Fingers And Tubes In Every Orifice

Blissful Ignorance

2007-06-12T16:43:00.000-07:00

Hey all! Blogging to ya from a remote tropical place where the sands are sugary white, the wind blows hard, and those little drinks with the colorful umbrellas never stop flowing. Being unemployed have never felt so relaxing. Truly this windsurfer's paradise. It's so awesome pulling off a duck jibe on a 65 liter board and a 4.0 sail. Rippin' it every day, man! The wind here is just unbelievable, steady and hard, while the water stay calm without the chops. But on the south side though, the waves breaks hard off the reefs. Oh man, perfect for wave sailing and surfing! Just visited the local ER, too, and they're hiring! Sweet! Tempting, but I haven't made a decision after the interview.

The internet connection here is slow and spotty.

I just checked Technorati and discovered that there's a healthy discussion here about one of my post. Unfortunately, many of these folks are non-medical and think that ambulance abuse is a rarity!

The Calling

2007-05-23T10:43:00.000-07:00

My 8 y/o nephew interviewed me the other day as part of his homework assignment for school. He asked me the ultimate question, "Why did you become a doctor?" I didn't want to disappoint an impressionable child with the truth, so I gave him the usual inspirational answers about wanting to make a difference, helping people, saving lives, etc... But the truth is, I didn't know what else to do at the time so I went to med school.

My application to med school was impeccable, I must brag. I was the total package, clawed my way out of the housing projects of Crack City to graduate at the top of my high school, graduated summa cum laude in engineering from a prestigious university with internship experience through several internationally recognized companies. Even won a couple of national collegiate engineering design competitions, too. I proudly enumerated all of my proud academic achievements and accolades on the application, of course. I also included 2 U.S. patents with my name on them, earned from my work as an engineer for 3 years with a very well known company recognized worldwide as the premier leader in its field. Heck the company pretty much has a monopoly in the area, and still does. Thank goodness I had the foresight to max out my employee stock options at the time. Oh, I also aced the MCAT to boot. But my career in medicine almost never happened, as my first med school interview was a complete flop. And I only applied to one school.

I walked up and down the corridors of the MOB (medical office building) looking for his office. Tucked far in the back hallway corner, I finally spot the sign on his door, Dr. Weinstein.

"Good morning, sir..." I introduced myself cordially.

"You're 15 minutes early, Mr. Charity," he grumbled in a deep baritone voice. "Why don't you just wait outside until I review your file and I'll call you back in."

I peered furtively into his office as he closed the door. There wasn't anyone else in there. It wasn't as if he was interviewing another candidate or something. Then why the hell was this man making me stand outside the hallway like a stooge, I wondered to myself. And since when is showing up early for an interview, or anything for that matter, a detriment? Oh this guy was a hard ass! I could tell from the very get go.

Exactly 15 minutes later, not a second more or less, the door re-opened and he instructed immediately, "Have a seat, Mr. Charity."

I didn't even have an opportunity to speak my mind. It was that quick and short.

"You have very impressive credentials, Mr. Charity," he tossed my files onto his desk, propped up his feet and opened the conversation. "Your essays are very moving. Powerful, I must admit," he complimented, "You're a very good writer. And the letters of recommendations, very persuasive in your favor."

My confidence was quickly shattered, though, when he sat up and dropped the hammer, "So, why the hell are you here?"

"Excuse me, sir?" I replied dumbfoundedly after being completely stunned by his informality.

"Why the hell are you here?" he repeated crudely. "It looks to me like you already have a successful career in engineering. You shouldn't be in medicine, Mr. Charity."

"Sir, I want to be in medicine...."

"Let's not waste each other's time anymore, heh," he interrupted. "You don't belong in medicine, Mr. Charity. You were born an engineer. Go back."

With that he stood up and showed me the door.

(To be continued)

Insurance?

2007-05-16T11:47:00.000-07:00

cc: "I think I'm pregnant again"

HPI: 22 y/o sexually active WF LMP "last month" c/o possible pregnancy. Denies pain. Denies vag. bleeding. Have not performed home pregnancy test.

ROS: 9 points ROS o/w neg.

PMHx: none
PSHx: none

POB/GynHx: G4P4Ao, all NSVD w/o complications, no STI's

PE: WDWN, AAOx4, NAD, ambulatory, drinking bottle of Sunkist soda.
HEENT: NCAT, EOMI, PERRLA, nonicteric
Neck: No LAD/mass/JVD/thyroidmegaly
CV: RRR, no m/r/g
Chest: CTAB no crackles/r/r/w
Abd: +BS, soft NT/ND, No HSM/masses. unable to palpate fundal ht.
GU/Pelvic: deferred since patient denies pain, VB or d/c
Back: No MT, no CVAT
Ext: 2+pulses throughout, no c/c/e
Skin: warm, dry, no obvious rashes
Neuro: grossly intact, no lateralizing signs, nonataxic gait.

Assessment: Young female requesting pregnancy test. LMP last month. Denies pain. Denies VB. PE benign. Abd. without pain on palp.

Plan/Dispo: Patient instructed to go to local pharmacy and get a home pregnancy test. If pregnant, f/u with her Gyn MD.

The above is the actual medical record documentation. The following is how things really transpired.

Me (after reading triage sheet and rolling my eyes): Hi, I'm Dr.____. I'm the doctor in charge of the EMERGENCY Department tonight. I see that you came by AMBULANCE. What was so bad that you had to call 9-1-1 at 3 AM to be rushed to the EMERGENCY ROOM by AMBULANCE? What is your MEDICAL EMERGENCY? What is your LIFE OR LIMB THREATENING problem??

Patient (clueless to the sarcasm): Oh, I think I'm pregnant again.

Me (thinking that this clueless girl still don't get it): You must be in a lot of pain or bleeding severely to come in by ambulance, huh?

Patient: No. I just didn't have a ride.

Me: So you're not having any pain or vaginal bleeding?

Patient: No, no pain. No bleeding.

Me: Did you take a home pregnancy test?

Patient: I didn't have one.

Me: You know they sell them at Walmart. They're open 24 hrs.

Patient: Well I couldn't go to Walmart in the middle of the night.

Me: So you took an ambulance?

Patient: Yeah, but my insurance will pay for it.

Me: Insurance? It says here that you've got Medicaid.

Patient: Yeah, that's my insurance.

Me: No, dear. Medicaid is not insurance.

Patient (quickly interupting me): Yes it is! That's my insurance!

