- "A Nation of Anxious Wimps"
- Is Airborn good for a cold?
- Lord don't move the mountain..
- To Sleep, You Must Cold
- Winter Update
- Good for a laugh
- Is there Life Before Death?
- I'M BACK!
- Plugging a Useful Meme
- Nurse, May I Have A Word?
- Residency Spot Anxiety
- Money Shots from ER Blogs II.
- Emergency--What Does It Mean?
- Oh, Fickle Fate!
- Bad Day.
- Why My Internship Isn't a Waste
- Surgeons as superheroes?
- Secret Lives of Doctors
- Money Shots from ER blogs
- Physician Assistants
- Bad Reaction to Anaesthesia?
- Book Review or Practice Vision?
In a single night I had patients come in to our emergency department, most brought by ambulance, for the following complaints: I smoked marijuana and got dizzy; I got stung by a bee and it hurts; I got drunk and have a hangover; I sat out in the sun and got sunburn; I ate Mexican food and threw up; I picked my nose and it bled, but now it stopped; I just had sex and want to know if I’m pregnant.Hilarious. Pic via.
...Just give me strength to climb it. Please dont move my stumbling block, Just lead me, lord, around it. Dont move this mountain. --Soulfire, Stand in the Fire Relaxing after a burly shift in the ER. Working with the right attending/boss on a busy shift is very satisfying. There is a harmony achieved where each will see/work up the different patient, and then switch, to emphasize/modify/push through/confirm/or question each others workup, blending, persevering, consolidating, reassesing, learning, laughing, frustrating, disbelieving, disapproving, criticizing, resuscitating, reanimating, engaging, enlisting, hand-waving, hand-wringing, consulting, sharing, politicking, magic-making, cajoling, enforcing, patronizing, brow-beating, and testosteroning our way through a shift. The only way out is through! No catastrophe too big! No work environment too austere! No PMD too unreachable! The show must go on! pic via http://roughwriter.yc.edu/2008/05/because-its-there-2/
NYT Article--to sleep, you must cold I remember during my internship year, the crucible, I was rotating in the ER. I was very excited to rotate there, as I had recently discovered the thrill of the emergency room in one of my last 4th year rotations as a medical student. My dreams of becoming a psychiatrist sloughed off me like I was molting. I was on a string of nights, in the middle of a hot summer. Despite having lived in my apt for nigh on 2 years, I had yet to invest in an air conditioner. Hey, I was a tough guy, living au naturel, windows and fan only, thank you very much. I could take it. I finished my third of four nights, increasingly sleep deprived, because, well, its hard to sleep, drenched in sweat, during the daytime. I bought an air conditioner. I bought a strong model--hey, maybe I could cool the whole house! After it was installed and began producing a cool, cool breeze, I went to sleep. I set my alarm clock, and slept very, very well. I woke up, and it was mostly dark. Not the winding down twilight that preceeded my upcoming night shift, but the silent crepiscule that heraled the end of my shift. Slightly uneasy, I was. The analog clock above my bed read 6:15. Perfect, I thought. Just enough time to get ready for work in my preferred leisurely fashion. Beep! goes the cell phone. Gee, I missed the alarm, thats weird. Oh hey, Ive got some messages. Lets check. "Hey Dex, its the chief resident. Just wondering when youre gonna make it to your shift." "Dex. Whats going on? Its two hours past your scheduled start time, and no show, no call. What gives?" Uh oh. I check the time on the computer. 6:20, indeed. Okay. I check the date. One day later. That sinking feeling turns into a vortex, sucking my stability away. I am suddenly aware of my heartbeat, which has been pounding away for a while now. Idly I realize that I am unusually refreshed and alert. Too alert. I just slept for 16 hours. I frantically call the chief; forcing calm into my voice I definitely do not feel. I tell the chief I just got his messages. I tell the truth about my heat induced sleep deprivation and the marvelous benefit of air conditioning on the quality of my sleep. I apologize profusely. I show up for my next shift. Early, of course, and eager. Very eager. Everything seems to blow over. Months later, at residency match time, I am so confident and sure of my assured spot as a resident in the next years class that I only interview at one other place, just to get some perspective on what other ERs look like. It seemed okay, but a bit of a hike from my current digs, which are perfectly serviceable now that my sleep is blissful. Confidently I check my status on the match website. Rejected. I am shocked, hurt, and victimized that my first choice for residency, the hospital where I sweat blood to get through, the epitome of The House of God, where I know Everybody, has rejected me. I barely made it onto their list. I was not going to be an ER resident there. There was a bright spot, however. My second, and only other choice, ranked me high enough to match. I had a residency spot. And Lo! though with His Left hand he Taketh Away, with His Right hand he Giveth. In my hurt I question my would be friends and mentors about why I wasnt ranked higher at my own institution. Well, They Replied, you failed to show up or call for a shift, and it was felt that endorsing such an unreliable precedent would be unwise. So yes, I am intimately familiar what a benefit to sleep a cool room can be. Painfully aware. And now you know too. -Dex
Hello world... Emergency Medicine is fantastic--I am posting here today because scheduling allowed me a three and a half day weekend this block! Much better than my colleagues in Medicine, Surgery, or OB-GYN--it would never happen on those rotations. Lets do a case. A 42-day old infant girl presents at 8pm, upgraded from the pediatric urgent care center located at your ER (dont you wish you had one!), with bleeding from the rectum. The parents were concerned because of a 5 day history of worsening blood mixed with mucous (currant jelly) and a normal appearing green stool. Stooling frequency unchanged--4-5x per day. No apparent pain with passing stool or abdominal pain, no vomiting, no fever. Weight gain was appropiate, and baby did not seem overly fatigued, although mother thought she was a little pale. No recent antibiotic use or NSAID use reported for baby or mother. They had come to the our ER after it started and baby was started on a soy based formula and sent home. 1 day previously, baby was started on Neutramigen (last resort before hyperalimentation), but the bleeding had worsened--more obvious blood in the stools for the last day. Prior to starting the soy based formula, baby had been breast feeding. Mother had had cracked nipple previously about two weeks ago with a little bleeding, but it had resolved after 2 days. Baby had been born 2 days post dates by C-section for failure to progress. Normal primigravida prenatal course, no NICU time, no peri-natal infections reported. Parents report an iguana and two dogs in the house, are non-smokers, have no medical problems, and the baby has no siblings. On exam, baby was well appearing, in no distress, and appeared well hydrated, with no pallor or jaundice. Mild baby acne over L lateral face and forehead seen. VSS, afeb. No bruises noted on skin. Oro-nasopharyngeal exam revealed pink mucosa without bleeding, hyperemia, or thrush. Normal cardiovascular and lung exam. Normal bowel sounds. No tenderness, distension, or masses on abdominal exam, no organomegaly. No caput medusa. No cracks, fissures, or hemmorhoids appreciated. During the (normal) digital rectal exam,I got an episode of forceful pooping for my trouble, getting baby shit on my pants, eliciting knowing smiles from the parents, and endearing me to them forever. Strongly guiac positive semisolid green stool mixed with red mucous. CBC revealed a HB/Hct of 12/36, WBC of 14, plt of 640. Complete metabolic panel within normal limits except for slightly elevated AST/ALT, but normal bilirubin and alkaline phosphatase. So whats the differential? --Whenever you see currant jelly stools in a child less than 2, my spastic reflex is "intussusception," which is a good reflex, as this is a dangerous and often-missed diagnosis, it can lead to "the process progresses to transmural gangrene and perforation of the leading edge of the intussusceptum." . Other features of this diagnosis missing from this picture: altered mental status, intermittent abdominal pain, vomiting, intestinal obstruction, preceeding upper respiratory infection, wrong age--"intussusception occurs in infants aged 5-10 months," and palpable abdominal mass. --Meckels diverticulum--which often presents with painless rectal bleeding, and can be a lead point for intussusception. However, in this case: no signs of abdominal pain, the bleeding was relatively mild (Meckels typically produces profuse rectal bleeding--because of ectopic gastric mucosa ulcerating), wrong time frame (remember rule of twos--2% of population, 2% manifest clinical sx, 2 feet proximal to the terminal ileus, and 45% of symptomatic patients are less than two years old) and again, no sign of obstruction, and the patient did not appear acutely ill (which would prompt perhaps a search for a meckels--typically via Meckels scan, a nuclear test.). --Necrotizing enterocolitis: Less common in normal birth weight babies, no peritoneal signs, and simply not ill. -- swallowed maternal blood--excluded by history in this case--cracked nipple most common--not an issue here. --Anal fissures, cracks, and fistulas--rectal exam is mandatory in case of rectal bleeding, fortunately negative in this case. --Milk protein allergy--quiet, can last for days after last milk ingestion, can lead to GI bleeding. This ended up being our probable diagnosis. The patient was discharged after a discussion with the PMD and referral for close GI followup. --dex *Picture from www.restaurantwidow.com
Yeah...the new place. Cant say where it is, course, yunnerstan, but...it rocks. I think one of the most critical things is that people are happy here. I mean, the people who have been here for a while. And they keep people here. Not like my last place, where people would only stay a couple of years (as attendings, I mean.) But this place--when I asked how many from the graduating class they hired, they said, "None!". And I thought, well, thats not good--the new attendings want to get away, right? No, actually...as it turns out, there were just no positions open; that lots of the graduating class would stay if they could, but there was no positions because nobody leaves because they are happy here. Ill have to admit, I really didnt want to move...so I didnt. Now I have an hour commute, but Im never bored, and I never wait. I figure Ill listen to my Gold Standard stuff left over from studying step 3. The pharmacology at least will still not be old. And since it is such a chore for me to study when Im home (Id rather watch Battlestar or The Daily Show or clean or read novels like Lois McMaster Bujold, or (hopefully) get back into Aikido or back into Guitar or talk to my GF.) As always, more later...
