'stop if you see brain'

Probably you saw the photo before you started reading. Probably the correct response, if there is one, is 'dear Lord', or an expression of your choice to that effect.

That's about right. That's what I say to myself too. A couple shifts ago I spent five hours on scalp lacerations, including history, eval, and then repair.

The first one was a bit silly; poor anxious girl had banged her head on the visor of her car after running into a post at 5 miles an hour and was more upset about what dad was going to say than the lac in her forehead. Aside from poor anesthesia, probably secondary to her anxiety, it was a quick repair.

The second was a stoic swiss farmer who had fallen off an ATV and hit god knows what; he had four inches of a jagged tear. The ED was busy. I went in to clean and evaluate it.

"Any pain here?" I asked, tapping on his exposed skull. His exposed skull. When I went in, the attending said, go ahead and clean it out well. Stop if you see a fracture or exposed brain. Always good advice, stopping when you see exposed brain.

The ED was still busy. Attending came in, looked, and said, 'OK, well I'd close with a couple sub-Q for approximation and then staple it. Let me know when you're done.' Twenty-three staples and five sub-Q dissolveable stitches later, it was a nice Frankenstein scar down the right side of his forehead. But it wasn't bleeding. And the bits of hay and dirt were gone.

Despite myself, it was an amazingly satisfying complaint. The guy needed help, but there was no way he was going to surgery. The perfect wound care challenge for the ED. And now, when I walk into a room with a lac and they say, 'have you done this before?', I have a lot more confidence in saying, 'yup'.

Wow. I can actually deliver care, instead of just going in and talking to someone. Gotta love this job. A small part of me still whistles internally as one would witnessing any dramatic incident from afar; the part that drives me at work steps up and sees what needs to be done. So much still beyond my experience, obviously. But there's getting to be more and more I can handle.

BTW, please don't ride your ATV without a helmet. Thanks. Remember how lucky the patient in this story was. His CT was normal.

Exam Under Anesthesia

Ah, ethics.

The OB rotation includes the requirement that medical students participate in 'exams under anesthesia', which are completed in almost all surgical specialties. Orthopedics is another rotation where you can learn a lot from these situations.

In OB, though, I'm not so sure it's so straightforward. Technically, we're performing an extra, and theoretically unnecessary pelvic exam. That's a bit different than an extra knee exam. And this with the patient unresponsive.

ACOG, the governing body of OB, says that exams under anesthesia are allowable with specific consent. But, like all things that involve consent, they are put on the form but not typically discussed in length. How many people would consent if you said, 'is it OK if the med student performs and extra exam on you while you're out?' Probably, some would, or even most, since many are open to helping education.

I completed these because, even though it felt weird, I would've had to cause a big stink to not do it. But ethically, we've been taught that we should avoid even the appearance of impropriety. Does this count? Is this something that is emotionally important enough to specifically discuss in consent? Or am I just uncomfortable? Probably I'm just uncomfortable.

There are a lot of times when we inconvenience patients for educational purposes. I think the way to deal with that is to recognize the debt you owe to all patients for those that helped you learn, and repay that debt with quality care.

But those exams still make me uncomfortable.

"Who are we to play God?"

I'm down to a post a month. Sorry. Things should pick up soon. Currently I'm taking a break from multiple choice questions contrasting various treatments for a rectocele, which, by the way, is caused by a loosening of the levator ani fascia, and results in the rectum encroaching into the vagina.

I have my doubts about my future career proceeding in uro-gynecology. Not that there's anything wrong with fixing such problems. Anyway.

OB has been hard to write about. But I figured it out reading an article in the NY Times about gender selection. The director of a prominent fertility center in the above article perhaps questioned a doctor's right to play God, but, interestingly enough, he was in support of allowing a patient to choose the gender of their child. He essentially said, if the patient wants to have a girl, who are we to play God and prevent them from making that choice? Clever, to turn the argument on it's head that way.