Me: No, dear. Medicaid is not insurance. Medicaid is a government hand out! It's only called insurance if you're paying for it.

Patient: Well, what ever! Medicaid will pay for it.

Me: Good grief! You didn't have to take a $400 ambulance to the hospital for a simple pregnancy test.

Patient: But I didn't have a ride.

Me: You could have taken a cab. Surely you got $20 bucks for a cab. And those pregnancy tests are under $20 bucks at Walmart ya know. $400 bucks ambulance ride versus $20 bucks...You could have save us tax payers a lot of money, ya know.

Patient: My insurance will pay for the ambulance.

Me: Good grief! How many times do I have to tell you that Medicaid is not insurance? And it won't pay for nonemergent problems.

A quick 5 seconds physical exam. Push on the belly, no pain. Scribbled the discharge instructions and handed to patient to sign:

Go to local pharmacy and buy a home pregnancy test. Follow up with your medicaid assigned gynecologist if positive. If having pain or vaginally bleeding, return to ER.

Patient: So you're not gonna run a test to see if I'm pregnant?

Me: No, a possible pregnancy is not a medical EMERGENCY.

Patient: But my insurance will pay for it.

Me: Not if I don't order it. And even if I did order it, Medicaid...Oh never mind, just go to Walmart or any drug store and get yourself a home pregnancy test, alright. They're the same urine pregnancy test that we use in the hospital anyway, and it's much cheaper, too.

Patient (indignantly): So how am I gonna get home now? I got 4 kids at home.

Me: Well, you should have thought about that before you took an ambulance. Surely you didn't think that we would admit you to the hospital for a possible pregnancy, did you? Your kids are not at home by themselves are they?

Patient: You're a mean doctor!

Me: No I'm not! If I was, I wouldn't have ask about your kids. They're not home alone by themselves are they?

Patient: No, they're with a friend of mine.

Me: Alright. I'll see if the charge nurse can help you with a cab voucher home. There's also a cop here from your part of town. Maybe he can let you hitch a ride home in a while.

It's so frustrating trying to convince the local EMS folks to be not so fearful of litigation and have the balls to call their on line medical control and get a refusal to transport order for all these silly nonemergent problems.

Adden: I must issue an apology to all of my EMS brethens regarding the above statement. The problem is not with the heroic folks pounding the streets because they are only following orders and protocols established their chicken-shit administrators and medical directors who are the real ones fearful of lawsuits.

Another Quote of the Night

2007-05-15T20:26:00.000-07:00

From the same charge nurse to hysterical patient with a stuffy nose whose chief complaint was "I can't breathe" -

"Ma'am, if you can talk, you can breathe...Ma'am, just calm down...Ma'am that hole in your mouth is bigger than the two holes in your nose! If you can talk, you can breathe!"

Crushing logic, isn't it?!!

Quote of the Night

2007-05-13T12:30:00.000-07:00

Direct to you from last night's shift, wicked words of wisdom from Crack City ER's charge nurse to belligerent patient after polite attempts at diffusing a situation failed:

"Sir, as a nurse, I will clean your ass, I will wipe your ass, I will even stick my fingers up your ass. I will exhaust every effort to save your ass. BUT, I will NOT go so low as to kiss your ass. And rest assuredly, if you continue to piss me off, I will not hesitate to kick your ass! Now plant your ass down or I will take your temperature with my boot!"

Dereliction of Duty

2007-05-05T09:00:00.000-07:00

It's May. My last month at Crack City so I'll try to blog as much as I can before figuring out my next move.

On some nights I'm just so sick and tired, so fed up with it all that I just wanna scream and ask, "AM I THE ONLY ONE WHO GIVES A SHIT AROUND HERE?"

Case in point, father of this 7 y/o little boy brings him into the ED last night reporting that his mother's boyfriend had beatened him black and blue with a belt, to which the mother did not deny. The couple had been divorced for a little over a year. On physical exam, the little boy had indeedly not been spared the rod at all. His buttocks and back were ecchymotic, black and blue with scattered scabbed marks from numerous whippings and beatings. It was unbelievable. Sort of reminded me of a scene right out of the TV mini-series Roots where LeVar Burton, portraying the main character Kunta Kinte, had been lashed repeatedly across the back. Yes, it was that gruesome.

The father had just picked up the little boy from his mother's house as he had court allotted time with the child on Fridays, Saturdays & Sundays. Upon giving the child a bath, he noticed the horrendous injuries and immediately called the mother, notifying her that he was bringing the child to our ED and will be filing charges. Poor kid was sleeping soundly when he arrived, whimpered a bit during the exam.

"It's OK, buddy. This is Annie, the nurse. And I'm Dr.____. We're just looking, alright. We want to help you get better."

His eyes were scared, not knowing how to react nor whom to trust.

Now the mother openly acknowledged that the boy had been "whupped" by her boyfriend, but defended the SOB over and over by giving a sob story of how rotten and misbehaved this kid had been. Reportedly this kid has ADHD, violent impulsive behavior, had tried to burn down the house several times in the past, once lit a fire in the classroom at school, is on Adderal, zoloft, tegretol, risperdal, and a bunch of other psych meds to control his behavior. Hell, the list of mood altering prescription drugs that this kid is on just boggles the mind. It is absolutely unconscionable and irresponsible for any physician to prescribe that many controlled substances and drugs to a child. That list was as long as those we typically see in debilitating elderly patients or those with end-staged renal disease on chronic hemodialysis.

Oh, how the mother sobbed like a squeaky violin trying to explain that the kid wouldn't go to bed even though it was 2 AM, screaming at the top of his voice, throwing things in the house, kept on wanting to watch TV, yada yadda yadda. So the boyfriend, whom she lived with, spared not the rod. Damn son of a bitch. He beated the kid to a pulp. Yet the mother still defended and condoned his actions.

Armed with this latest injury to his son, the father remarked, "I'll be gettin' custody now!"

In response to the father's threats, the mother began telling a disturbing story of alleged sexual abuse against the child by the father, how the father has a large collection of child pornography, watches it in front of this kid, etc...and was somehow able to ditch evidence of all of it during the divorce proceedings and investigations. I suppose that's how she got custody of the child and he has visitation rights?

God, I was so nauseated and sickened by it all...He said, she said...the child was the unfortunate victim and I was sadly caught in the middle trying to figure out whom to believe. I had mother and father moved to separate consultation rooms at each end of the ED and placed a hospital security guard at the child's bedside.

