May 11, 2008
Anyone out there using the glidescope? I’d like to know what you think, we are thinking about getting one.
May 8, 2008
Says Whitecoat, ranting about the indiscriminate use of antibiotics, and I couldn’t agree more. In the last five years I’ve seen cipro transform from a “big gun” to a throwaway antibiotic, useless against skin infections and ineffective (at least locally) in one of four UTI’s.
So I too try to do my part. No shots of rocephin or Z-paks for the various ways viruses decide to show up in my ER: bronchitis, sinusitis, gastroenteritis, or my personal favorite: the all encompassing “viral syndrome.” Strep throat? Penicillin works just fine, thank you very much. Ditto amoxicillin for toddler pneumonia. No you don’t need anything “stronger,” there’s really no such thing, what you think of as stronger is really broad-spectrum, killing more varieties of bacteria, but unnecessary when we have a pretty good idea of what’s causing the infection.
So I feel good about my practice of medicine in this respect. Then again, I also feel good about taking the recyclables out to the curb, but for neither do I harbor any illusions of making a real difference. Just as your spouse might cancel out your vote this November, so too are my puny efforts negated many times over across the country in various pediatrician’s offices, family practice clinics, urgent care centers, and ER’s.
Not to mention there are ways of getting antibiotics without a prescription (my professional advice: don’t take fish antibiotics). But despite all the leaks in the system, and all the problems it has spawned, at least we still have some regulation. Many African, Asian, and Latin American countries sell antibiotics directly to the public, no script required. My eyes were opened to this long ago, during a spring break trip to Matamoras where I saw dozens of antibiotics available over the counter as if I was channeling directly into some uptight soccer mom’s wet dream. (I also saw a stand where you could buy ten tacos for a dollar, but that’s another story.) I would never profess to be any kind of expert on Mexican culture, but when you live in a county where one person out of every three is Latino you are bound to learn a thing or two. And what I’ve learned, not surprisingly, is that when antibiotics are readily available they are taken with alarming frequency. Throughout life for every symptom imaginable or even just for general health maintainance they are a country stuffing themselves with antibiotics like farm raised cattle.
But the problem with too many people is if they’re not ignorant, then they just can’t see past the boundries of their own skin to the greater good. And as bacterial resistance increases at ever alarming rates, new antibiotic technology emerges slower than ever (guess what: pharmaceutical companies care about developing drugs that you take for a lifetime, not for a week). We may very well be headed back to the abyss Alexander Fleming pulled us from eighty years ago, where people die from routine infections as we, despite all of our 21st century technology, can do nothing but stand idly by.
May 6, 2008
Recap of Last Week’s ER: The TV Show
A guy and a girl get in a bad car wreck. Unbeknownst to ER staff, they had just stolen tens of thousands of dollars worth of jewelry. The girl decompensated, and ended up in cardiac arrest. After undergoing an unsucessful emergency thoracotomy the team was ready to call the code. Not so fast, said the guy, brandishing a gun and ordering the team to keep trying. They recommended surgery, but having barricaded them in the trauma bay he refused them access to the OR. No surgeons no OR no problem, the ER team tried the operation themselves but unfortunately without much success. Meanwhile, word of the hostage situation made its way though the hospital, resulting in a mass evacuation and activation of law enforcement. Finally, it was clear that the girl wasn’t going to make it. After an emotional and tearful goodbye, the guy gave up his gun, whereby he was promptly shot in the head by a SWAT sniper.
Recap of Last Week’s ER: My Life
It’s 1:30 in the morning and there are only a few patients in the department. A quietness abounds, augmented by its unusualness, penetrated only by the hum of the fluorescent lights and occasional idle chatter. The nurse-who-likes-to-listen-to-music puts on some terrible sugary soulless 80’s tunes that I secretly like.
An old man with a history of constipation checks in because he can’t poop. After asking a few questions I have him roll over on his side, pants down below his hips and a chux pad underneath. I lube up the index finger of my double-gloved right hand and place it in his rectum. Sure enough, I meet some resistance and start pulling out chunks of hard dark brown stool. Again and again I keep digging until finally there’s none left. Using some wet gauze I scrub his bottom clean and then pull his pants back up around his waist. He now feels much better and is ready to leave.
I take a few minutes to offer a sincere apology to my index finger, who wonders what the heck happened as up until then we had been contentedly clicking our way across the internet. Meanwhile, after being kind enough to dispose of the stool-loaded chux the nurse starts emptying cans of air-freshener trying to cover up the smell of poo now emanating throughout the entire department.
