Glow-In-The-Dark Pee

R the nurse was walking down the hall with an open urine cup, looking at it and smelling it. That doesn't happen too often. It looked like it was glowing; Mountain Dew straight out.

"You should put that under a Woods lamp (a black light)", I said. So we did, and gosh darn if it didn't glow like a kid's glowstick at Disneyland.

So what's the guy's story? He was an ingestion, unclear history, suicide attempt for two days...perhaps he decided to add antifreeze to his list. Antifreeze has a compound called fluorescein added for this exact reason, because antifreeze kills kidneys, tastes sweet, and tends to get ingested by kids and dogs. And alcoholics.
His blood alcohol level came back at an impressive 0.390, which is a personal best for me; this, actually, was really good news. Antifreeze is fun for two reasons--one for the fluorescent pee, two because the old school antidote is a lot of alcohol. The two are metabolized by the same pathway, but alcohol is a better substrate, so if you drink enough, you can prevent the antifreeze from being changed into it's toxic metabolite.

As with anything that's 'interesting', the guy's antifreeze level came back very low. Possible we just missed it and he had peed it all out. But, a Google search also turned up a wide variety of things that turn your pee fluorescent. In fact, there was an article in a pediatric journal that discussed a random sample of 30 pediatric urine tests, 21 of which were fluorescent underneath a Woods lamp. None of those patients had antifreeze poisoning.

Turns out niacin and other B vitamins turn your pee fluorescent, among other things, including certain other medications. I also wonder about food coloring, especially in children (perhaps why 21 of 30 randomly selected had fluorescent pee--have you seen what they eat?)

So the next time your friend drinks a pint of antifreeze, take him or her under a black light and hand them a fifth of tequila. And, again I'm reminded, even the classic cases, aren't.

Jaded

The slow progress from naive to bitter I expected, but the first patient who burned me I didn't see coming.

26-yo female came in with lower pelvic pain and bleeding that she truthfully attributed to endometritis, and had a long history of work-up for the same. I don't know about the literature, but I've seen a couple patients have significant pain from this condition, where implants of uterine lining in the pelvic cavity cause pain secondary to bleeding; though outside the uterus, they are hormonally responsive. It's not fun, partially because the pain and scarring isn't life threatening, so patients tend to feel their complaint is minimized.

The nurse, Robert, recognized her immediately and warned me that she was a 'frequent flier', and had been to the ED numerous times in the past six months. Her first request for pain medication was for Dilaudid, which I've seen used multiple times in my first ED but not at my second. It's considered overly strong. Too fast acting, too likely to cause respiratory depression. I'm sure the high is killer. I'm also sure that the pain relief is both quick and dramatic.

Most patients who are opiate-naive don't have a favorite yet; they may remember what they had last time, but they often mangle the name or just don't remember. The nurse was suspicious from the beginning that she was exaggerating her complaint to get more substantial pain relief.

The work-up, as expected, was negative for any of the more dangerous causes of bleeding and lower pelvic pain like an ectopic pregnancy or a ruptured ovarian cyst. I went to check on her, and sat down at the bedside. She was shaking, sitting curled up. She said she was frustrated by the pain she was still having and didn't feel like she was under control; we had offered a Percocet script to take with her and a dose of Toradol (similar to ibuprofen) before leaving, but that wasn't sufficient. She said she'd call for a ride if we could help her control her pain.

I walked back to the attending doc, who said he'd be willing to do that after she called for a ride. So I went back and told her and she said she'd call and picked up her phone. I went back and told the doc.

"Did she call?" he said.
"She was going to", I said.
"She can't have anything until she calls and her ride is on the way", he said. Then he looked at me. "Here's what's going to happen. She'll say she's getting a ride, get the shot, and take off. Then she'll drive herself into an abutment with narcotics in her system".

I didn't believe it. I thought she was genuine. Then I went back and talked to her again, and she said, 'Oh, did you want me to call? I wasn't clear'. The context made it suspicious. Maybe she was just gaming me into getting her high. The tricky part was that she did have genuine pathology; no one was arguing that. The argument was that she was way too into a shot of Dilaudid. By the time she finished her plea, called, and then 'couldn't get a ride', she would've had good relief from her oral pain meds.

So that plea, where she was shaking and frustrated and talked about how her pain had gotten worse after the pelvic exam, all calculated? Who knows? Perhaps all genuine but just accentuated. These are the drug seekers I have to get used to, the ones who are really sick. The most egregious are sickle cell patients, classically. They get so zonked out that they'll be close to respiratory arrest and still requesting meds. No one, however, will argue that a sickle cell crisis is faked. You try having your hemoglobin precipitate out in your peripheral arterial system.

The IV component can't be underestimated, either. Benadryl would never be considered a drug of abuse, but in the form of an IV push (given in one dose) it produces a high just because of the route.

I guess I'm a bit more cranky and jaded than before my shift started. I still believe pain must be treated, but, just as with every other complaint, the world is grey--or, in the case of the ED, a bit green.

What do this shack and a little girl have to do with an EKG?

So there's a foundation, Hearts for Kids, that helps kids in Africa get heart transplants. That's awesome. This picture, from their website, is where their patients live.

I don't know anything about them, I just found them with Google while I was searching for rheumatic fever. If you do a Google image search for the same, you'll see a lot of black and white pictures from the pre-antibiotic era of people who died from RF, including Mozart. Then I saw this picture. Not black and white. Full color. Hmmm.