"Where the f*k is that motherf'er!!!" I suddenly heard the profuse profanity from the hallway. "I'm gonna kill him! I'm gonna kill him! Nobody beat up my kid like that and gets away with it. I'm gonna kill that son of a bitch!"

The repugnant boyfriend apparently had showed up. Pandemonium erupted in the ED as you can imagine. We had to tackle down the father to keep him from pouncing the boyfriend.

CCPD naturally had been contacted earlier and as soon as the two officers showed up, the boyfriend took off like a hot rabbit and ran out of the ED through the ambulance entrance. Did this guy have a previous criminal record? I asked myself. Or was he just scared shitless about getting arrested for being a child beater? Hell, we should've let the father of the kid kicked his ass.

Here's where things become even more sickening and frustrating. Children Protective Services was of no help at all. I personally spoke to the guy over the phone but it took him over 3 hours to show up. The dude was a completely useless imbecile. He spent 2 hours interviewing the father, the mother and the child without offering any helpful solution to the problem. I had expected him to take the child into state custody until pending further investigation, but he didn't.

"So, what're we gonna do with the kid?" I asked when he was all done.

"Umm, we're very familiar with this family. We've taken several reports on them before. You can send the little boy home with his mom," the imbecile replied.

"What?!!! Send him home with his mom?!!! But the guy who has been beating this child lives with her! I ain't sending this kid home with the mom. No way! You need to come up with a better solution than that."

"Well, I talked it over with my supervisor, and..."

You can understand why I started tuning out whatever the imbecile had to say afterward.

"Listen, the guy who has been beating up this kid is still out there. The mother lives with guy in his house for goodness sakes! What makes you think that he won't beat up this kid again?"

"The father already pressed charges and the police is looking for him."

"That's good to hear, but they haven't gotten him yet, have they? Did you missed the part about the mother and this kid living with this guy in his house? They got nowhere else to go. And from my discussion with her, it doesn't look like she intends to move out anytime soon. What's gonna happen after the police release him or if he post bail?"

"What makes you think he's gonna beat this kid again?"

"Fk! Did you see the horrendous wounds on the back of the kid? Have you seen it?! Hell, it's a chance that I'm not gonna take!"

"Well, the mother has legal custody of the kid and we can't send him home with his father."

"Man, you're completely hopeless and useless. Thanks-for-nothing! When you're driving home later, think about what you just did and see if you can live with it. You make me sick, man! You should be ashamed of yourself! Child Protective Services my ASS!"

It gets even worse. I had the pediatrician on call paged. And he, too, balked.

"Hey, Phil I got this little kid down here..." I explained the situation.

"What do you want me to do about it?" came his totally unexpected response. "If CPS isn't going to take this kid into custody, what am I going to do? There's no medical criteria for admission here. Medicaid won't allow it. I can't do a social admit and be an indefinite baby sitter."

WTF!!! I argued back and forth at length with this pediatrician about doing the right thing, being a child advocate, protecting a kid from getting abused...but DAMN, all to no avail! He was a wall. When did this pediatrician lose his compassion for children? I sadly wondered. When did this pediatrician's decisions become solely business based? No medical criteria for admission? Medicaid won't allow it? Shit! I ended our phone conversation with much needed words of impugnity.

"You're peds, Phil, you're not suppose to be this jaded. We're not suppose to punish a child for the stupidity of the parents, aren't we? Where's your love, Phil? Where IS your love? Have you lost it, man? Have you lost it?" I hung up not giving him an opportunity to mouth back at me.

Oh, it gets worse. Desperate, I called the psychiatrist on call, who agreed that this child should be admitted for his safety but wouldn't do it himself.

"I'm sorry I can't admit him. He's not..."

I started tuning out his psycho babble...

"It's psychosocial, man. It's all related. I can't believe that you guys are so willing to load him up with a bunch of psychotropic meds but won't admit him when it becomes inconvenient for you."

So then, I called the hospitalist on call, who commiserated with my situation but quickly pointed out, "Look, I'm not peds. My liability policy does not cover 7 years old kids. I'm sorry, man." Oh, my God!

Desperate again, I called the surgeon on call and tried the trauma-related angle. "It's a horrible situation, but what am I gonna do but consult the pediatrician and social services like you already did. I'm sorry, man."

I didn't want to resort to having to wake up the hospital's Chief of Pediatrics nor the President of the Medical Staff. It would have been pointless and useless anyway. They weren't on call for the night and wouldn't have answered the page anyway. So, I placed another phone call to the police to see if they have anything to offer...NADA. "We can't take him to juvies..." I don't want you to! I was hoping that they would know of some social services or shelter that would take the child in until things were sorted out.

Child Protective Services - Strike one
Pediatrician - Strike two
Psychiatrist - Strike three
Hospitalist - Strike 4
Surgeon - Strike 5
Police - Strike 6

AM I THE ONLY ONE WHO GIVES A SHIT ABOUT DOING THE RIGHT THING ANYMORE?

I ended up admitting this kid last night to my hyperbaric service, because I can. It's the only inpatient admitting privilege I have. It's just easier for me this way, and with so much less aggravation of having to argue back and forth with a bunch of derelicts. Not to admit this kid and release him to his dysfunctional and degenerate parents would have been a true dereliction of duty. I was raised by a military father never to shirk duty and honor. And I was not about to disappoint him.

This morning, the HBOT team was completely surprised and concerned about why a 7 years old kid is on our census list. "It's another one of Charity's social admits again," they complained. The kid's wounds do not meet HBOT criterias of course. The morning doc in my group wasn't too happy about having to round on this kid so I told everyone that I would personally round on him myself and take care of his disposition come Monday. I'm not sure yet what I'm gonna do or how to even disposition the kid. For now, I'm just glad that he has a safe place to sleep for the weekend. So far the nurses have informed that the kid has been very well behaved, a complete angel and not a problem at all. Not surprising how a little love and TLC goes a long way, I suppose. The only medication that I wrote for him is Motrin and Tylenol as needed for pain. No psych meds. A hospital security guard is posted at his bedside, of course. Funny how the hospital security folks are the only ones who understand the situation and have not complained at all about having to post a sitter with the kid 24/7. I just added them to my Christmas list for the year.

Tricks of the Trade

2007-05-04T07:09:00.000-07:00

Our friendly blogosphere urologist Dr. Keagirl over at Urostream had this nice thing to say about us ER folks when she got called in to help with a difficult foley on a trauma patient. Grunt Doc thanked her for coming in on behalf of all of us ER guys.