No, actually it really isn’t much like the TV show.
May 3, 2008
Doc Shazam returns from Honduras with an fantastic story, highlighting how immensely gratifying real medicine can be. It is also a reminder of how privileged we are in this country, and the ridiculousness of the entitlements that it has spawned. Start here with Part 1, it’s definitely worth your time.
April 29, 2008
Me: Hi I’m Dr. 10/10, what brings you to the ER?
Patient: Cough, congestion, chills, phlegm…um are you the doctor?
Me: Your story is very concerning for a heart attack. You’ll need to be admitted overnight.
Patient: Can’t I go home?
Me: Your tests here are all normal. You should be fine to go home.
Patient: Can’t you please keep me overnight?
Me: This patient has appendicitis by CT. She’s had 12 hours of belly pain with migration…
Surgeon: Enough. I’ll be down when I can.
Me. This patient has appendicitis by CT.
Surgeon: (Pause, then with snark) Well why don’t you tell me a little more about them.
Me: This patient has appendicitis by CT. Good history, good exam, white count of 14, scan showing a dilated appendix.
Surgeon: What’s the white count?
Me: Have you seen this patient’s nurse?
Staff: She’s on a smoke break.
Me: Have you seen this patient’s nurse?
Staff: She’s at lunch.
Me: Have you seen this patient’s nurse?
Staff: She’s taking another patient upstairs.
Me: Hi I’m Dr. 10/10, what brings you to the ER today?
Patient #1: No habla ingles.
Me: Hi I’m Dr. 10/10, what brings you to the ER today?
Patient #2: No habla ingles.
Me: Hi I’m Dr. 10/10, um, er, do you speak English?
Patient #3: (Offended) Uh, yeah I speak English.
Me: This is a pregnant patient with a PE.
Obstetrician: Call cardiology I can’t manage a PE.
Me: This is a pregnant patient with a PE.
Cardiologist: Call OB I can’t manage a pregnant lady.
Me: What’s taking so long with the BNP?
Clerk: Oh I’m sorry I thought you ordered a BMP.
Me: Looking at triage note of well appearing patient.
Triage Note: Sudden onset of worst headache of life.
Me: What’s wrong with the computers?
Staff: Scheduled downtime.
Me: Hi, what’s this meeting all about?
CEO: How come you’re not admitting more patients?
Me: This patient needs to be admitted.
House Supervisor: We don’t have any beds.
Me: End of shift, everything wrapped up.
Clerk: Next doc just called, he’ll be 30 minutes late.
Me: End of shift, way way behind.
Staff: Hey next doc, what are you doing here so early?
Me: How come you’re here?
Patient: No insurance.
Me: How come you’re here?
Patient: I have medicaid, but no one accepts it.
Me: How come you’re here?
Patient: I work, can’t afford insurance, don’t qualify for medicaid.
Me: How come you’re here?
Patient With Great Insurance: I called my doctor but they couldn’t see me until next week.
April 24, 2008
Two shifts ago I saw twenty patients without admitting anyone. I couldn’t remember a day where no one came in. It felt kind of historic, like a no-hitter or something. The various consultants threw me a ticker-tape parade on the way home.
Turns out the universe felt compelled to make up for it. I saw twenty-five patients last shift and admitted nine of them, an insanely high number on an overnight shift when I generally see a lot of trivial stuff (Congestion for three weeks? Really? You do realize it’s two in the morning). A long night for patients and staff alike, and the consultants ended up keying my car.
I would like to humbly request of the universe to make this next shift nice and regular.
April 22, 2008
I stood behind a patient’s head, laryngoscope in hand, having made the decision to intubate.
As preparations continued around me, I reflected on whether this was the right thing to do. He was disoriented but in control of his airway by objective criteria and his respirations were strained but adequate. I worried that this was too aggressive, that once we hooked him up to the ventilator he would never come off of it. But he was old and frail and sick, and needed multiple interventions, and he seemed to be getting worse. I decided that not doing it now would mean intubating him some hours later, out of the controlled setting of the ER, with much less margain for error.
The usual drugs were pushed into his veins and I swept the tounge away and found in place of his vocal cords a stagnant pool of thin gray secretions. As I sucked them away and slid the tube in their place I felt a wave of vindication and relief because I was right about the intubation, and in fact he wasn’t just heading to that place he had needed it now.