Aside from chuckling at the inversion of logic evident in such a turn of phrase, it got me thinking that doctors constantly play God, so to speak. Fertility is an obvious example. But every operation or intervention is essentially an attempt to monkey with the divine design of nature. Are we not playing god when we insert three or four instruments into someone's belly to extract a hemorrhagic ovarian cyst? Certainly we are not trusting to nature to sort things out. Certainly there is some element of intervention there.


And we would not have it any other way. The hubris necessary to even think of taking a person caught in a car accident, opening their stomach, and ripping out their bleeding spleen in a matter of minutes is a bit mind-boggling. Thank goodness we do it. If we weren't a bit hubristic we'd be paralyzed by indecision.


But what's the real difference between that and fertility other than speed? The person in the car accident may have made any number of questionable choices, just as some say fertility seekers and the doctors who treat them are on shaky moral ground. The trauma victim may have been a 21-yo, intoxicated, unbelted, ejected driver found on the scene of a multi-car accident unresponsive. In the absence of any recorded spontaneous resuscitation and splenic rupture repair in the field, I'd have to say, we're 'playing God' and altering the natural consequences of his choices.


So to say that fertility docs are somehow monkeying with God's natural order more than doctors in general is a bit false.


I don't actually support choosing a gender, and I think most couples who want the most expensive fertility interventions should actually adopt, since they often aren't using their own genetic material anyway. But that's my personal opinion, not my professional one. Let's face it, we're playing God all the time. Perhaps the real hubris comes when a doctor says, 'you may play God', and, faced with someone else, 'you may not'. Perhaps the very argument should be discarded altogether.

This one isn't sorted out yet, more later. Back to Burch slings and cystoceles.

NY Times Takes on Pharma

The New York Times has recently had two fascinating and, I think, accurate articles highlighting the relationship between doctors, health care, and pharmaceutical companies, in anemia treatment, and in antipsychotic use in children.

I posted once about problems with the use of antipsychotics, but this is a whole different issue. This is a major problem. It looks like doctor's groups in NY that were prescribing variants of EPO, which boosts red cell production and is thought to be useful in conditions like chronic kidney disease and chemotherapy, were receiving rebates from the pharmaceutical companies based on how much they gave patients to the tune of millions. Millions. Sounds a bit fishy. Getting rebates based on the drugs you give people.

Then, there's a second article about psychiatrists receiving payment from drug companies in Minnesota, which publishes such statistics unlike most states. It said the most money received by a doctor was over $600,000 in a year.

Now, I'm usually one to point out that doctors don't make as much money as CEOs, or business folks, or lawyers; in a recent book, Better, Atul Gawande pointed out that the return per year of schooling for doctors was on the order of 16%, as compared to almost 30% for business school. Still, we're not about to end up in the poor house as a profession. We should know better.

There's good evidence that these trips and gifts and, well, cold cash in bank accounts, influence prescribing practices. It seems obvious with enormous rebates, but it's true even of the pens and note pads. Ask your doctor about it. Go ahead. And check out a site that some doctors have started in protest, called No Free Lunch. It has just started a directory of providers who have pledged not to accept gifts from pharmaceutical companies.

Yes, we need drugs. Sure. But we don't need to be paid by the companies that make them. Sheesh. And we all supposedly took ethics in med school. I suppose it's easier for me; drug reps aren't allowed to visit UW physicians. I've never seen one.

Merlin Deficiency

Neurofibromatosis has two types; medical students are taught to think of it whenever they see cafe au lait spots, literally 'coffee with milk' according to those crazy French people who, as Steve Martin says, 'have a different word for everything'.

A couple interesting things. We associate these with all sorts of syndromes in children, but it turns out that something like 1% of caucasians and up to 27% of african-americans have 1 to 2 spots (as found and presented well by a classmate). Like unequal pupils, most of the time this doesn't mean disease.