Back in action, folks...was really overwhelmed in March, couldnt post. Good news--Got a new job; as a new emergency medicine intern at a good sized hospital, thats an excellent program, old (by ER standards), and with a lot of institutional memory and experience. Bad news is Ill probably have to move, leaving my beloved apartment, but the program is that good, that I can leave the apartment behind with nary a tear. Continue the progressive march to the glorious future, comrades! And for some ER news, as many of you probably know, new guidelines for prophylaxis for infective endocarditis have been published by the AHA, and the good news is the number of people at risk for IE is much fewer than previously thought. The guidelines therefore are much more restrictive than previously, saving a lot of antibiotic prescriptions and preventing antibiotic-associated complications like C. dificile colitis, anaphylaxis, tachyphylaxis, and antibiotic resistance--heres a synopsis... New guidelines regarding antibiotics to prevent infective endocarditis The American Heart Association recently updated its guidelines regarding which patients should take a precautionary antibiotic to prevent infective endocarditis (IE) before a trip to the dentist. The guidelines, published in Circulation: Journal of the American Heart Association, are based on a growing body of scientific evidence that shows that, for most people, the risks of taking prophylaxis antibiotics for certain procedures outweigh the benefits. These guidelines represent a major change in philosophy. The new guidelines show taking preventive antibiotics is not necessary for most people and, in fact, might create more harm than good. Unnecessary use of antibiotics could cause allergic reactions and dangerous antibiotic resistance. Only the people at greatest risk of bad outcomes from infective endocarditis — an infection of the hearts inner lining or the heart valves — should receive short-term preventive antibiotics before common, routine dental and medical procedures. Patients at the greatest danger of bad outcomes from IE and for whom preventive antibiotics are worth the risks include those with: artificial heart valves a history of having had IE certain specific, serious congenital (present from birth) heart conditions, including: - unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits - a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter interventions, during the first six months after the procedure -any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or prosthetic device a cardiac transplant which develops a problem in a heart valve. P.S. all photos and pictures will now be created by yours truly to avoid copyright infringement.
2006 Medical Weblog Awards are here! Go here to vote. Im not nominated. Like, whatever, man. Who cares about your stupid contest anyway. Next: My interview at North Shore-LIJ.
Ive enabled word-verification for comments after deleting dozens of spam comments. I had a dream the other night about how to get back at them spam commenters. I thought about becoming a hacker, an uber-h4XX0R, dealing out DOSs attacks to the sites the spams link to. We would be locked in epic combat, me versus the spammers, using ever-more sophisticated tools to punish the wicked spam-commenters and protect the innocent bloggers. Then I woke up. Happy New Year!
Imagine this was your drug rep. I was over at #1 Dinosaurs, and he said hed just been over at DBs, guess what he said: Just say no to drug reps! And I thought I was all alone. (US site down? WTF?) TANSTAAFL, people. As a doctor and prescription-writer, I consider myself a judge of what medications to give, or not. "And you shall take no gift; for a gift blinds those who have sight, and perverts the words of the righteous." -Exodus 23:8 And now Ill repost (theyre that good) Robert Caldinis "Six Weapons of Influence". "* Reciprocation - People tend to return a favor. Thus, the pervasiveness of free samples in marketing. In his conferences, he often uses the example of Ethiopia providing thousands of dollars in humanitarian aid to mexico just after the 1985 earthquake, in return to past gestures Mexico had with Ethiopia. * Commitment and Consistency - If people agree to make a commitment toward a goal or idea, they are more likely to honor that commitment. However, if the incentive or motivation is removed after they have already agreed, they will continue to honor the agreement. For example, in car sales, suddenly raising the price at the last moment works because the buyer has already decided to buy. See cognitive dissonance. * Social Proof - People will do things that they see other people are doing. For example, in one experiment, one or more accomplices would look up into the sky; the more accomplices the more likely people would look up into the sky to see what they were seeing. At one point this experiment aborted, as so many people were looking up, that they stopped traffic. See conformity, and the Asch conformity experiments. * Authority - People will tend to obey authority figures, even if they are asked to perform objectionable acts. Cialdini cites incidents, such as the Milgram experiments in the early 1960s and the My Lai massacre. * Liking - People are easily persuaded by other people that they like. Cialdini cites the marketing of Tupperware in what might now be called viral marketing. People were more likely to buy if they liked the person selling it to them. Some of the many biases favoring more attractive people are discussed. See physical attractiveness stereotype. * Scarcity - Perceived scarcity will generate demand. For example, saying offers are available for a “limited time only” encourages sales." Strewth! --dex. P.S. Wikipedia is having a pledge drive a la NPR. Reflecting on my heavy use of it, I gave $20 bucks. You should too. Its one of the best things about teh intarweb.
Hulk is getting ANGRY! J/K. In response to Doctor, May I Have A Word?: First off, good post by Emergiblogs Kim McAllister. Second off, much respect. Third--sharps. I agree wholeheartedly. I absolutely endeavor to police my sharps myself every time. I even get a little miffed if somebody wants to "help" by picking up my sharps. This messes up my count. I dont want to be stripping the bed only to find out my sharps were picked up without telling me. Anyway, go ahead and remind me. I do not mind. I will thank you for reminding me. Safety first. Go ahead and remind me to wash my hands, put in orders, finish the paperwork, too. I dont mind. "Please let me push the drugs, doctor." I had a learning experience emphasizing this when I first pushed 5 of morphine. Silly me, I simply unplugged the I.V., fitted the syringe into the clave, and pushed 1 ml of morphine directly into the patients hand I.V. I watched, fascinated, as the patients arm turned bright red, creeping up from the hand. My previously AAOx3 patient said, "ooooh, Im itchy," and again I watched in amazement my patients rapidly deteriorating mental status. I stood there like a statue, transfixed by this metamorphosis, until a small, still voice echoed in my head--"Histamine release!". I snapped back to reality, and calmly asked the same nurse who had given me the morphine, "25 of benadryl I.V., please. Stat." The entire episode lasted about a minute, and the patient just as dramatically recovered after Benadryl was given. Lesson learned. No blood, no foul. Omerta! So yeah, you should give the meds, nurse. Not only to avoid above rookie-type mistakes, but also for the sake of documentation. However, dont look at me crosseyed when I want 4mg of Versed "to go," (accompanying delirious patient to MRI) or "5/2/1" mg of Haldol/Ativan/Cogentin "just in case," (okay, Ill evaluate the 250 pound gorilla in florid psychosis. No problem!) or the 20 mg of labetalol "for the road," that I want to be armed with as I escort my 92 year old pretzel with Afib/RVR to telemetry. Sorry if I bogart the chart at times. I always try to ask. Doesnt really apply in my ER cuz we got a pretty good EHR, with patient tracking and results reporting in-line with nurses and doctors notes, in real time. Slam! Respect for the triage and intake ritual. This usually isnt a problem for me--we are usually so swamped, I am 8 patients behind all the time--no chance to be chomping at the bit for more work. Almost a non sequitur where I work. You get first crack at the new patients coming in. Believe me, I am grateful you do this--forewarned is forearmed. Vital signs are vital, as they say. In fact, unless the patient is crashing right there, I want you to spend MORE time doing this. More than once Ive been blindsided by "historicus alternans," or inappropriate triage acuity. On my last shift in the ER as an intern this year, I picked up a 65 year old with a chief complaint of "dont feel well", triaged to low acuity. The patient had been waiting 4 hours or so. The history was almost impossible to obtain--the patient