My Pet Peeve

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

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FMOE: Toxicology Cases

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

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

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

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

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

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

2. What is the treatment?

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

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

1. What did the kid drink?

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

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

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

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

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

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

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

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


Learning a Craft, Revised

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

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

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

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

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

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

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

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

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

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

7th attempt DL: miss, no predicted difficulty.

8th attempt DL: success, no predicted difficulty.

9th attempt DL: success, no predicted difficulty.

10th attempt DL: success, no predicted difficulty.

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

11th attempt DL: success, no predicted difficulty.

12th attempt DL: success, no predicted difficulty.

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

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

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

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

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

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

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

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

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


L'il D

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

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

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

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

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

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

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

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


See Below

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

FMOE: Cope's Appendicitis

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

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


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

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

Physical Exam.

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

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


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

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

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

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

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

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

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

This is how I think.

The Thirty

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

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

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

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

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

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

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

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

Photo Credit

FMOE: The Apathetic Adrenal

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

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

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

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

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

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

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

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

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

Photo Credit.



I saw 155 patients this month, in 21 shifts.

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

That's 0.67 patients per hour.

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



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

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

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

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

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


Cases of the Priviledged

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

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

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

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

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

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

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

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


Some days you eat the bear...

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

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



You got an MRI for a stress fracture?

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

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

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

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

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



No joke, the chief complaints of the previous night.

I have a bruise. Of course, by ambulance.

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

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

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




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

'But she did have guarding', I said.

'What's guarding?'

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

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

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

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


Is That What I Think It Is?

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

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

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

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

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


FMOE: How To Not To Screw Up Headache Patients

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

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

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

Red Flags:

1: sudden onset.

2. "The worst headache of my life."

3. altered mental status.

4. true meningismus. See this post for what 'true' means.

5. unexplained abnormal vital signs.

6. focal neurological deficits.

7. worsening under observation.

8. new onset of headache with exertion.

9. history of HIV.

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

All Clear Signals:

1. previous identical headaches.

2. normal alertness and cognition for exam and for history.

3. normal neck exam. Our Brit attending does this well. Patient actively ranges chin to chest and looks up, looks side to side. Then, he supports the neck and asks the patient to go all floppy. He then gently but quickly turns the head side to side, for so-called 'jolt accentuation'.

4. normal vital signs.

5. normal or nonfocal neurologic exam.

6. improvement under observation.

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

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

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



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

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

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

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

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

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

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

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

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

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

My other favorite:

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

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

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

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

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


No Sissies!

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


FMOE, OB: Shoulder Dystocia

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

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

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

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

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

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

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

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

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

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

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

Reichman and Simon, Emergency Medicine Procedures, McGraw-Hill


Shoot. Can't Vote for McCain.

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

"anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)

"So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.

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


The MD-patient Relationship

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

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

FMOE: Obstetrical Bleeding, >20 Weeks

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

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

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

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

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

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

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

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

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

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

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

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

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


Umm, Not Our Fault, So Much

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

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

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

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

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

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

Total Cluster Averted

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

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

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

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

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

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


No Hay Ganadores

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

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

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

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

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


Interns Can't Move Meat

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

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

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


MedFlight Tribute Page

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


Dear God, No. No, no, no!

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

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

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

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

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

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

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



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

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

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

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

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

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

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

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

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

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


Iron Man = Hypomania

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

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

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

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

Why I Love My Gal

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

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

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


Waxing Poetic

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

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

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

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

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

Silver is the most popular color for automobiles because police surveys have shown that because silver is a bright color, silver automobiles are involved in crashes less often than cars of any other color.
Now, if that doesn't describe a politician, I don't know what does.

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


The Female of The Species

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

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


For the Dearly Departed

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

White Cloud?

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

White Cloud

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

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

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

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

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

Transition, Part 2

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


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

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

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

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

Me, MD.



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

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

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

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

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

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

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

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


The Laying On of Hands

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

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

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

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

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

Here's to the fun cases.


La Raza, or, Am I Racist?

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

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

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

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

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

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

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


Respect the Momma Bear

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

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

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

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

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

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

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

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