Still, neurofibromatosis sydnromes are associated; these people deal with a variety of tumor types that grow out of Schwann cells, normally responsible for covering peripheral nerves in myelin, a sort of insulation that speeds transmission and makes life possible. Depending on the type these can be on the skin or, commonly, in the eye or ear.

But the real reason to post is that the alternative name for the gene in type 2 is 'merlin'. As in, the wizard. So, it's correct to say that the little girl receiving chemo down the hall right now for a resistant optic glioma has a shortage of magic in her life; specifically, a shortage of tall, long-bearded wizardry.

Gorgeous

The iris is ignored. Unless there is an iridectomy, and irregularity, ophthalmology goes right past the iris after checking for sufficient anterior chamber depth. But I think it's gorgeous. These pictures on the web discuss the beauty of their subjects, but they miss the patent fact that the iris is a thing of beauty in ninety year old veterans, too.

Look at that thing. The texture is wonderful. Irises like Saharan sand-dunes, like kelp in the Pacific. And when you look at it, it moves, contracts, bunches up and then relaxes. Sure, lens, retina, fovea, hemorrhages, optic nerve, blah, blah, blah. But let's not forget the beauty inherent in our patients in or mad rush for pathology.

Wear Your Seatbelts

A classmate recently had a roll-over accident and sent out a mass e-mail reminding people to wear their seatbelts with pictures of his car.

I prefer to remember a couple of patients. It would start with a funny feeling, and then the pager would go off; a text page. Level 1, 24-yo unbelted ejected driver high-speed MVA, GCS 3. Then some vitals, unstable. His arrival is busy, scrubs, x-ray lead, and gowns blur around him, while I remember his head, bright red from across the room. His scalp is bleeding. His nose is bleeding. His ears are bleeding. He bleeds around his intubation. The blood pools in the antihelical fossa of his ear as it drains out of the canal. Blood, blood, blood. We take a stapler to the scalp, which is the trauma way of treating a minor injury. One can only imagine what his brain looks like. I clean the blood from his nose for a while, then stop. There are bigger problems.

Or, in rehab, another young man, recovering from an unbelted ejection from his car. He had been on his way home from picking up his brother upon return from Iraq. It's not hard to imagine, and indeed forgive, the idea of stopping for a few beers. Now, months after his injury, he can't speak, walk, or remember three objects you tell him to remember for more than five minutes.

So yes, wear your seatbelt. Put your children in their car seats. All the king's horses, all the king's men.

Can't Escape the Psych

'I don't know. I can't localize his lesion; he's had three episodes of left-sided weakness, he says it came on suddenly followed by headache, and he had pins and needles on both sides. So, if we were to go with one lesion, motor only, let's say, that could be his right internal capsule...but to have three episodes that resolve completely and last for days?'

Dr. S strokes his beard, says a non-commital 'yes', which means, 'I'm thinking of how to tell you what I think', and says, 'I don't think he's had a stroke. At this point, I'm hesitant to call it conversion disorder...there's always a kernel of truth to these. And, just because this isn't, quote-unquote, real, doesn't mean he can't have a real stroke'.

'What about the one-sided migraines that affect 0.00005% of the population?'

'Well, it doesn't fit the onset...and before you really go and lay your nickel down and say, 'I think it's migraine', we would need to rule everything else out...'

Conversion. As in conversion from the brain to the body, crossing the border, if there is one. Conversion disorder occurs most in young women with other psychiatric diagnoses. As in, 27-yo female w/hx of OCD presents with acute onset of bilateral pins and needles in hands along with right-handed weakness, worse in her fingers than wrist. Oh, BTW, she just had a huge fight with her boyfriend and he's moving out. There's no explanation for her neurological complaint. None. You can't put it anywhere in the CNS. So the patient 'converts' their emotional stress into a syndrome that fits their own idea of illness, and makes it real. The opposite of self-help.