was verbal and calm, but confused. Relatives were in other states, and no primary care doctor could be elicited. No significant medical history or medication list could be elicited. The only corroborating story coming from the helpful but clueless neighbor who found the patient. The patients answers to all my questions were noncommittal, vague, or just plain "I dont know". Unsure of what I was looking for, I proceeded with my exam, which revealed an obvious global cognitive deficit, and mild motor weaknesses in the right upper and lower extremities. Patient in no acute distress. Vital signs rock solid. Puzzled, I presented the patient to my attending, lamely attempting a synopsis of the patients present illness, with a working diagnosis of dementia, geared towards my plan of "social" admission until home care or nursing home placement could be arranged. As my attending stared at me in disbelief, I became painfully aware of how pathetic my assesment really was. "Confused with unilateral weakness, huh? Whats her baseline?" my attending snapped. "Uh, she lives at home by herself." "Do you think that lady," nodding towards the patient, "could shop? Clean? Cook for herself?" "Uh, no." "So its fair to say that this is an acute change in functioning." "Yes." I surrender! "Did it occur to you that this patient had a stroke?" I look at him in horror as my stomach churns. "There was no history!" I blurt. "It took me 45 minutes to get a chief complaint!" My final defense--blame the nurse: "She was triaged to the lowest acuity! The chief complaint was dont feel well!" We upgraded the patient to the resuscitation area and activated the stroke team. I was struck by the ridiculous absurdity of this sudden rush to action, given that this patient had been docilely parked in a far corner for 4 hours. Coupled with an indefinite time period, anywhere from 3-4 hours prehospital, put her well out of range of any thrombolytic or interventional therapy. The head CT showed a large fronto-parietal infarct. The temporal sparing, ironically, is probably what prevented her being promptly diagnosed--no aphasia, and the other clue of acute onset of weakness was clouded by the confused and noncommital history. The attending saved most of his anger for the nurse for missing the (now) obvious signs of stroke during triage. The fact that I missed it too did nothing to assuage his righteous indignation, since the nurse in question had 20+ years experience. I am reminded of four rules I learned in surgery (okay it wasnt all bad); 1. Dont trust anybody. 2. Do it yourself. 3. Do it now. 4. Write it down. As far as waiting to take report from EMS until the nurse is present, Im right there with you. Thanks for the tips! --dex
Im worried. Worried that, come March 14th, the day of reckoning for all residency applicants, Im going to come up bupkis. My EM spot at Metropolis is assured, my inside guy tells me, but again, he is fickle, and who knows how much pull this guy really has? I started worrying for real when one of my interviews, actually one of my safeties, went south because they had no spots for PGY-2s. Briefly I considered asking for an interview for a PGY-1 spot, but after the hell I went through as a rotator in Surgery, I said nothing. Ive told people I wouldnt mind repeating PGY-1 in a linked program, repeating Surgery I dont want to do. So now my eggs are pretty much all in one basket at Metropolis. Ill have to admit, it seems like a sure thing, but another intern in my program is also rotating at that ER, and she is also wants a spot there. I need a Plan B. Options. Heres what Ive been thinking: 1.) Calling up the programs I didnt hear from and asking for an interview. Im going to do this regardless. 2.) Prepare for The Scramble--several EM spots in my area went unfilled last year, so I definitely have a chance. Id put my odds at 50-50 for this, though. Taking the USMLE ("U-Smile!") Step II, although unnecessary (Im a D.O., and have done well on the COMLEX II), might be an ace that would tip the cards in my favor. Ill have to plan it for late Jan or early Feb in order to have the scores back in time for the Scramble. Or I could take COMLEX step III, required for licensure. Easier, and perhaps more useful given some options Ive listed below. Post-Scramble: 3.) Scramble into IM or FP. Not exactly what I want to do, but Ive always enjoyed primary care. Actually, Ive always thought of EM as primary care on steroids, and I mentioned my primary care skills as a strength in my personal statement. Additionally, my FP mentioned hed like to retire soon, and intimated Id have a practice if I went FP. 4.) Hold out for a second round of EM applications. Id be growing a little long in the tooth for residency, and Id have next year to fill with some kind of meaningful activity: a.) EM research would be an obvious choice here, if I could get it. Probably would be a great resume buff to add publications and research experience in the field, especially given ACEPs mandate for research for residency accreditation. b.) Taking Step III as mentioned above and apply for licensure. Hit the streets and try to get a job as a "physician extender," maybe in a clinic or a private office. Maybe work some connections. c.) Medecins* Sans Frontieres: See the world, save some lives. Pros: learn another foreign language, get great experience, and who cares about money when youve got no debt and are living in a shack in Nigeria. Cons: would they even take me? Id be licenced but not board certified. Flying back for interviews would also be difficult, not to mention expensive. Family might help out, though. Parasites and privation would be a problem, but it would demonstrate my commitment to medicine as well as humanity. Might be a valuable lesson. d.) Join the military. As a doctor in the military, I think Id be part of the solution versus part of the problem vis-a-vis the Iraq war, which I was wholeheartedly opposed to from the beginning. Helping out our own guys or possibly even helping out some Iraquis, Id be doing my part. Sure itd be dangerous. But again, itd be a great experience, and would probably form the basis of any future residency application. Again, however, interviews might be a problem. With a little planning, it might work. However, with the ominous "stop-loss" program currently in place, the time commitment might very well be indefinite, anywhere from two years to four. Id be a great candidate for residency, but Id be at least 3 years out of med school, still looking for a residency spot. Although, the military has its own system of residency training... d.) Find work with Big Pharma or the medical device industry. Hold my nose, sell my soul. I hear the job market for doctors in medical companies is pretty good. Unpalatable, to be sure, but I gotta eat. Related posts at SDN: Scramble advice from a PD. List of unfilled EM spots for 2006. Getting interviews. Im not alone. Comments? *Changed "Docteurs" to "Medecins": Thx Dr. Couz! Jai besoin de perfectionner mon francais! UPDATE:Two more Interviews! Just shows to go you. I need to improve my negative capability.
Round and round we go... OOOH! New (to me, at least) ER blogs! More grist for the mill! Fuel to the fire! Throw another virgin into the volcano! BOHICA! Seriously, I love coming home and warming up to a nice long session of emergent goodness. The more, the better! Always room for one more! Avast, ye wretches and wenches! AARRRRR! Mr. Hassels Long Underpants -- SHAZAM! Cant believe I dint blogroll this before. Some choice tidbits: "Life threatening problems are easier to treat than patients who arrive with high expectations and non-life threatening problems." Amen, brother. "I am more than just a triage doc with ACLS/PALS certification! Not that I need to convince myself of this, but it irks me that some docs really think this of ER docs." Yeah, were just glorified triage nurses, or stuck in intern year the rest of our careers. Whats that, you say? Difficulty breathing? No sweat. You finally got those rock-hard abs you wanted, but the peritonitis got you down? Relax. Started your patient on Celexa and now hes blowing a deer rifle? Chill. Your patient will be here in the morning. Go back to sleep. Trauma Queen -- "I stand in the middle of the weirdest shit, big heavy scary stuff, the dead and dying, people whove "not been seen in ages" who we find festering on their mattresses, surrounded by a stained outline that saves the police some chalk, people whove slashed their wrists in the midst of a houseful of screaming relatives." Some potent prose there, pal. Hallway Four -- "One interesting thing that happened during the past month is that I did my first solo intubation." Yay! "Once you’ve paralyzed someone, they are completely dependent on you to breath for them, so if, for some reason, you can’t breath for them, they will die." Simple does not equal easy, eh? Remember, air going in and out, blood going round and round. "...the