment or that one.
-You are kind, good-natured, and have been a good person in this life.

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#2
Bubba said...
I will seek and find you.. I shall take you to bed and have my way with you. I will make you ache, shake & sweat until you moan & groan.I will make you beg for mercy, beg for me to stop. I will exhaust you to the point that you will be relieved when I'm finished with you. And, when I am finished, you will be weak for days. All my love, The Flu


-ER Doc

Flu Rant!

I am so sick of the Swine Flu. I know kids are dying and it's scary. I'm not going to say the normal "people die from the flu every year" thing. I do believe this thing is worse...but damn I am sick of it.

It's not the people who are really sick that's bugging me. It's that EVERYONE thinks they have the flu. I primarily work at a big county hospital for residency, but I also work in a children's hospital, an urgent care, and a small rural ER (moonlighting gigs for extra money). EVERY single one of them is filled with people daily who want to be tested and treated.

They don't care about my clincal assessment of them. They don't care that testing for the flu is basically worthless...they want the test. They want to call and tell everyone they have the swine flu. They swear their neighbor has it or the shopping cart they used had it. They could care less of my training and clinical acumen. They know what they have and what they want. I try and try to talk rationally and teach them the recommendations and pathology, but they don't care. I spend time and energy and it doesn't matter. And if I succeed and talk them out of it, I get negative patient satisfaction scores.

I know what sick people look like from the flu. They are hypoxic, febrile, have rigors, and having breathing problems. Slam dunk cases that will be treated or admitted. But a year ago....we would NOT be running all these tests and treating all these iffy cases. We would call them URIs or viral syndrome or bronchitis and let them be. This country is going to run out of Tamiflu....and then....

"Shoo Shoo Retarded Flu"--The Howard Stern Show

Thanks for letting me rant,

-ER Doc

Till Death Do Us Part

An 85 yo man and 84 yo female married couple arrived to the trauma bay after a head-on-collision in which the man entered the freeway going the wrong direction. Both of their injuries were critical. The man sustained a severe pelvic fracture, and his wife had a hemothorax (blood in the chest cavity). The wife was more critical than the husband, so we intubated her and placed a chest tube to drain the blood.

Shortly after placing the chest tube in the wife, she became bradycardic and lost a pulse. After about 30 minutes of resuscitation, she died. Afterwards, I went over to the husband to reassess him. He kept asking me "how's my wife?" I couldn't answer him. I proceeded to get the CT scans that he needed. He again kept asking everyone "How's my wife?" At that point, we debated not telling him until he got to the floor. He kept asking and then said "We have been married for 65 years." We told him....and it seemed he let go. He died later that afternoon, shortly after he was told that his wife passed away.

-Doc senstive

Saying no to drugs

I remember when I was a kid hearing Nancy Reagan saying "Say No to Drugs." I deal with this every day in clinic. I'm not even talking about ice, smack, weed, crack, bumpin' a rail, etc. I mean the honest to goodness, legal prescription stuff. Every day I have to talk with patients who are abusing there benzos. Residency training programs are a great place for benzo abusers, because the residents cycle in and out, and nobody takes ownership of bad situations, therefore problems just get passed along. Even though our patients sign medication contracts, they still try to abuse the system.

Since I have recently begun clinical rotations, I have been stuck in numerous predicaments such as this. Patients abusing their priviledges. Psych Doc draws a line in the sand. Patient retaliates. Some examples.

Patient #1 presents for refill on her valium. She was fired from another clinic in our system for repeatedly overusing valium, calling for early refills, and on one occasion, showing up totally stoned on weed. My attending physician told me that I got to be "the bad guy" and take her off valium. We had a fairly pleasant discussion, however she did inform me that if I didn't prescribe it, she would send her grandpa to Mexico or Canada to get it. She also told me she should be able to smoke weed whenever she wants. On the way out of clinic, she screamed "Psych Doc is a Demon from Hell!" That didn't exactly brighten my day, but it did provide the name for my fantasy football team this year.

Patient #2 I inherited on Klonopin 1mg TID. She insists that it is QID, though it's been prescribed TID for > 6months. She ran out early. She could barely stay awake during the nursing assessment. Once again, I get to be the bad guy, cuz nobody else wants to set limits. I tell her we're going to taper her off Klonopin over 4 months because she's been abusing it. She asked, "Is there a higher authority than you?"

I resisted the urge to answer, "Maybe God would qualify" but decided I would leave that to my surgical colleagues. Instead I replied, "Do you mean like a patient advocate?" to which she answered in the affirmative. As she wrote down the advocate's name and phone number that I provided, she was so stoned that she couldn't operate a standard ballpoint pen. She then slammed the door on the way out, went into the waiting room and told the other patients, "Good luck with Dr. Asshole."

I am so frustrated with the users. As one of my attendings used to say to these patients, "Excuse me, but do I look like a vending machine?" I really try to do what's in the patients' best interests. Use the lowest possible dose (all meds, not just benzos). Avoid polypharmacy. Prescribe high risk meds when appropriate.

Some days I wonder why I went to med school.

Say "Thank you" to your doctor today.

Regards,

Dr. Asshole aka Demon from Hell aka Psych Doc

Cuts like a butter knife

A 45 yo strange looking female arrived to the ED with chief complaint of "bright red blood per rectum." I went into the room and asked her "What brought you in today?"

She kind of avoided eye contact but matter of factly stated, "I have been constipated for the past three days, so I took a butter knife from my kitchen drawer and I used the knife to alleviate my constipation. After the first bowel movement, I noticed blood in the toilet. I am not very concerned, but my family made me come in to ensure nothing serious was happening."