Or, factitious disorder. The patient fakes it, but in order to take on the role of the patient, be cared about, get tests, perhaps in an attempt to compensate for some loneliness curled around their heart. We look at their hearts, often, with sound waves, with dye. We don't see the loneliness.

At extremes, people may contaminate their own surgical wounds, give themselves thyroid hormone. An historical precursor was named after a German baron, Munchausen, who told amazing tall tales upon returning from a war with the Turks.

That's him. But the idea that these patients are making up their lesions is somewhat more sinister than his tall tales of riding on a cannonball, or pulling himself out of quicksand by his beard. I've blogged about one before, the patient below who would put her head in the pillow to drop her O2 saturation. Perhaps not faking, but on a spectrum from the professional patient to Munchausen's.

Or, most distasteful, described in my lifetime, Munchausen's by proxy, in which a parent, usually a mother, makes their child sick deliberately in order to receive care for themselves. Perhaps I won't say any more about that.

These people are included with malingering in some articles, people who are faking pain, for example, in order to obtain narcotics. But I don't see them in the same spectrum. Imagine being so lonely that the attention of a stress test relieves some need; that the clustering of your family in a tiny room, with the gentle beeps of IV monitors to guide you, starts to feel more familiar and comfortable than home, or what passes for it. That seems worse than wanting narcs bad enough to complain about abdominal pain, a lot.

My world tilts a bit more towards the bizarre; or, more likely, I see a bit more of what's real. I still can't let go if the idea that he has the migraines that cause paralysis, and that's he's in that 0.00005%.

Anisocoria and PFO

25% of us walk around with a hole in our heart. When we're little, the foramen ovale allows blood flow from right to left without having to go through the lungs, which don't work right. But in up to 1 in 4 of us, it doesn't close, and we're never the wiser.

20% of us walk around with unequal pupils, anisocoria, which is a finding on neuro exam.

Just something to think about. Not all that looks broken, is.

Trach, PEG, SNF

"So, someone like this, who is already on the borderline of having her husband take care of her at home, with a major cerebrovascular incident, it's unlikely she'll be back...it looks like she's headed for", count them off on fingers, "trach, PEG, and SNF".

As in a tracheostomy, because she can't breathe, a PEG tube, which allows us to dump food directly into her stomach, and a SNF, or skilled nursing facility, which some used to call nursing homes.

She can blink, but can't tell her right from her left. She easily coughs with the whole-body-but-silent cough of necrotizing pneumonia on a ventilator; the sound doesn't come out, but all the lines on the ventilator go crazy. When she came in she couldn't even move; she was in a seizure that wouldn't let her move that lasted forever and a day. Status epilepticus.

She has infarct upon infarct upon infarct in her brain, three, layered, all of which could result in her waxing and waning weakness on one side; one way it is described is as an anamnestic respose, literally an 'unforgetting' that the brain engages in when put under stress. Old strokes become new again.

I keep wondering where mercy lies. The triad, the trach PEG SNF triad, an epithet, a plan, an epitath--would I want to be kept alive? Are these still people who can live meaningful lives? The same question comes up again and again for the 30-yo in an earlier post, off ventilator, on ventilator. He's strong, responsive, too. He can open his eyes sometimes, squeeze fingers, communicate. He was trached and PEGed today also.

The choice to withdraw care is somewhat like the choice to have an abortion. People who haven't stood in that circumstance can't know what it's like, and that includes me. If it were my parent, or aunt, or uncle, or spouse, I might want to keep them alive as long as humanely possible and longer. If it were me, I might be more cognitively aware than I thought. Would I feel trapped and ready to go, or would I cherish every flicker of light I could see through the skylight of the intensive care unit?

I guess we'll have to wait and see. My only advice from three weeks of seeing people vanish into their own bodies is that judgement on any decision about end of life care is not something to be taken lightly. Someday, we all might be trached, and PEGed, and SNFed.