intubation went off without a hitch and we got her on a ventilator and her 02 sats improved and she stabilized and went to the ICU a few hours later." Congrats! Now do it 10,000 more times. Retire. Tatoo "DNR/DNI" to your chest. Await celestial discharge. Richard Winters, M.D. -- A diamond in the rough. Great stuff from start to finish. Too many delicious pithy morsels to list, but heres a few... "Dear Sir: Congratulations! You got the job! That is probably what you were hoping this letter would say. But it doesnt, because you didnt. Sincerely, Personnel Department" Yuk, yuk, yuk. Sob. "I think Taser should consider making a defibrillator gun. Id like to be able to defibrillate someone while standing 30 feet away. Id see v-fib on the monitor. Id whip out the Taser Defibrillator Gun. Id shout "CLEAR!" The patient would wake with a jolt of biphasic joules. Of course, I might miss and hit a nurse. That might hurt nursing recruiting." [Grin] "I see a fair amount of people who present as RTT with BBB. Rata-Tat-Tat with a Baseball Bat." Ill add it to the list. KnifeMan -- "I had to move small bowel obstruction out, and off to theatre, hope that stridor would hold her own for a bit. That gave me the chance to see dislocated ankle (with bonus altered conscious level) and pull the offending limb; once that was done, we whipped in dislocated hip - lots of pain, very anxious - albeit with no real success. This calm procession was interrupted by acute lower GI bleed (?perf) man, and his party trick, "the vaso-vagal". Once MY pulse normalised, I was able to attend to young fractured wrist , large scalp lac kid and the re-do ankle manip. In the background was a poor unfortunate lady with a broken hip. To add insult to her, already substantial, injury, her heart kept trying to give out on her. Time for a deep breath." Bread and butter, man...bread and butter. Trench Doc -- Intern stories: "While the intern was performing a rectal on a teenage female, the nurse decided to help the young girl by saying, “If you don’t relax, it’s not going to feel as good.” Wink, wink. Nudge, nudge. "Say no more!" "While attempting to reduce a priapism (pathologically engorged penis) an intern noted, “hmm, you know this is the first time I’ve ever held a man’s erect penis in my hand… it feels weird.” The patient was unimpressed." Like this --> :-| Or this --> :-/ "An intern, quite full of himself, yelled at a nurse, “why hasn’t the patient gotten the tylenol I ordered”… Nurse- “you ordered it to be given IV.” Intern- “that’s damn right, and that was 20 minutes ago” Nurse- “yes, and just like 20 minutes ago, tylenol still only comes in pills” HA HA! Stupid intern! [Rushes off to change IV Tylenol orders.] More later. Thats all folks! -dex
From the 30 tabs Ive got open all relating to EM. Saturday call tomorrow. The worst. Cake plays in the background: Sad songs and waltzes arent selling this year. Time to get the eye on the prize--EM residency. Immerse myself in it, and forget my suffering. "He who has a why to live, can bear almost any how." --Nietzsche. So, a little exercise to remind myself of joy. Free association/Google treasure hunt to "Emergency"--Go! Charity Docs -- lawsuit woes--respect medicine--fear is your ally--a doctor with a reputation for safety or for recklessness? GruntDoc -- still having fun after all these years. Kim -- my teammate, my comrade, my right hand. Shadowfax -- You are judged by how you treat those lower than you. Go Dems! Dont let me down. Obama for President! Nick Genes -- Fellow ER res. The first ER blog I read. I read all his posts. Organized Grand Rounds, fer chrissakes. Props, man. Lets have a beer. Central Computah -- a salty ER nurse. I feel like I know him, like hes in my crew. Tells great fin stories. He would tell this story better than me: Pt: "What do you mean I cant see my doctor! Im in pain!" Platypus: "Doctors busy. You twisted your ankle playing weekend warrior. Its 3AM. You got pain medicine a half-hour ago. Youre obnoxious. Citizens with real emergencies get treated. Trolls who waste our time wait." Pt: "WHAT! How dare you! Ill have your ass! I know people! Im litigious! Do you know who I am?" Platypus [over his shoulder]: "Hey guys, he doesnt know who he is. Get the leathers--hes moving to the psych holding area. Seems hes suffering from acute Vitamin H deficiency." Aw yeah. Scalpel -- Dad? Is that you? My blog Attending. Panda Bear -- Yo, dude. Solid. Part medical travelloguer, part ER God. Mad Props. Cadeuceus -- Good writer. How about a new post once in a while. Mark Foley is SOO October. MORE! Dictate a post to your resident, I dont care! I want more! Dr. Couz -- Makes me want to move back to Canada--yes, Im a Canuck. Im politer than you! ER Docs got it good in Canada. I got a sneaking suspicion the Canadian medical system is the bomb. And dont whine about no MRIs when you can just crawl across the border and pay for it yourself, you need it so bad. At least Canada has a functioning and respected primary care system. There they understand that docs arent greedy, they just want to make enough not to worry about money so they can focus on patient care. Of course this type of system is subject to abuses, like in the UK where the system is a cruel joke. If Kafka and Ayn Rand had ever collaborated, their most fiendish allegory of apocalypse by bureaucracy would be canonized as gospel by the parasites at the top of the NHS. Tyson Lewis -- The fire in your heart is out. You are an artist as a writer. How it must hurt you not to practice your art. Please post more. Pretty please? [At this point I just googled "Emergency" to invite serendipity in for a chat.] Meditations in an Emergency -- And I thought my paragraphs were long. Dude. Trim. It. Down. Read some Hemingway. Brevity is the soul of wit, like the wise man say. Next. Emergency Medicine Journal -- Hmm. Interesting, if a bit busy. Wheres, like, the content? Bookmarked for further review--------------> Emergency.blog -- unfortunately, the prime www real estate is inhabited by a crackpot. Id be more likely to be asking this guy about why the CIA wants to kill him while wondering if his tinfoil hat could be used as a weapon. Wonkette -- The venerable. Not really EM relevant. Katherine Harris--TOBASH, yeah, but is this really an emergency? More like a sad inevitability. I guess its actually a painfully true commentary of EM. "Emergency" seems to have lost some of its urgency, neh? Baby Toolkit --In contrast to the myopic hysterics of the polymorphous perversity squatting at emergenc y .com (purposely misspelled to avoid backlinking), the eminently sensible syllogisms of citizengeek shine like diamonds. Overtly wrapping itself in the ancient stereotype of geeks as useless techno-fetishists, this blog seeks to propogate the association of "geek" with masculine competence and power. Associating "geek" with the Godfatherish qualities of problem-solver, deal-maker, or "Fixer" flies in the face of traditional high-school impressions of ineptitude, misunderstood obsessions, and pathetic meltdown under any kind of stress--a reputation for calm effectiveness being nigh anathema. But when the wheel of fortune deals you instant karma, who better to rely upon than the emergency geek? NNSeek -- The politics of triage. "Triage" in EM-speak is almost an article of faith. Failure at the top results in a bad situation turning into a disaster. This little editorial shows that Dear Leader should have an ER Doc as Chief of Staff. docuticker -- Dextromethorphan is a little-recognized OTC opiate used as a cough suppressant. Needless to say, lots of it ==> ER visit for some Narcan. "An estimated 12,584 emergency department (ED) visits involved pharmaceuticals containing dextromethorphan (DXM). This was 0.7 percent of all drug-related ED visits." And sudafed is restricted??? Lifehacker -- More on non-medical emergencies, this time from one of my favorite sites. A winter road-kit. Duh. Do it yourself, dude. Seems that preparation and a judicious aforesight re: your anticipated environment/situation is a common theme for mitigating emergencies. [Strokes chin thoughtfully]. Emergency.com -- Hey waitaminit! I thought I had already relegated this site to the dustbin! Seems the parent site/portal is a lot better than the blog. Unfortunately outdated--the table of contents has "Y2K" and "Bosnia" as glaring anachronisms justifying safely relegating this site to another google dead-end. FEMA -- the case study of Bushs leadership failure. Yes its his fault. Interesting deep-links for the attention-deficient: Grants and Assistance Programs for Emergency Personnel Protect Your Family and Property Prepare for Hazards "Emergency!" -- Eh. Google delivers what people link to. "Youll never go broke underestimating the intelligence of the American people" --P.T. Barnum. This post is way too long. Ill stop with a gem: eMedicine EM reference -- eMedicine delivers. Again. Nuff said. Go forth and learn.