One thing that has always puzzled me is...well here's the comment I left on her post with a little picture at the end:

Ditto, what Grunt Doc said.

I find that most urologists are very "ER friendly" and accomodating.

One of these days, I'm gonna have bribe one of them to show me some tricks of their trade in placing difficult foleys. Or at least get one drunk enough to reveal their secrets! Most of the time, the nurses have tried, at least over a dozen time with different size catheters. Then I get a crack at it with numerous attempts using different size catheters and coudets, from smallest to biggest as well... Firm grasp with the fist and pulling the penis straight up in the air toward the ceiling like we were taught during trauma rotation in med school, or angling it down toward the end of the bed, applying pressure at the prostate, pushing down against the bladder, some ativan, lots of KY and viscous lidocaine jelly, left handed, then right handed, then instructing the nurse, you grab I'll shove the catheter or, I grab you shove...and finally giving up myself after a few dozen exhaustive and frustrating tries. I then am forced to bow in humiliating defeat and have to place a consultation.

In comes happy-go-lucky, out-going urologist with the urology cart. One easy slip and it's in. Damn! Drives me nuts!!! Especially that smirk of triumph on their face afterwards every time. Oh yeah? We eased it up for ya!

I swear, it's a heavily guarded secret that they'll teach to no one else except one of their very own during some special secret session held only for urologists at some far and remote super secret locale where none of us mere non-urology mortals are allowed to know about or attend. I betcha anything that this is one of their esoteric board requirements for certification - How To Place Difficult Foleys And Make An ER Doc Look Like A Clown!

I knew it! I knew it! Look at the smirk on her face!

Look at her... gloating! ;-p

Toothache

2007-05-01T14:35:00.000-07:00

"Hey Liz, could ya bring back the lady with the toothache?" I asked the triage nurse over the phone.

"Which one? There are several of them out here."

"The 68 years old one who just came in. Oh, please put her in Room 5 instead of the ENT room."

"Why, you know her?"

"Nah. Just a hunch."

"She told me she's been having the same toothache for 2 weeks. Room 5? You sure?"

"Yeah, Room 5."

"Okay...the other people who came in before her will be very mad..."

BOOYAH! Tombstones!

"How'd you know?" Liz asked.

"How many 68 years old li'l lady have you seen coming to the ER in the middle of the night for a toothache?" I answered.

"None," she replied.

Bingo! It was really a matter of knowing about the generation gap and using it to your advantage that made all the difference.

As an aside, I hate it when people with toothaches come to the ED. There's nothing meaningful that I can do for them. It's really a waste of my time. I'm not a dentist nor am I an oral surgeon. It's not that I can't do dental extractions and such, because I've rotated through the OMFS service during residency as an elective and spent 2 months pulling teeth, drilling, filling them, wiring jaw shut a la IMF for mandible fx, etc... I don't claim to be an expert in the field but I've done many of these dental procedures before. I just have no desire to do them again for obvious reasons, as well as liability issues. Plus we don't even have the proper equipments to do things, nor do I have the time to perform these elective procedures in a busy ED either. And far be it also for me to claim to be as capable as a dentist or an oral surgeon in performing these procedures.

For many of these toothachers, their problems are chronic and they are nuisant frequent fliers to the ED. They know that we do not and cannot perform dental procedures in the ED, and have no oral surgeons nor dentists on staff either. Yet, they still show up in droves every night, again and again.

"Look, I know that your teeth hurt, but there ain't no pain medication nor enough antibiotics in the world that'll ever solve your problem! You need to see a dentist or an oral surgeon, not me!"

If I see an odontogenic abscess, I'll be sympathetic and will give narcotic pain meds plus antibiotics without ever giving them much grief. But the vast majority of these toothachers who show up do not have an abscess nor any clinical signs of Ludwig's Angina. They just choose not to see a dentist, granted that many will cite limitted financial means as a reason why they can't see a dentist and cannot afford an upfront wallet biopsy when they are greeted by the receptionists at the dental clinics. But still, why come to me? I can't help ya with that either. You don't ask a plumber to do an electrician's job so why ask an ER doc to look at your rotting teeth?

Plus many of these toothachers are drug seekers.

"How long have your teeth been bothering you?"

"Just tonight." Or usually, "2 days."

C'mon, I ain't no idiot. Those rotten teeth, worn down to the nubbins at the gingival line, have only been giving you pain for just 2 days? Do these losers really think that we were born just yesterday? I was taught the 4 P's in caring for toothachers during residency...Pain pills, penicillin, and punt to clinics. These days I just punt. I'll offer them a dental block, but all of these drug seekers will refuse them citing fear of needles.

"Why can't you just give me some pain medication?"

"Because I don't want to. You'll just come back here again wanting more pain medications when you run out instead of going to see the dentist like you really need to."

"But I am gonna go see a dentist..."

"That's what you've said the multiple previous times we saw you in this ER. We keep records, you know."

"So how long does the numbing medication last?"

"A few hours."

"So what do I do when it wears off? Why can't you just give me some lortabs or vicodins?"

"So what will you do when the lortabs or vidocins wear off? Your logic is screwy."

I have this same screwy conversation every night on duty. What pisses me off even more is when they take an ambulance for their rotten teeth. That's why there's an obligatory 3 hrs. wait, at least, to be seen in my ED if you come in for a silly toothache. Longer, if you show up by ambulance.

"Damn it, these people take better care of their asses than they do their teeth!" an oral surgeon once whined to me.

"Wha d'ya mean, Greg?"

"I'll betcha that they'll wipe their ass after taking a dump every time, but do they brush their teeth every day?"

Hahahaha! LOL! He's got a really good point there!

Back to the EKG showing that the li'l old lady was having an acute MI (heart attack)...So how did I know that this old lady would have something bad? How did I know that she wasn't a routine toothacher. Experience. Elderly patients do not come to the ED in the middle of the night for stupid toothaches, as a general rule. It's just that simple. Plus, I've seen many with similar complaints of toothache over the years, only to find on exam that their teeth are fine or that they are edentulous or wearing dentures and having aginal equivalents of coronary ischemia. So when her name and age popped up on the computer screen after she triaged in for complaint of toothache, I had her brought back right away. I always keep my eyes on who's out it triage. Seen and heard too many triage horror stories not to pay attention.

This li'l old lady was a slight bit tachypneic and clammy after she was walked to the back from triage. One look at her teeth and I knew. Placed her on the monitor right away and saw the tombstoning ST-elevations. She was whizzed up to the cath lab and did fine. Her RCA was stented.