And then I stepped back from myself a little bit and thought about how strange it is that I do these kinds of things, and that finding that fluid was the highlight of my day.
April 18, 2008
Like oil and water. Toothpaste and orange juice. Ectascy and diabetes.
So learned a recent patient of mine in dramatic fashion. In general I like sick patients to be nice and obvious about it so as to not mistakenly send them home, and he did not disappoint. As I walked to his bedside to ask him his name, his only response was to fully open his eyes revealing no colored circles but instead only the pale white sclera underneath. Pretty freaky, and even though that phenomenon is not part of any medical textbook I know of I went ahead and took it as a bad prognostic sign.
I began to take in the whole picture. Dry skin and parched mouth. Thin shallow respirations. A rapid heart beat with superimposed atrial fibrillation. A glucometer reading of ”HI.” Even though it’s an ER, it’s not all that common to see people teetering on the edge of death, and they are a group often withered by a long fight with some variation of COPD, cancer, fatty arteries, dementia. They almost never look like he did, a fit muscular teenager who in the race of life should still have the starter’s gun ringing in his ears, not the finish line in sight.
It was just the two of us in his room, so I left to find some help. It was busy in the department, and for a few prolonged moments it felt like I was living a bad dream, aware of some imminent disaster, needing to warn people who I knew were there but couldn’t find. Finally I tracked down his nurse and we went back into his room.
Where we found him sitting straight up, still white-eyed, arms flailing while trying to work his way over the guard rails and out of the gurney. We don’t ask a lot from you when you’re that sick, but we do kindly request that you stay in the bed. He was way past reason, so instead was intubated, and as fluids poured in through his IV his lab work begin to return as a parade of critical values. pH of 6.7. Glucose of 1,050. Bicarb of less than 2. In my young career it was the worst case of DKA I’ve ever seen.
The hospitalist picked up where I left off and over the next couple of days he responded to all of our treatments. For us the story had a happy ending — the tube was taken out of his throat, his lab values normalized, and he, maybe an hour or so from death, made a complete recovery. It was over for us but not for him. When it became apparent that he would make it his mom, a fantastic woman by all accounts, promptly yanked him out of the university, took him back home, and generally made him long for those days he slept critically but blissfully in a coma.
April 14, 2008
Your Tax Dollars At Work, Case #304,581
Posted by Ten out of Ten under ER, Life, Medicine[12] Comments
I am told that some people have normal blood sugars but I’ll believe it when I see it. As far as I can tell, everyone is either too high or too low.
Recently, I saw a lady who was an expert in the latter. She presented with her third hypoglycemic episode of the day. EMS was called out each time, where they would find her about as responsive as a tree stump. She would quickly normalize after getting some D50 run through an IV, and being unable to stomach yet another run to her house the medics finally managed to talk her into being seen in the ER.
I looked up her old records. She had fourteen visits for hypoglycemia in the past year and a half, managing to simulatenously beckon Death with one hand while staving him off with the other. Through medicare she had a family doctor, diabetic educator, and home health nurse but despite access to these resources she was unable to grasp basic elements of caring for herself, like knowing the name of her medicine or how to check a glucose level on her own.
I dutifully went through some diabetic educational stuff with her and her daughter and then left her to complete my fancy 21st century medical treatment: dinner.
A short time later the next chart hit the to-be-seen rack with a clunk. I pulled back the curtain and who was sitting there but the low sugar lady’s daughter, who just five minutes before I had been in a calm discussion with. Now she was complaining of one week’s worth of right shoulder pain, with a longer history of similar pain on the left treated, so she said, with narcotics by another ER up the road.
No, you can’t have any vicoden.
Speaking of this lady, I know how to solve America’s ER crisis, and all it would take is 25 bucks or so.
April 11, 2008
Sometimes as I’m interviewing a patient their eyes become big. They turn their heads, distracted, and cry out in pain. I sit still, unaffected, waiting for the episode to pass, as it eventually always does.
Kidney stone pain? Needles? Setting a broken arm? No, these patient’s suffer the torment of the automatic cuff inflating to check their blood pressure.
Even though they might think otherwise, these people have low pain tolerance (LPT). This is useful information, as it immediately becomes far less likely that anything is seriously wrong.
Note: while this test has excellent specificity for LPT, the clinican should recognize that the sensitivity is lacking.