X-posted from my comment to Scalpels post My Second Lawsuit. I very recently had a similar situation. I am a rotating intern covering a surgical service. One of my general surgery attendings routinely operates on very sick patients. R.R. was very sick with recurrent acute cholecystitis and a history of being 5 years s/p double mastectomy for breast cancer. She also had brittle diabetes, requiring 40 units of Lantus twice a day, 25 units of Aspart before meals, and still hit 300mg/dl at least once a day. Mr. R. was an active member of the community and a member of the hospital board. From 25 years of involvement in the hospital he had some knowledge of medicine, and he would routinely barge into the nursing station demanding this work-up, that consult, and the other expensive, irrelevant, time-consuming radiology study. They all turned up normal, including an extensive cardiac work up along with innumerable ekgs and serial enzymes. 2 weeks after admission the patient finally underwent laparoscopic cholecystectomy. She did well immediately post-op and was tolerating a full diet by POD#3. Everyone cheered, high fives all around and the seniors quietly disengaged themselves, leaving me and another intern to mop up the leftovers and discharge the patient post haste. Mr.R finally relented from his Munchausen-by-proxy and agreed to a discharge plan after several days of continual reassurance by myself and the team as to Mrs. Rs satisfactory recovery. On a fateful Friday I rounded on the patient with only a preoccupied 2nd year supervising, as both senior residents and the attending were elbows deep in emergency surgeries. The patient was complaining of mild chest pain, and I could see she was a mildly of breath. We dismissed these as chronic, for the patient had had thorough workups for both issues. "Just get her out," my 2nd year whispered as we left the room. I acknowledged his meaninful stare with a vigorous nodding, and rushed off to finish the paperwork. Mr. T., undeterred, called our attending, and demanded a pulmonary consult. 2 hours later, discharge instructions in hand, I reviewed the 2-day old CXR with the pulmonologist. I excitedly pointed out the mild cephalization, and Mr.R angrily pointed out a mild R effusion, which we had previously dismissed as sympathetic, with atelectasis. The distinguished lung doc summed up our observations, mildly pointing out the elephant in the living room--"Shes in CHF". "This is new," I thought to myself. Uh-oh. In a mild voice, the consultant suggested sligtly increasing the lasix, repeating the chest x-ray, and matter-of-factly recommended a cardiology follow-up. He left in a hurry without leaving a note. That left me (feeling nauseous) and Mr.R (visibly approaching critical mass) staring at each other in silence. I excused myself to call the cardiologist, double-time. The day was a-wastin, and I quickly put in for an EKG while paging the cardiologist. The team assembled soon after. The EKG and the cardiologist arrived at the same time, and we grudgingly conceded the obvious display of a-fib with RVR. We reluctantly got yet another set of cardiac enzymes. Mr. R, while not talking to various Important People on the phone, glowered at us accusingly. CHIEF RESIDENT said to my co-intern, "now, see...where you see defeat, I see opportunity." We brought up the idea of a transfer to medicine under the cardiologists service, but Mr.R refused. We were astonished, but went about transferring the patient to our telemetry unit. I went home, elated that I had not been blamed. I told myself this was another false alarm, and started drinking. Two days later I returned, grateful to find the patient had been transferred to the cardiologists service. A Pyrrhic victory. My joy curdled when I saw the patient. In the MICU. Intubated. Transmural MI. Mitral valve rupture. Shit. I conveyed my sincere condolences to Mr.R and left, dismayed by her clinical free-fall from stable, to fair, to guarded, to poor, to critical, in the space of essentially one 24 hour period. Mr. R naturally wanted heads to roll, and settled his sights on CHIEF RESIDENT, and curiously, on my co-intern. Seems my co-intern, an actual surgical intern, and a damn good one, had lost it the night previously to the disaster, and had rudely dismissed all of Mr.T.s endless criticisms and complaints, saying she was fine and would be discharged the following morning at the earliest opportunity. Mr. R blamed the intern for the entire debacle. Strangely, Mr. T. had developed an inexplicable affection for me, going so far as to write a letter of recommendation for me to the head of the EM department through his innumerable back channels. He told me my residency spot next year was a done deal. Not only was it in the same breath as saying my co-intern would be sacked after his meeting with the chair of surgery, but I hadnt even interviewed yet. I was dumbstruck. The whole thing is extremely weird and terrifying to me. My supposedly stable patient suffered a massive post-op MI under my nose, and I ignored the red flags my conscience raised because I was afraid of displeasing CHIEF RESIDENT. Thank God Mr.T. had the balls not to allow his wife to be discharged. Im really frustrated by his wifes decompensation, but at the same time Im thrilled to have such a powerful ally. Im a bit uneasy about it, though--TAANSTAFL. My career depends on the whims of a cantankerous godfather like this? Yeesh. -dex
THE FALSIFIERS, woodcut # 29 by Salvador Dalí.
"Virgil now hurries Dante on to continue the journey. The poets now look into the tenth and last ditch of the Eighth Circle of Hell, and here they see the FALSIFIERS. They are punished by afflictions of every sense by darkness, stench, thirst, filth, loathsome diseases, and a shrieking din. Some of them run ravening through the pit, tearing others to pieces. Just as in life they corrupted society by their falsifications, so in death these sinners are subjected so a sum of all corruption."This is what CHIEF RESIDENT thinks of me. His evaluation of my first month of surgery-- FAIL. Once more, with Feeling...
"...the falsifiers--alchemists, evil impersonators...counterfeiters, and false witnesses. These sinners, who in life, corrupted all, now are made to endure every sort of corruption and pain. Darkness, dirt, filth, disease, hunger, thirst and noise surround them."I have to repeat a month of surgery. AND!--- Wait for it...wait for it... Hes going to evaluate my second month of surgery as well, ending in 1/5 weeks. Guh.
X-posted from a comment to Dinosaurs post Ancillary My Ass: I agree with a thorough assessment before ordering any testing besides vital signs. Some points to consider with respect to testing, from the meagre experience of a lowly intern. 1. You cant make an asymptomatic patient feel better. Exception: screening--http://www.ahrq.gov/clinic/pocketgd.htm 2. In general, clinical suspicion comes before biochemistry comes before radiology comes before pathology. Example: 21 y.o. F, no PMHx, /c F/C & anorexia x 1d, 5x NBNB N/V, RLQ pain, Pelvic/guiac (-)-->Bl Cx, UCx, U/A, Chem7, LFT, GC/Chlam, RPR, PT/PTT, T&C-->EKG, CXR, XR Upright & Decubitus/Supine, CT Abdo /c IV/PO contrast, (+/-) RUQ U/S, (+/-) Pelvic U/S-->OR for tx and final pathologic dx. 3. Dont do a test unless it is going to change your management; alternatively, dont do a procedure unless you can manage the complications. Ex: Only use sedation if advanced airway management is readily available. 4. Incidentalomas are a bad thing. The more testing ordered, the greater the probability of discovering an abnormality that, once documented, must be investigated, however irrelevant to the current clinical problem. Many legal ramifications--ex: lung nodules, liver/kidney/ovarian cysts, slight anemia/hypertension/hyperglycemia/LFT abnormalities. 5. Poor communication/ history taking/ rushed sign out/ lack of PMD involvement leads to needless reinvestigation of stable chronic problems. Very common in patients with diminished capacity/ inability to communicate/ foreign-language speaking only/ lack of social support/ or with poor compliance. Overall, for common conditions, tests should be ordered mainly to confirm clinical assessment, to rule out rare or atypical presentations, and (unfortunately) to keep the sodomites at the door.
As I drag myself through two general surgery months in my internship, bleeding and drained, I still can not fathom the motivation that enables doctors to endure this torture. Surgery has a quasi-religious, paramilitary feel to it. With apologies to Dr. Sid Schwartz, allow me to vent. My chief resident has me parroting this refrain: "The chief resident is always right". Even when hes wrong, hes right. For example, on evening rounds, (I had literally just begun my call, and had been away for 18 hrs, a lifetime on a surgical floor) he mentioned that a particular, delicate, demanding patient was tolerating clears. I happened (being the intern, I am expected to have all information about the patient on hand) to have the orders list in front of me. There it was, the order HE wrote that very morning, for a clear liquid diet. This is unusual in that; 1) the chief resident rarely, if ever, writes orders himself; 2) that he would forget an order he wrote; 3) would fail to take advantage of an opportunity to pimp a hapless intern in the minutiae of patient management. I, keeping above drilled maxim in front of my thoughts, refrained from correcting him. Subsequently, he reported to the attending the same, which the attending plainly denied--it was right there in the orders--"DIET: CL LIQ". I received a verbal beating for failing to correct the senior resident, and was held responsible for his embarrassment in front of the attending. This kind of pathological evasion of responsibility is beaten into the training resident from the beginning, and represents to me part of the fundamental inhumanities of surgical training. You know, I wouldnt mind the 15 hour days, the narcissistic, entitled patients, the petty vengeful nurses, if I had some support from above. If theres no team, the whole thing falls apart. It reminds me of a conversation I had with an attending at a different hospital who wrote me a letter of recommendation. I asked him why surgeons have to start operating at 7 or 7:30, thus needing to round at 6 AM, thus making necessary prerounding at 4:30 or 5. He said it is because the surgeon is the ultimate doctor, responsible for every facet of knowledge of medicine as well as surgical mastery. In short, surgeons must be super-heroes. While the rest of us struggle to maintain our humanity in the face of death and awesome responsibility, surgeons reach towards some ultimate, the ideal, to be the ubermensch. Boing boings Cory Doctorow frequently refers to comic-book superheroes as "underwear perverts," and, given the surgeons chosen attire, Im not sure I disagree. My point is that, perhaps in struggling towards omnipotence ("The only way to heal is with cold steel") and omniscience (c.f. my attendings explanation), some essentially human aspects are minimized and overlooked, like compassion, responsibility, and appreciation. Its enough to be human--sometimes trying to be more than human involves denying simple humanity. One must be human.