Logic

2007-04-28T07:19:00.000-07:00

Drug seeking patient with chronic toothache returned to the ED claiming that someone had stolen his Lortab prescription generously written to him during the previous shift by one of our more easily persuaded/fooled physician in the group. I quickly looked in his halitotic mouth. Rotten molars worn down to the nubbins.

"I left it right there on the counter and someone stole it!" he claimed.

"Did they steal your Penicillin prescription, too?" I played along.

"No. I still got it right here."

"That's so terrible!" I empathized. "Some people, stealing other people's prescription like that, un-buh-lievable!"

"Yeah, can you give me another prescription?" he asked

"Why certainly! I'll write ya somethin' that they won't steal!" I answered accomodatingly and whipped out the prescription pad.

Rx: Motrin, 800mg
dsp: #10 (ten)
sig" 1 PO Q4h w/food prn

Hehehe. The guy was, needless to say, quite pissed and went ballistic. Couldn't stand the crushing logic. Had to be escorted out by hospital security.

Whar's the Bullit?

2007-04-25T08:10:00.000-07:00

First the xrays, as usual. More later. No peeking by clicking on the xray. I'm too lazy to change the name of the file. It's one of those rare cases that ya don't see every day.

---------------------------------------------

"Hey, this ain't bad at all!" I commented as soon as I stepped into the ED to start my shift and noticed that the census board was rather "clean."

Marsha, a veteran ED charge nurse with over 30 years of experience hesitated not a bit in giving me a quick bop to the back of my head like my older brothers used to do. "Why'd you say summin' like that for?!!" she protested in a displeased but not too incensed tone of voice. "You done jinxed us all!"

"Hey, er..." I started stammering and rubbing the back of my head after realizing that I had violated one of the cardinal rule of the ED. "I didn't specifically refer to nothing," I argued back unconvincingly. "I was just saying things in general, you know, like life ain't bad at all. That kinda thing. It's a generic reference."

"Yeah, but we know what you meant. You done said it. You done jinxed us!"

"Man, you guys are too superstitious. That kinda thing has never worked for me anyway. I've always been the shit magnet, the black cloud, I get dumped on regardless of whether I say the word quiet or not. So there! I said it. QUIET. NOT BUSY. QUIET! QUIET! QUIET!"

"Oh God! He said the Q word. Hey everybody, Dr.___ just said the Q word!"

"Gee, thanks, Dr._____. You done jinxed us!" they groaned.

I shook my head and replied, "What-ever! I don't believe in that whole jinxing crap anyway. If that's the case, then I'm perpetually cursed because I can't even remember the last time we had an easy night here. I can't even remember the last time I was able to sit on my ass and finish a crossword puzzle or surf the internet like in the old days when I first started here. I can't even remember the last time I was able to take a short nap. Shit, on many nights, we get so busy, I even forget to go take a piss, much less eat something. It's like as soon as I show up, the ER gods said let the activated charcoal run and we get dumped on."

Just as soon as I ended that li'l whiny rant about placing patient care above even emptying our own bladders, Billy, one of the new nurses who got suckered into transferring from the SICU to work in the ED, came up to me and informed, "Hey, they need you on the radio. It's AirMed 1.

"Alright, here we go! Told y'all, he done jinxed us!"

"AirMed 1, this is CCMC med control, go 'head."

"Hey doc! AirMed 1. ETA to you in 20 minutes from Podunc County. 23 y/o male, GSW to the left flank. He's in hypovolemic shock. BP 70/palp. Sinus tachy at 150, O2 sat can't pick up but breath sounds are equal bilaterally. He's awake but diaphoretic and lethargic. 2 large bore IV's with fluids wide open on pressure bags. We're loadin' him up right now. Permission for RSI..."

"That's an affirmative! Etomidate and Sux per protocol. Go 'head and secure the airway. Make sure you check for end-tidal CO2. Pavulon as needed. Update us of any changes. CCMC out."

"Notify the OR, please," I went into Defcon mode. "Get Dr. Slasher on the phone. I want 4 units of O neg blood here now. Warm up the Level I infuser. Chest tube set up, suction..."

"See there, damn it, you done jinxed us!!! I can't believe you said that!"

We met the patient at the helipad. He didn't look spiffy at all, had that CD square look about him (circling drain, waiting for celestial discharge).

"4th and 5th bag of saline hanging, doc. Last BP 90 systolic, still tachy. His uncle shot him while climbing out of the bedroom window! S.O. (Sheriff Office) said that he'd been 'messin' with his ucle's wife!"

"Yup! That would explain Podunc's gene pool!" I couldn't contain the chuckling after hearing that comment from Marsha.

We rushed the patient into the trauma bay and proceeded to violate every orifice with our prying fingers and invasive tubes, while going rapidly through the primary and secondary survey of ATLS. Massive volume resuscitation was delivered with uncrossed match blood along with IVF pumped in by the Level I infuser at full speed.

"We're just waiting on The Slasher," said the OR crew hovering around waiting for the go 'head word to whiz the guy up to the OR.

Single GSW with entrance wound to the left flank, no exit, was all the injury that the guy had on full body exposure and log-rolling.

"Got your chest xray and KUB up!" announced the xray tech.

"Whar's the bullit?!" I kept on asking out loud after seeing both unremarkable xrays. "Whar's the bullet, whar's the bullet...No exit wound...Whar's the bullet?"

"Let's go lower," I then instructed the xray tech. How 'bout...."

"He's bradying down!" yelled Billy.

It was then that the answer became very clear. The guy's right leg and foot suddenly turned ominously purple and pulseless. Only the 2nd time in my career have I ever seen such a case. Here are some more views with the lateral:

Holy Shit! Single GSW to the left flank, no exit. How the hell did the bullet end up in his leg? There were no wounds in his leg.

A bullet embolus! The bullet penetrated the aorta and embolized to the popliteal artery of the leg causing a complete occlusion at the trifurcation.

"He's in V-fib!" yelled Billy again.

We shocked him into an idioventricular rhythm and gave a few rounds of Epi achieving a return to a sinus tachycardia. The rhythm then quickly degenerated again to a pulseless wide complex bradycardia.

"Let's cross-clamp the aorta and stop that bleeding. Set me up a thoracotomy tray!!"