RF is still on our diagnosis list of kids with fever and migratory rash; it can attack the heart most famously, or cause people to have similar symptoms to Huntington's disease, also known as Syddenham's chorea. During a grand rounds last week, a distinguished class of residents at a top program didn't recognize a video of it. That video was taken in Africa. To learn about it, I've had to use the Internet, textbooks, and slides, because I've never seen a case, and likely never will until I travel overseas.

According to an NEJM article, rheumatic fever in the US has decreased precipitously. From being a more common topic than stroke in the era from 1967 to 1976, it is now rare, and a search of all medical journals in the US yields only eight articles between 1997 and 2006. But in places like that in the picture above--that is, the 80% of the world without access to prompt antibiosis for strep throat--there are 470,000 new cases of ARF each year.

What got me on this topic? EKGs, actually. Wolff-Parkinson-White syndrome is a sub-set of supraventricular tachycardias, or fast heart rhythms. It is a characteristic, classic finding on an EKG; there is a bit of an early rise in the QRS complex called the delta wave, and it represents a track of heart muscle that goes around the normal pathway of conduction. It typically does not cause problems (story to the patient) but can proceed to ventricular fibrillation (story to students) if you block the normal pathway.



Our hearts have a built in delay to allow for filling of the ventricles. Because the WPW pathway bypasses that system, if it becomes ascendant, it conducts directly from the atria to the ventricles at a rate of anywhere from 150-300 beats per minute. That is sometimes called 'badness'. If the patient is unstable, the best treatment is to shock them (electrical cardioversion). If they are stable but fast, a variety of drugs can be used; I learned that adenosine, which is usually used even in the field by paramedics for narrow-complex tachycardias should not be used for WPW, but some texts seem to suggest it is acceptable. I'll have to read more to figure out the differences.

WPW was first described by a few physicians, as often happens, but Paul Dudley White, who worked at Harvard at the turn of the century, described it in 1908. It is interesting to note why he became a physician, and to wonder why he decided to focus on the heart. He, like countless others at the turn of the century, before the advent of penicillin, lost a sister to acute rheumatic fever at the age of 12.

Tired

My speech doesn't slur so much as pause, catch. I'm still processing the last thought as I ask for the next.

Slow, and careful. Musn't miss.

Light is a soft glow at the edge of vision. Sounds encroach. Monitors pace thought, insistent, racing.

Moments magnify. As if the previous one isn't gone yet, new one already here.

My stray thoughts are of sheets, and food. Heavy, sweet food.

Standing in the middle of this river, current stronger than it appears. How tempting to float rather than wade.

To be the responsible one at 4 am.

And, finally, the morning air.

Genius Parade, part 1

At first he just laid on the backboard, stabilized. Two giant styrofoam logs on either side of his head helped keep him from moving.

Perhaps we should've left him there. He refused to tell his story. How did you get that 3 cm gash on the back of your head? Did someone jump you? No answers.

Try a bit of cajoling, which, of course, he doesn't respond to, being a young, drunk male. Where are you? What's your name? No response.

Normally, I suppose petulance works well to control your situation, but in an ER it's more likely to get you intubated, which I told him. He winked at me. Like, you understand, don't you? I can't tell the police what was happening.

Despite myself, my response at that point showed how old I really am. No, I don't understand you, genius. What the hell are you thinking exactly?

Restraints came next, eventually, as he got less and less cooperative and started to insult nurses, doctors, guards.

After we spun his head (CT) and found nothing, it was time to fix the laceration. It was a Y-shaped laceration with relatively clean lines that I could re-approximate well. Having done a few scalp repairs, I was hoping to try for a good result with a stitch at the Y that re-approximated the three angles loosely; Y-shaped lacs are notorious for losing blood flow at the middle of the Y since there is often a tearing force involved.

So that's where my head was. How can I technically approach this problem to get the best result for the patient, with regards to infection prevention and cosmesis?

His head wasn't at the same point. Just to get him turned over we had two security guards holding the limbs out of restraints. As soon as I started to irrigate, he started moving his head around, shaking it. To truly irrigate a wound the minimum amount is probably on the order of a 1/2 liter or so of tap water or saline. That didn't happen.

And my plans of stitching didn't happen, either. Once the wound was tolerably prepared, I asked him if he'd allow me to fix it, and he said, 'you do what you have to do, but as soon as you start, I'm going to go like this'--and he shook his head violently back and forth.

Now I'm less worried about him than us. There were four people in the room trying their best to help this genius, and the time it would take to suture him wasn't feasible. So he got staples. Less than 30 seconds, and his wound was closed. There was a touch of satisfaction that I would be lying to deny in stapling his head. 30 seconds was about all we had as someone had to hold his head down, and his free arm.

During the time we were screwing around trying to take care of genius no. 1, there were probably about 15 other patients that came into the ED and needed help, including a couple cardiac arrhythmias, a woman on the edge of sepsis, little kids that were really sick in the middle of the night.

Re-reading this post, I can see my writing is a bit choppy and odd. Probably because I'm still suffering from counter-transference--that is, strong feelings that arise in a provider in response to a patient that should, ideally, be put to the side. Not always so easy to do.

Perhaps I'm younger than I think, and still too close to the time in my life when I made my own stupid decisions. He certainly made it difficult to help him. Perhaps I'm not the most patient person by nature. Or, perhaps I was starting to be aware of everything going on in the ED that needed attention.

I'm still sorting this one through. What are the consequences of helping everyone? Can you make a judgment on how deserving someone is of help? If so, how?

In the meantime, I'll try to be less of an idiot, if only for the sake of others.

'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.