This posts rating: HCPO-health care providers only. WARNING: Insensitive, cynical, insulting, derogatory humor follows. Im just beginning my 2 month (mandatory) surgery rotation. THe Surgical service and residency program is known to be quite malignant. Not too long ago, all the surgeons and ancillary staff were forced by risk management to take anger management seminars after several battles betwen surgeons and nurses in the OR, throwing surical implements at each other. Im a rotating intern, which means Im: a) completely unfamiliar with the idiosyncracies of Getting Things Done, b) agonizingly slow, c) a juicy scapegoat for any frustrations of my superiors, d) overwhelmed by my patient responsibilities, e) pimped and mocked twice daily on rounds, f) seen as a simpleton, charity case, or dismal failure by senior residents, nurses, and medical students, respectively and e) thankfully exempt from departmental politics (ass-kissing, back-stabbing, all other social climbing activities). Crumbs of thanks and praise I hoard and cherish like a refugee come from grateful patients and families. I reveal these to no one, they are mine. Black medical humor has been a delicious coping mechanism, to wit: TOBASH: Take out back and shoot in head AMF, YOYO: Adios, motherf*****, youre on your own! Total Body Dolor: syn: Acute Puerto Rican Syndrome, FABIANS, FHHS, FINE, Goldbricker, Status Hispanicus, etc, etc. Unfortunately, inevitably, and astonishinly completely unrecognized symptom of nonexistent Doctor-Patient relationship, see "AMF, YOYO". FHHS - (US) Female Hispanic Hysterical Syndrome (screaming and wailing) FINE - F*cked up , insecure, neurotic & emotional. Im not talking about the patients. :-/ FABIANS - Felt Awful But Im Allright Now Syndrome Assmosis: promotion by kissing ass. BOHICA: Bend Over, Here it Comes Again. PLGFD: Patient Looks Good from Door. Typical surgical progress note. Chocolate Hostage: Constipated. Snowed: Sedating an agitated patient with Vitamins A(tivan), H(aldol), or M(orphine) in order to shut them up. COPD - Chronic Old Persons Disease (unwell, no specific cause). CYA - My Prime Directive, the true indication for most medical tests, and the raison detre of bureaucrats. Paper Pusher - AKA "Voldmort," "Darth Vader," "Ghengis Khan," "Pol Pot," etc. Nameless, faceless, unaccountable, creeping carcinogen. Power over others from an impenetrable fortress of regulations, the paper pusher is entropy personified. DFO - Done Fell Out--either syncope (ER) or Ortho Consult if inpatient. FCBP - Fellow of the College of Bystander Physicians i.e. doctor having a look-see *Special Comment - Private (non-surgeons) IM Docs frequently round on our patients (unconsulted) and order limitless tests and procedures that not unfrequently delay discharge or directly conflict with our management, behind my back, i.e. repeated reordering of bicarb drips for non-acidemic pts, messing with vent settings, ordering tests irrelevant to the surgical problem but convenient for them, all under the surgical service. They shout "Ollie Ollie Ox-and-Free!" because it then becomes our problem, i.e. pos D-dimers on a pt about to be discharged, ordered at midnight the night before, without telling any surgeon. My secret weapon--order MORE tests and declare VICTORY by transferring the patient to their service. Ha! Whats that you say? Pt care suffers? Sorry, I dont have the spare brain cycles. Call for help from a senior resident? Whatever, dude. Blood from a stone. HAIRY PSALMS - Havent Any Idea Regarding Your Patient, Send A Lot More Serum. The rule rather than the exception. Intubate Mr. Johnson: What floor nurses do during a code, e.g. "Jesus is coming, look busy". /me ducks. LMC--Low Marble Count (i.e. low IQ). LOL in NAD - Little Old Lady In No Acute Distress. WNL - We Never Look. NAD - Not Actually Done. GOMER - Get Out Of My Emergency Room; A demented and abusive patient. TTFO - "Told To Fuck Off," or, when being deposed, "Told to Take Fluids Only". PPP - Piss Poor Protoplasm, i.e. coagulopathic. OB/GYN- "Oh Boy! Got You Naked!" Yuk yuk. PHD = Pakistani Healing Dance (a useless procedure performed for benefit of patient and family). PID - Pus In Dere (PID actually means Pelvic Inflammatory Disease). Slow Code - A full code run half-assed because of medical futility-see CTD. CTD - Circling The Drain, Fixin to Die, Trying to Die - moribund patient, especially poignant and pathetic when the family wants everything done, see Denial. Denial - Not just a river in Egypt. Crimea River... - Where all young health care providers idealism curdles. Dont forget the chorus: ...build me a bridge, and get over it. SOCMOB - Context of all traumas. The most dangerous activity known to man...Standing On Corner, Minding Own Business. Best place to meet "Two dudes". Two Dudes: Bin Laden is a choir boy compared to these criminal masterminds. Throckmorton’s Sign - in the unconscious male, the penis points to the side of the injury. UNIVAC - Unusually Nasty Infection, Vultures are Circling. Double-Oh Doctor - "Licensed to Kill" - A dangerously incompetent physician. Patients inexplicably, paradoxically swear by these Drs. See syn "Hand-Patter". Hand-Patter: A physician whose primary treatment modality is reassurance, often ignoring dangerous warning signs, and/or mismanaging simple medical problems, creating complications that are ignored until the patient guppies, then consulting every service in the hospital at once. Infuriatingly, their patients love them and revere them as medical gods. Alternatively, a doctor who admits patients with exceedingly minor, self-limited medical complaints, using homeopathic (vanishingly small) doses of medications until the patient gets bored, or the family comes back from Barbados. See "Pillow Fluffer". An endangered species; see "Sodomites". Sodomites - Medical malpractice lawyers, aka Ambulance Chasers. See "BOHICA". Carpenter - Orthopedic Surgeon. Plumber - Urologist. Guppy - a patient with agonal breathing. Looks like a dying fish. Pillow Fluffer - The Nurse counterpart of the Hand-Patter, Pillow Fluffers do anything the patient wants, ignoring unpleasant physician orders and neglecting actual competent nursing care. An endangered species, Pillow Fluffers are retiring violets who can not tolerate the fast-paced, dehumanizing, and brutal world of modern medical care. Urban Outdoorsman - Homeless person. Vampires - those who take blood samples, e.g. lab techs or medical students. Scut work - busywork unrelated/incidental to patient care; usually the majority of an interns (AKA "Scut-monkey") responsibility. VOMIT - Victim Of Modern Imaging Technology (i.e. try treating the patient, not the report from radiology; particularly referring to invasive procedures for false positives.) Wallet Biopsy - (US) free medical test performed by hospital insurance department before patient is treated. Zebra Hunt - for fever of unknown origin (FUO), or a (service) patient managed by a medical student. The student is indulged his improbable workup until the DRG money runs out, the patient is Turfed to Street, and the MS is told, "When you hear hoofbeats--think horses, not zebras." Also see HAIRY PSALMS. A disclaimer - take this in the spirit in which it was intended--a coping mechanism to deal with the constant barrage of death and suffering. An ancient samurai saying, "Treat every light matter seriously, and every serious matter lightly," Another one, "The situation is hopeless, but not serious." Amazingly helpful to lighten the mood and let everyone "reboot" and get back to our calling; the alleviation of suffering, the prevention of death and disability. Greet every insult with a grin, keep em guessing. Join us as we liberal hearts and artists bang our head against some mad buggers wall.