--------------------------------------------

It was all anticlimatic from there, I'm afraid. Wide-complex bradycardia is an ominous sign in trauma resuscitation. My hope was to get his heart back to ROSC (pronounced rosky for Return of Spontaneous Circulation) with a pulse. And since he's young, hopefully would have a better fighting chance in the OR. I haphazzardly squirted betadine onto the left chest and threw some sterile towels onto the stretcher. Breached the parietal pleura with one firm, swift slash of the scalpel. Smooth, like cutting butter. After cranking the rib spreader, I dug my hands into the posterior thorax. All of the injuries seemed to be below the diaphragm as there was no blood at all in the chest. After locating the descending aorta, I quickly cross-clamped it. Just then, in come Dr. Slasher, young general surgeon extraordinaire.

"Looks like y'all started the party without me."

"Single GSW to the left flank, no exit. Look at where the bullet is on the xray," I pointed out and reported to The Slasher.

"Holy Embolism, Batman!"

Slasher snapped on sterile gloves and gave cardiac massage. I loaded up the needle and gave an amp of intracardiac epi. ROSC!

They whizzed him up to the OR, but his injuries were too extensive. Got the bowels, got the left kidney and penetrated the aorta just infrarenally. He made it out of the OR but died in the SICU a few hours later. Sad part of it all was that no family member or friends ever came to ask about him. I'm not a believer in getting jinxed or anything, but the night was just pure pandemonium and busy as hell afterward.

Gripe Day 2007

2007-04-24T12:25:00.000-07:00

I've got nothing witty or whimsical to post so might as well do a Gripe Day filler.

For this year Gripe Day, I've decided to be a little more selective and weed out all the potty mouth comments undeserving of any response. And there were lots of them, too. Here are the chosen few that I've considered "best of breed."

This one in response to my post about the time I saved a patient's life with noninvasive BIPAP after she was inappropriately placed on a DNR order by her primary care doc:

"My poor precious Mother has CHF and has had Bi-pap twice in the last 5 weeks. We have DNR’s but just added not to use the Bi Pap in the future….She is miserable.She has 15 % ejection fraction or less…she can barely walk, is severely depressed, having panic attacks nightly, the entire journey has been a nightmare. Where do you draw the line? I hope that the emergency room Drs. Adhere to the families request…my mom is in misery. But, bi-pap saved her life.. if that is what you call it. She has also lost 10 lbs in the last 5 weeks...5'3" and 108 lbs. Not a pretty picture...she is also legally blind. We have noticed that her short term memory is now shot. Her DNRS were with her both times in emergency..."
(Anonymous) 9/10/06

I guess that not realizing I have the comments moderation on, this reader sent another message:

"My poor precious Mother has been given the Bi-pap ... My poor precious Mother has been given the Bi-pap in the emergency room two times in the last 5 weeks. We just changed her advanced directives not to allow the Bi-Pap She is miserable. 15 % ejection fraction or less…she can barely walk, is severely depressed, having panic attacks nightly, the entire journey has been a nightmare. Where do you draw the line? I hope that the emergency room Drs. Adhere to the families new request…my mom is in misery. But, bi-pap saved her life.. if that is what you call it. She has also lost 10 lbs in the past 5 weeks. she is 5'3" and now weighs 108 lbs... Mom had her DNRS with her....going to the hospital..."

Umm...OK, she has a DNR. THEN STOP CALLING THE AMBULANCE TO HAVE HER BROUGHT TO THE HOSPITAL EVERY TIME! Why not allow her the dignity and comfort to die at home? It has always puzzled me as to why families of patients who are on hospice, or have a DNR due to end-stage diseases, insist on bringing their very sick, "poor precious" loved-ones into the hospital by ambulance and expecting us to perform a miracle, but at the same time not wanting us to do anything invasive. And worse even, rescinding hospice/DNR orders and demanding that "everything" be done. Death is a part of life that many cannot accept, I suppose.

This next comment came in response to THIS STORY about me choosing to resuscitate a gunned down police officer instead of the scumbag who shot him:

"I am appauled at your decisions that were made that night. And to have you be so vocal about this, when you were blatently wrong not to treat the "scumbag." Who gave you that power? Surely not just because you have an MD behind your name. I am a registered nurse, and i am literally nauseated after reading this."
(Anonymous) 8/8/06

Psst...there's no letter u in appalled, and it's blatant, with an a.

The reality is that with a GSW to the head and the other wounds that this scumbag sustained, he probably wouldn't have survived even if we did try to treat him. Be that as it may, I chose to resuscitate the police officer first and will forever be comfortable with that decision. Who would you choose to resuscitate if you were in my shoes?

Who gave me that power? Because I have an MD behind my name? Oh my!

Another reader in response to same post:

"First time reader, and prob'ly the last too.

I'm going to don my vest of anonymity and go against popular opinion; the story does not ring true.

I don't believe that an ER as busy as the one you describe has only one physician or one resus bay. The shooter, or "scumbag" as you called him more times than I can count, should have been resuscitated. If not by you, then by another staff physician or senior resident.

I also don't believe that you can work every day in Crack City and act like you've never witnessed execrable behavior. Granted, witnessing the event you describe is extreme but if you couldn't put aside your judgements and emotions and do the job at hand it may be time for a mental health leave.

When people present with a need for resuscitation we don't debate whether they are worthy of the effort. We give it our all and let the chips fall where they will. You failed.

I suppose that what's the worst about this is that you proudly described your failure as the right thing to do."
(Anonymous) 7/29/06

Err....Don't let the door smack you in the ass as you leave..."First time reader, and prob'ly the last too." Like I give a shit. OK, maybe I do give a little turd since I'm responding to this comment.

Crack City Medical Center where I have been working for the past 7 years is not an academic institution complete with hard working residents and eager medical students. CCMC, in fact, does not have any trauma center designation, nor do we even have a trauma team. But being the largest public hospital within the 9 surrounding counties, we are the major referral center for the region. And yes, after 1 to 2 AM, the grave yard shift doc flies solo in the ED. CCMC is very typical of many public hospital, understaffed and insufficiently funded, with a piss-poor reimbursement rate in the very low teens percentile. We barely survive through state and federal funding, while rationing, cutting corners, and doing the very best with what little we have. You are surely delusional and ill-informed if you think that hospitals like Crack City Medical Center doesn't exist in this country. All is not utopia!

Let me summarize the scenario of the case I presented...2 patients in the ED with multiple gunshot wound injuries, the policeman with a bullet in the heart, and the scumbag (yes, SCUMBAG) who shot him. One doctor, one nursing team in the ED. I chose to resuscitate the noble police officer first. No regrets.