Sometimes, it's difficult to maintain a professional demeanor. I had to put the chart over my face to avoid smiling and laughing at this poor patient. I had many questions I wanted to ask, such as "Is this a normal dinner discussion in your family? Wouldn't you keep that a secret?" Nevertheless, I decided to avoid any additional questions because I didn't really want any answers.

I did a though anal exam with an anal scope to look for deep cuts in her anus. Thankfully, it appeared nothing was seriously injured in her butter escape hole. I discharged her with a script for a stool softener and gave her strict ED warnings to avoid butter knifes.

I can believe its not butter!

-Doc Sensitive

Honored to Serve

A 92 yo male arrived to the ED complaining of severe abdominal pain. Upon examination, I could immediately tell that he had a severe surgical abdomen because he displayed rebound and guarding on physical exam. When I asked if he had any past surgeries or medical problems, he said "Son, I got shot by a German artillery in WWII when I was young. Besides that, I dont have any medical problems." I was rather interested and asked him what he did during the war. Turns out he was a fighter pilot.

He was a very humble and nice man. I knew his chances to survive were slim after I saw his upright chest x-ray illustrating free air under the diaphram. I called the surgeons and soon forgot about him. For some reason I recently searched his name on Google, and learned about him through his obituary. He was a true hero.

As an ED physician, you often encounter certain patients that make you wonder what kind of person they were to touch your life so genuinly- even if briefly. I'm not sure why he stuck in my mind. Maybe it was that he reminded me of my grandfather. I wanted to know more about his career and what "the war injury entailed." More importantly, I wished he was still farming and alive to tell the rest of his WWII stories. In a way, I feel honored to have served him during his last days, just as he served his country and the world during WWII. He served a greater good and higher power then I can ever dream to serve- salute and cheers.

-Doc Sensitive

"Awesome"

Ok...a change in subject. I feel like I am sitting on the floor of the senate after reading all those comments. Great to have an involved debate though.

So....a story about a funny trauma case. Saturday night, 230 AM. The bars had just closed. EMS called to warn us they were bringing in a gun shot wound...to the TESTICLE!! Ouch. A 23 year old pulled a "Plaxico" by carrying a gun in his pocket to the club. He accidently fired the gun in his pocket, and the bullet went through his testicle into his thigh.

He presented in a great mood actually. He was drunk and calm. His testicle was hanging outside of his sac by its cord, obviously dead. When he was asked if he had any medical problems, he replied "You mean besides being awesome!? Then no." Not the typical response you would expect from someone with their left nut hanging outside its cage. He was taken to the OR and the testicle was removed.

Two days later I saw the gentleman in the ER again. This time it was daytime, and he was sober. He presented with severe constipation, presumably from the narcotic pain meds he was prescribed. After 2 enemas and a bottle of mag citrate, we had him feeling "awesome" again.

-ER Doc

Compassionate death?

I recently spent some time in another country that has socialized medicine and thought I would share a story that illustrates the differences b/w our system and socialized medicine:

72 yo deaf and demented male from a nursing home arrived looking pale, diaphoretic, and not responding to voice commands. The gentleman looked very critical, and my instincts were to get ready to intubate him. However, my attending on duty looked at the patient and realized his quality of life was very low considering that he was deaf, at the end of his life, and living in a nursing home. He told me to not intubate the patient(even though no family members were present). I then got an EKG illustrating a very wide complex tachycardia with high t-waves suggestive of hyperkalemia (high potassium). I drew a state venous blood gas which confirmed a high potassium level of 7.0 (normal is less than 5).

When the potassium gets very high, it can cause the heart to stop beating if is not corrected. I brought the EKG to the attending with the lab result of the high potassium and asked him if he wanted me to push calcium gluconate with IV glucose/insulin (the treatments for a high potassium). He said, "No. His condition is already very critical because he is in urinary retention and has an acute abdomen. We need to just let him die peacefully."

It was quite shocking b/c in America we would have intubated him and performed heroic measures, but it begs the question- "Why do we save everyone and not take into account individuals quality of life? Would I want to be treated if I was demented and lived in a nursing home? Is it more humane to just allow people to die peacefully?"

Rather then giving him calcium and glucose/insulin, I gave him Morphine for comfort. He died peacefully about an hour later.

-Doc Sensitive

Shoulder Pain

Shoulder pain is a very common chief complaint in the emergency department. It's also a pretty easy work up and disposition. This case was no different, but the story behind it was classic....

So the patient was a 30 something year old male. He complained of bilateral shoulder pain. Further history revealed that it had been worsening for 2 years. When I asked him if he had any clue what could be causing the pain....he had a pretty good reason:

"Well doc, ya see it's like this. I like to go down on my girl friend. I spend a lot of time down there. I mean like 4 to 5 hours at a time. When I'm down there, I have my hands stretched above my head to play with her nipples. I think all that time with my arms up messes up my shoulders. I don't think all the meth helps either."

It was one of the only times in my short career my jaw dropped during an interview. Totally caught me off guard. I discharged him with a prescription for some NSAIDs and advised he takes breaks while he's "down there."

After his classic quote, I noticed he had really bad teeth. I wonder if it was from the meth or from.....

-ER Doc

MADD (Moms Actively Drunk Driving)

Sad night....24 year old female was drunk at around 10 pm Friday night. She was driving around 50 mph in a residential neighborhood and drove into a house. When EMS got there, they noticed an 8 month old baby in the back seat. To make matters worse, mommy was so drunk she couldn't figure out how to strap her child in properly.

There's more....no drivers license, no insurance. And...this was her 2nd DWI! Instead of asking about her baby, she asked me to call her boyfriend, who was still at the party. Instead I called CPS and the Police.

Alcohol level.....194.

The baby is ok, thank God.

-ER Doc