Asking for evaluations is a way to dilute responsibilty. Bureaucrats hate making decisions, especially decisions for which they will be held accountable. Evaluations and other forms of "decision support" are tools to deflect criticism if something goes wrong. Consensus is a totally gutless form of management employed by the spineless. -Panda Bear Sunday night. "CODE BLUE, RM._____, CODE BLUE, RM.____," came the blaring hospital intercom system. Damn, its 3 AM and Im the only doc in the hospital. The ICU nurses and I are the only ones who answer these Code Blue activations in the middle of the night anyway. Why cant they just call our departments directly by phone instead of blaring it over the loud speakers and waking up all the sick patients in the entire hospital??? -Charity Doc "Today, people think of us as drug-dispensing walking lawsuits who are in fact less informed than their Internet phones". -GruntDoc Do women dress differently when they ovulate? ...Dr. Kavokin presents a very exhaustive examination/explanation of the causes of Yellow Poo...You will know you are “in” with the nurses when they let you have the last piece of pizza... -Emergiblog "I heard about you used to do spinal taps with your eyes closed," chimes in another[resident at Scalpels residency alma mater]. "They said you preferred to do it by Zen." -Shadowfax New treatment for DVT--This blows me away. A deep venous thrombosis is crossed with a wire via a percutaneous approach, balloons are inflated on either side of the clot, a thrombolytic is administered through ports between the balloons (remaining in the target area), a spinning twisted wire acts like a blender which chops up the clot, and then everything is sucked back up into the catheter. Instant cure. -Scalpel or Sword? And other assorted excellence from my esteemed EN colleagues--see the links on my sidebar!-->
My uncle recently had an interesting case of gut trouble. My uncle is a citizen of Spain, and presented there with bowel obstruction. Details are sketchy, but somehow my young (49), vigorous, unmedicated, chain-smoking, life-loving firecracker of an uncle ended up with an diverting colostomy. Holy Cow! What? I thought he was gonna live forever! My odious grandfather was the sick one! My uncle is one of us! Young, healthy, oppressed! Recently, my odious grandfather passed away, leaving the sick role open for anyone to take up. My aunt tried to take up the sick role with her divorce and depression, but her essential youth, responsibilities as a mother, and my familys circling of the wagons bouyed her, and now shes fine. My grandmother, despite two hip replacements and age well over 80, is too interested in living to sacrifice herself to being sick. My father, the eldest child, is simply too busy, with too many responsibilities (including, until recently, me, now gainfully employed). That really left my other uncle, also a physician like my father and battling ankylosing spondylitis, yet with small children to raise. His time will come. My uncle, the jolly travel agent, was next. His entry into the healthcare system was abrupt, severe, and expensive. So after his colostomy, my father, an oncologist, arranged to have him fly to the States for the best medical care money can buy, at one of the nationally known best cancer centers in the U.S. (Hint: Not Sloan-Kettering), for surgical treatment of his supposed colon CA. He got a private room and lots of amenities that impressed my fathers family. His course was complicated by a laparotomy wound infection that left my uncles wound to close by delayed primary closure. Preop CT showed a thickening of the wall and constriction of a 10 cm length of ascending colon. Not exactly an apple core lesion, but good enough to resect. My father, the oncologist was concerned about cancer, but the lesion had not revealed itself on colonoscopy. I brought up the possibility of colitis and was ignored. Grossly, the 10-cm section of colon in question showed diverticulitis and concomitant colitis. THe surgeon did not appreciate any cancerous mass, but the final pathology report is still pending. Meanwhile, my uncle experienced a surgical site infection that required removal of his sutures, allowing the pus to drain. Now he has a 15 x 8 open surgical wound, is afebrile and recovering, but still with colostomy. My father wants to know about VAC dressing. At first I thought, "Is he on antibiotics? Why is he out of the hospital?" Then I remembered an old dictum from graduate school, "If you have a question, go to the library and look it up." Heres what I found: "Vacuum Assisted Closure® Fascial Vacuum Assisted Closure® (V.A.C.®) therapy (Kinetic Concepts, Inc, San Antonio, Tex) is a relatively new concept in the management of the open abdomen that allows for fascial closure as long as 1 month after the initial laparotomy. This avoids the need and attendant operative risks incurred with abdominal wall reconstruction in the future. The main functional component of V.A.C.® is the use of a nonadherent, polyethylene sheet to cover the exposed viscera and the placement of a polyurethane sponge under controlled negative pressure. The polyethylene sheet helps prevent visceral-abdominal wall adhesions that inhibit movement of the abdominal wall. The polyurethane sponge, when placed under negative pressure (suction), provides the countertraction required to inhibit abdominal wall retraction" [ed note: (i.e. "loss of domain," when the abdominal cavity contracts after full or partial evisceration (in Pepes case, an open (albeit with closed fascia from Alexs picture) laparotomy scar); if the wound was closed, the resultant increased pressure (because of decreased (contracted) abdominal volume) would create an abdominal compartment syndrome, decreasing blood flow to the kidney and mesenteric vessels. ) "and creates an environment where approximation of the abdominal wall may occur. The alternative is secondary (i.e. by myofibril contraction in the third phase of healing) healing, leaving a large scar after a prolonged (months) natural wound closure time, or delayed primary closure, possibly leading to skin grafts or subsequent infection." However, this seems moot given the ileostomy in the picture--hes going to have to be opened up again in the near future to reanastamose the bowel. But, the vac may assist in a shorter delayed primary closure in the subsequent laparotomies as well, given the reduced loss of domain. By the way, I hope this episode has impressed upon [uncle] to improve his lifestyle re: smoking, obesity, and sedentary lifestyle... Bonus: Surgical site infections patient risk factors: Risk factors: Systemic factors include age, malnutrition, hypovolemia, poor tissue perfusion, obesity, diabetes, steroids, and other immunosuppressants. Also smoking. Wound characteristics include nonviable tissue in wound; hematoma; foreign material, including drains and sutures; dead space; poor skin preparation, including shaving; and preexistent sepsis (local or distant). Operative characteristics include poor surgical technique; lengthy operation (>2 h); intraoperative contamination, including infected theater staff and instruments and inadequate theater ventilation; prolonged preoperative stay in the hospital; and hypothermia. All from diverticulitis (tics!) -the emergencist P.S. Yeah, I know this posts not technically EM, but "wound healing, revisited" is. Has implications for trauma, too. So there.
In response to some emails and some posts regarding my overbroad criticism of neuro PAs, I wrote the following email:
I appreciate the time you took to send a note-- As well, I am grateful you took the time to read my post. I hope you will understand my consternation at the situation I was in. Here I was, watching as the fabric of medicine fell apart. I am not entirely sure (I didnt bring it up with that particular PA) but I think a goof was made. Whether it was made by the ER doc, the neurosurgeon, anaesthesia (who I point the biggest finger at, since that was the rotation I was in--anaesthesia is meant (from my understanding) to be a kind of "medical" check to surgerys go-go-cut mentality--i.e. gee the patient should have adequate attention paid to his coagulation status before surgery.), or the neurosurgery PA, the patient is the one who suffered. In defense of anaesthesia, the case was done "emergently," meaning rapid sequence intubation, and then please STFU, anaesthesia. My understanding of the position of the PA in this is full of holes. I do not know how much responsibility they have. I know that my father employs NPs to great effect as "physician extenders"--i.e. they are equipped to make medical decisions and act basically at the level of a mid-level resident. Is this wrong? I know that my hospital employs many PAs in the ED for nonacute cases, SIGNIFICANTLY (via "fasttrack" etc.) improving the situation for both ER docs and patients. My dad loves his NPs because he doesnt have to worry thats theyre doing some crazy shit and not telling him, like some doctors that hes previously employed (and subsequently fired). NPs (and by extension PAs) are the perfect solution to this problem of the doctor (in my fathers case, an oncologist in a rural area) not being physically able to see all the patients. Given enough information from a trusted source, management can be effected, often with brilliant results, by a physician extender, in the same way that a decent resident (i.e. me) can enable a primary care doc to see maybe not twice as many patients, but maybe 1.5 times as many. Bullshit like documentation can be comfortably delegated to an experienced practitioner. At LAC+USC, where I bowed before the gods of EM, PAs who had been there 20+ years taught the residents casting, splinting, and suturing. Again, brilliant. HOWEVER. In this case, and with this particular PA, I feel he overstepped his bounds, failing to adequately ensure coagulation balance before the first surgery, which would have prevented the second surgery. Of course, if the first surgery was also emergent, then this whole episode falls under the category of "the patient had a complication because the patient was sick." This is partly the fault of the neurosurgeon. This particular PA has also berated and abused my senior attending anesthesiologist (with 20+ years experience in neuroanesthesia) for some bullshit I dont even give the credit of memory for. (extreme chutzpah). This mirrors the attitude of another neuro PA in a different hospital abusing medical students (namely me). So youll forgive me if Ive got a sore spot when it comes to neuro PAs. Ive had very favorable encounters with PAs in other disciplines. I value the role that PAs play as long as they dont aggrandize themselves above other doctors they work with, to the extent of unprofessional behavior. It just stands out more---that which may be forgiven in an attending is certainly not excused in a PA--which illustrates the difficult nature of the job. I have generally quite positive impressions of PAs and other "midlevel" practitioners, Dr. Crippen (NHS Blog) and his quacktitioner crusade notwithstanding. Midwives fill an absolutely critical role in my neighborhood, where I can count the number of OB-GYNs on both hands for a population of millions. so, my hats off to you, and sorry if I offended, Yours, Dex, the emergencist.So, to all you PAs, please accept this olive branch. I would just like to add that I did not start any fires at the time, either during the case or in the patient record. In the anonymity of this blog, however, Ill say what I think.