BTW, we have 4 major resuscitation rooms. They are really two separate rooms with a curtain in the middle, deliberately done that way so one doc can simultaneously run 2 codes in one area when the situation arises, and it often does. The other rooms are all monitored rooms that we routinely use to resuscitate critical cases when the 4 trauma bays are occupied.

And from foofoo5, a prison/forensic psychiatrist who went as far as calling me a criminal and sociopath who belongs in jail:

"100% of my patients are mentally disordered convic... 100% of my patients are mentally disordered convicted felons confined in a Level-IV maximum security prison. 75% are high-control because they have a history of violent criminal behaviour; of these, roughly 30% are sexually violent offenders and sexual perpetrators of children. Some are held in Administrative Segregation for violence perpetrated against staff or other inmates. Gangsters, murderers, armed robbers, thieves, and the popular "willfull cruelty to children" galore. I have had urine thrown in my face, been pelted with feces, my nose was broken, been knocked unconscious by an inmate who grabbed a stapler from a nurses desk, and bitten so deeply on the forearm by an HIV/HVC-infected patient that I was placed on Combivir prophylactically and tested for HIV/HCV for a year. I have no need to trade "war" stories with you and your commentators. To you it's just "drama." The question is, then, have I ever really hated a patient, really wished them harm, really wished to get even and punish them? Yes, without hesitation and without question. But would I restrain a patient to tear out their sutures and re-staple; pump them with activated charcoal or conduct other unnecessary procedures simply to make them miserable; would I openly violate triage protocol; or would I knowingly withhold treatment from a "scumbag" that resulted in death? No, absolutely not. Why? Because it's unethical and criminal. Name the medical board that would condone such behaviour. I say again, my hope is that these are grandiose embelishments or fiction, because what you report is the conscious infliction of pain and harm on those entrusted to your care. Yes, it's a great blog, well-written, titillating and dramatic to the last word. I don't know how you can look yourself in the mirror."

What can I say, foo? You are much more of a saint than I. I am undeserving of even buffing your shiny halo. Do be extra careful and watch yourself while around those loathsome scumbags, a'ight. Bitten, broken nose, flung urine and feces at...my goodness.

BTW, I have no problems looking at myself in the mirror. I ain't that gruesome.

And finally from Genie in response to my tribute to Barbados Butterfly

"I have a huge feeling that everyone has missed quite a lot of important details with regard to the "Barbados Butterfly" issues. I have worked with BB in the last year, and it was nothing short of a breach of privacy, to patients and staff, with regards to her posts.

I can understand that, if I were on the other side of the world, I too would find t amusing to read, but when you are the intern she so gravely dislikes (but doesn't have the courage to say it to your face), it is nothing short of a kick in the guts.

By the way, all of those scans she put on her website were from her patients.....WITHOUT CONSENT. How would you feel if you were her patient?

Let's not even mention the fact that she didn't put anything up about her own personal life, because she was too busy destroying everyone else's..."

I had long been a faithful reader of BB's blog since its very beginning. I see nowhere in that blog was there ever a breach of patients' privacy. No names were ever mentioned, nor were there ever any personal information given to consider it a violation of confidentiality. I, too, post pictures of xrays and CT scans on my blog frequently, just as medical textbooks have photos, xrays, CT scans, and MRI's in them. How is that a violation of privacy when no personal information was divulged?

"Destroying" everyone else's lives? Aren't you exaggerating and overreacting just a bit too much? There's not a single line on BB's blog that I haven't read. I saw nothing vindictive nor invective in there at all. I adore BB's grit & conviction, as well as her blog.

One-Question IQ Test

2007-04-19T21:33:00.000-07:00

Here's a one-question IQ Test to help you decide how you should spend the rest of your day.....(I turned my computer off)

There is a mute who wants to buy a toothbrush.

By imitating the action of brushing one's teeth, he successfully expresses himself to the shopkeeper and the purchase is done.

Now, if there is a blind man who wishes to buy a pair of sunglasses,
how should he express himself?

Think about it first before scrolling down for the answer...Oh, enjoy the following pics.

No cheating now! Don't scroll down until you really think about it!

Got the answer yet?

Cute Frogs, huh?

Look carefully at the following picture. There's more in it than meets the eye.

Look more carefully at the above picture. You'll discover more new things and images in it every time you look at it. You might even discover yourself! The blind shall see and the dumb will speak!

OK, now scroll down to see the answer.

He opens his mouth and says. 'I would like to buy a pair of Sunglasses'.

If you got this wrong or took more than 30 seconds to get it right-- please turn off your computer and call it a day.

I've got mine shutting down right now.

It took dopey me quite a while before it dawned on me that I wasn't as smart as I my ego thought I would be. My wife, on the other hand, answered the question immediately...ARGH!!! I'm such a pea-brain, it took me way too long.

(You know you missed it too, so shut down your computer)

Loss of Autonomy

2007-04-06T05:22:00.000-07:00

I guess I do owe you, my blogspace friends, an explanation of my previous post. I am taking a sabatical from my job at "Crack City" Medical Center. Heck, I've actually already turned in a letter of resignation with the required 6 months notice, but instead have been coaxed into an indefinite leave of absence. In essence, I'm still on the medical staff just in case I change my mind. "We don't want to lose someone of your caliber" convinced the folks in my group. At any rate, I've agreed to finish out next month's schedule, since it has already been made. Then afterward, I'm outta there.

Years ago when I was but a numbskull, doe-eyed medical student, I was already well forewarned by one of my mentor attending that this day would come. I told myself that if the day ever come when I am being told by some nonclinical administrator what tests I can or cannot order for my patients, I would resign my clinical privileges at that hospital. I promised myself that the day when the Utilization Review Nazi come after me, I would quit. Justified or not.

During last Monday morning departmental meeting, I was heartbroken. A completely nonclinical administrative staff handed out a some papers with detailed statistics on how many xrays (and of what body parts), CT scans, EKGs, CBC, Chemistries, Cardiac Enzymes, etc...that each one of us in the group had ordered for the fiscal year, with a ranking of each individual compared to our peers and that of the rest of the medical staff. Though she did not explicitly state that we can't order such and such studies, the implied message was quite evident. My spirits were crushed.