I page the attending anaesthesiologist. "Hello, Dr. H? The patient is in the room." "Already? Ok, fine." At this point, Id already seen the patient with the resident (the REAL resident, not me the fake resident. The morning lecturer had referenced a clarification about autotranfusion postpartum I had asked for after her previous weeks OB gas lecture, noting that "the medical student" had made a good point. Im still a little raw about it.) Id already gone through the history, a s/p posterior cervical laminectomy for numbness/weakness/paresthesias in fingers and toes the day before. The resident and I had already "lined-up" the patient with EKG, 02 sat, BP cuff, 3L nasal cannula, and transferred him to the operating table. All was left was to paralyze him, intubate him, and position him to the neurosurgeons preference. An emergent surgery for acute epidural hematoma. Curiously, the patient had also developed b/l DVTs between admission and , so for an unexplained reason they had already put a greenfield filter in--as medical management is the standard of care, however, perhaps they had already anticipated the current complication which contraindicates anticoagulation --epidural hematoma. However, the complication had already occurred? Why? This line of questioning had lead me to investigate lab values--INR 1.3--a little high. Why? No coumadin on board. No record of heparinization. Also no LFTs. Ah. My curiosity is piqued. How does a patient with an obvious bleeding diasthesis go for a week in the hosptial without liver function tests? I can only assume neurosurgical oversight. Reminds me of an old joke:
An intern and a crusty old attending were rounding the corner to the elevator when the attending spied one going their way. Moving with a speed heretofore unsuspected by the intern, the attending just manages to wedge his hand in between the elevator door and the jamb, whereupon it opens. The intern gasps, "Doctor! You couldve lost a hand!" The salty old medicine attending replied with a shrug, "Well, Im an internal medicine doctor. I dont really need my hands anyway!" The intern ponders this significantly as the doors begin to close again. The intern glances up and sees a surgical resident dashing towards the elevator door. Just as the door is closing, the surgical resident sticks his head in between the closing door and the jamb.So anyway, I mention the probable liver disease in this 65 year old man. "Ah well," he says, "it doesnt matter anyway." "But wont it make the patient harder to wake up? I mean, we should reduce the dose of anesthesia." "Nah." Not surprisingly to me, the patient took a full half hour to wake up and be extubated. I looked ruefully at the drainage bag from the posterior cervical incision site, draining almost 500cc of bright red blood (an indication of poor clotting, another indicator of severe liver disease) by the time we got to the recovery room. This patient came in without a primary care doctor. I think this is the reason why he got such shoddy care ( = ignorance of liver function status.) If an intern in a normally hypervigilant and over-testing-prone teaching hospital can spot a failure of care, its bad. On the ER note of this respectable, employed, family-oriented grandfather? "Alcohol use: 3+ drinks of hard liqour per day x 30 years." Nobody reads the ER chart. Sigh. -The Emergencist P.S. Yes I had a great time hyperlinking this post.
"Just trying to save a few lives: tales of life and death in the ER" by Pamela Grim, M.D. Warner, 2000. As I move through my hospitals departments, everybody asks me what Im going to be when I "grow up," a familiar refrain from medical school, only now Im a doctor, being paid to repeat my 4th year. Cant complain. Right now Im in anaesthesia, and this weeks subject is scopes. Endoscopies and colonoscopies. Guts. Poop. As a future ER doc, I have superhuman powers--among them is emotional immunity to all bodily fluids. As wet, Golytely inspired farts escape around the colonoscope, which looks surprisingly like a bronchoscope, or the endoscope, the GI docs grimace and apologize to everybody in the room, for the noise, and the smell, which is considerable. Most of us are concentrating on our tasks, and a little smile comes to my face as I think, "youre gonna have to do better than that to gross me out." Its surprising that a GI doc would have such almost Victorian attitudes towards farting, especially since his job consists of inserting tubes in peoples butts all day long. So one unusually talkative GI doc asks me, de rigeur, what Im going into, after similarly grilling and passing judgement on the medical students hopes and dreams (anesthesia: approval!). His reaction to my choice, EM, is kind of a pained, confused look. His explanation of his disapproval is, "why would you want to be an intern for the rest of your life?" i.e., presenting patients to specialists. His second criticism of ER is that, well, gee, you have to know so much! Yes, there are classic emergencies, bread and butter stuff, acute MI, stroke, sepsis...but what do you do if you dont know what to do and there is no specialist to save your butt? His example was a bad fracture of, say, a hand, where you have no plastic/hand surgeon to consult, for example in a rural ER. I was amused. Mainly becuase, even in my limited 8+ weeks or so of direct ER experience, Id already managed many open fractures of the hand, and started reciting the management, "well, youve got to explore the wound to assess integrity of the tendons and the joint capsules, and generally start antibiotics--Im thinking ancef, here--and dont close, cuz theyll need to do washout and further inspection...oh wait." Hmm, no hand/plastics/ortho? What to do if no orthopod is around or willing to carry the ball after you stabilize? Do you turn the ER into some kind of half-assed clinic or make an appointment with any available specialist, knowing full well that, unlike in the ER, wallet biopsies will be performed as triage in those offices? And so, on to the book review, and the darker world of a lone star ER doc. ER docs have a reputation for being "cowboys". In fact, its one of the aspects of ER that attracted me initially when I did my first ER rotation as a student on the opposite coast in a huge County hospital. How few consults and non-ER specialists I saw! A closed ER, where anybody there is ERs responsibility! How many residents I saw routinely handling cases where specialists in my top-heavy home hospital would fear to tread! They used to joke, after presenting cases for M & M, how all patients belong in "C-Booth!" corresponding to my current hospitals resuscitation room. The irony, of course being, that ER docs, especially at that hospital, would routinely and confidently manage complicated and decompensating patients that would make residents from other specialties croak in terror, making yellow stains all over their pristine white coats. Cowboys (and cowgirls!). Dr. Grim illustrates the flip side of this aspect of ER: [spoilers ahead! Avast!] that, given an impossible situation where help is nowhere to be found, YOU are the doctor. The buck stops with you. If there is nobody to pass the ball off to, youre it. She does so with cases of precipitous deliveries in the ER, including several stillbirths, maternal deaths, and one eye-popping case of anencephaly. Also cases of frustration and death, sometimes of colleagues (police officers are considered comrades and brothers-in-arms of ER ppl). Stories of beating your head against the wall, trying desperately to put your finger in the dam of afflicted humanity swamping our nations ERs. Walking wounded and the uninsured, punctuated by the occasional actual trauma or resuscitation. She talks of burnout. The dreaded B-word, second only in potency to the dreaded C-word. Ive heard tell that this happens much less often to board-certified and trained ER docs versus the "other" specialties grandfathered into ER work. The crux of the matter is this--since you are a cowboy, you must also undergo significantly more scrutiny, both from within and from without, of your management of cases you may or may not be qualified to handle. But you were there, and you were it. So you did your best. But the criticism doesnt care. Thus are born the seeds of destruction--self-doubt leading to burnout. Other contributing factors include simply the sheer volume and magnitude of bad news that you are intimately involved with. Death, disability, and disfigurement--ER docs are often the first, and sometimes, only doctors to take responsibility for such cases. According to the books phenomenology of burnout, you gradually lose contact with emotions and become numb as the emotional overload of suffering and stupidity and frustration, amortized over years, gradually strips you of your humanity. Personal insight is the first emotional capability to go--thus assuring your continued downward spiral if left unaddressed by coworkers, etc., since you are unaware of your ever-more-limited emotional and psychological coping mechanisms dissolving away. Eventually the only emotion left is anger, which quickly becomes your permanent and dominant emotion, subject to irrational outbursts and "small stuff," manifesting finally as burnout when the frayed nerves snap. She also describes insane schedules that contribute to burnout, like "after the tenth/twelth 12-hour shift," which is a bright spot as this situation no longer exists as far as I know. Side note--Im told by CHIEF RESIDENT that residents hours are limited to 60 (versus 80 for floor schlubs) and that they are calculated week-to-week, starting Monday, at least at my institution, with no more than five days of shifts per 7-day period. When I asked him about the difference between these hours and other residents hours, he said--its because 60 hours in the ER is like 80 hours on the floor. My other rotating interns experiences mirror mine in that you dont really get a chance to sit down or take a break for most if not all of those 12 hours. Her descent is vivid and gripping, although blog-like and autobiographically pedestrian (I was struck with the similarities between some of her chapters and some blog entries I had read) at times. A philosophy professor in my sophomore year at college (Robert Goff, Ph.D. at UCSC), a textbook unto himself, regularly dispensed such pearls as , "Dont psychoanalyze your friends!" which I remember and continue to apply in my life. One of these, echoing Bob Dylan, "Behind everything beautiful theres some kind of pain," was that yes, beauty comes from pain, suffering, and anguish, but theres a difference between true craftsmanship and simply spiiling your guts out onto the page. Im afraid Dr. Grim devolves into the latter at times, telling her best "war stories," without really integrating them meaningfully into her narrative. Other characters are flat, and the chapters are haphazardly arranged, jumping between time periods, linked only loosely by theme. One gets the sense of exploitatation of these patients pain in the service of the doctors effort to save herself, but we are not taken along for the ride. Still, a gripping account of the state of EM and healthcare in general in this country, linked together with a useful insight into the nature of burnout. -The Emergencist.