Yours truly was singled out during the meeting for ordering more CT scans than the rest of the group, and in fact, more than any other physicians on the entire medical staff. I quickly asked for stats of how many patients I saw for 2006, as well as patient seen/hr. in comparison to the others. Guess what? For CT's per patient seen, my number was actually very low. Just slightly above the part time doc who only work 2-3 swing shifts a month for us, and lower than the rest of the group. I then asked for the even more important stats, the number of positive CTs, how many of them were done on trauma patients, etc... The CT Nazi didn't have the numbers immediately on hand. I then asked for the medical record numbers of all the patients on whom I ordered the CT's. She didn't have that list either. So I left the meeting right in the middle, went onto the computer and logged into our web-based medical records. For the past few days, I've spent hours and hours going over every patients I saw for 2006. And boy, I saw a lot too, ~12,000. Only second to a partner physician who works more shifts than I do. And I only work weekend nights (Fri, Sat, Sun.), with an occasional swing shift to cover any hole in the schedule! Come to find out, some of the CT's ordered were done at the request of the surgeons on call (such as the appy's that you know were appy's but the surgeons wanted a CT), many were trauma related because of mechanism of injury (such as drunk or unresponsive roll-over MVA, or drunk and unresponsive with head trauma). You gotta scan these trauma cases with significant mechanism of injury because of a lack of history. Excluding for all the traumas, the majority of CT's were abd/pelvis CT's on elderly patients and patients with kidney stones with positive rate of over 90% for pathology. Some were of the chest looking for PE's, aortic dissection, etc...but accounted for less than 3% of total ordered. I wanted the stats on which docs have diagnosed the most aortic dissections and PE's by CT scans but they weren't able to provide that for me. I would dare argue that I'm right at the top of that list. Many of the CT's done weren't even ordered by me but by the admitting physician whom I consulted. But because my name was already assigned to the patient on the computer, the unit clerk just entered the order under my name. There were also many instances where the person ordering the CT was not me but one of my partners on the same shift. This happens because when the patients hits the door and get registered, they are assigned on the computer to a physician on duty in the ED to expedite standing orders. The name of the physician on the chart is not necessarily the one taking care of the patient because there are at least 2-3 of us on duty for any given shift, except after 1AM when the night guy flies solo.

The point of it all is that I DON'T WANT ANYBODY, clinical or nonclinical, to tell me what tests I can or cannot order on my patients when I am the only one who will ultimately held accountable in a court of law! I will not allow any MBA wielding pencil pusher with no clinical experience or background whatsoever dictate what I can and cannot do for my patients! I realize that medicine is just as much a business as any other businesses, and bottom lines must be met or kept in check. But the day when a physician loses his or her autonomy at a hospital, it's time to pack up the bags and call it quits, or move on. I'm taking a firm stand on this issue!

Speaking of lawsuits, here's Lawsuit #9 that I'm currently dealing with, adding to the stress and insult of it all. Three years ago, I saw a patient who came in complaining of "blood in urine" with dysuria, urinary urgency and frequency. Standing orders on her had been done by the triage nurse by the time I saw her. Her CBC was normal, negative on the urine pregnancy test, U/A showed large leukocyte esterase, many WBC, and many RBC's (not gross hematuria, only microscopic), but negative nitrite. The ratio of RBC to WBC was about 2:1. It was a clear cut case, I called it a UTI and discharged her on Bactrim DS without ordering a urine culture. Her physical exam was unremarkable, no CVAT. I gave instructions to follow up with her family doctor in 3-5 days or the internist on call that day for outpatient referrals, and also to return if worsening symptoms such as fever, vomitting, etc... It's one of those lawsuit nightmares that we've all read about in the medical journals, but it happened to me just the same. 3 years later this same patient returned to our ED, now she has gross hematuria, TNTC rbc's in her urine, severely anemic with a Hgb=6 and tachycardic. A CT scan showed a bladder mass with metastatic disease to one of her kidneys. She was transfused, underwent a full cystectomy and nephrectomy for transitional cell cancer. She now has a urostomy tube. Yes, I'm being sued for a misdiagnosis. And I do feel horrible for the lady that she had a bad outcome, but the situation was completely and truely beyond my control. She had exactly 2 ED visits, the first one 3 years ago, and the 2nd one when she was diagnosed 3 years later. Nothing in between. She never followed up with anyone during the intervening 3 years, and I guess she expected me to have a magic crystal ball up my ass! She argued that when I instructed her to follow up with a family doctor, she didn't have one. The internist that I had referred her to in the event she didn't have a family doctor, she never saw because she was wallet-biopsied when she showed up at his office. But she never returned to the ED until 3 years later despite persistent worsening symptoms even after finishing the week's course of Bactrim DS that I had prescribed. The plaintiff lawyer, with his expert witnesses, claimed that had a urine culture been ordered it would have proven that she didn't have a UTI, and that had she been appropriately worked up with a cystoscopy, she would have been diagnosed earlier. Bullshit! Strongly positive leukocyte esterase, many WBC's, microscopic hematuria, with symptoms of dysuria, frequency and urgency... is text book pathognomonic for a UTI. They argued that consultation with a urologist should have been done. The plaintiff attorney also charged that I had entirely ignored her complaint to me about severe gross hematuria and back pain in the history. Bullshit again! In medicine, there's the subjective history from patients and then there's the objective findings. The latter proved that she did not have grossly bright red urine when I saw her. By their ridiculous arguments, every patient with a UTI would then need to see a urologist for a cystoscopy. Absurd!!! And also, there's the issue of the statute of limitation. C'mon, I saw her 3 years ago! But the letter of the law is rather obscure and is up for interpretation. The exact wordings on statute of limitation in this state is weird, it refers to the "time of discovery", which allows the plaintiff lawyers room for much laxity.

The straw that broke this camel's back has come. It's one thing having to put up with the Press-Ganey bullshit and having artificial patient satisfaction survey scores tied to your reimbursement, but this loss of autonomy is a devastating blow to the heart. I can't take it no more! I'm standing firm on principle. It's time to move on after 7 years at CCMC. The hospital administrators won't give a crap whether I stay or go, of course. Their contract is with the group, not me. I'm just a doc in a box and working stiff to them. ER docs are easily expendable, and that's a fact, jack. No matter how exceptional you are! They can fire our group and bring in another one at a drop of a hat. Our group's contract with the hospital expire in July anyway. Many corporate groups out there would gobble up the opportunity to come in and take over. In fact, 6 of them bidded against us for during last year's contract renegotiation. I guess I can find another job at an ED elsewhere, but this erosion of the physician's autonomy is probably gonna be the same everywhere. I hate being a hospital based physician as the position puts you at the mercy of the hospital administrators who don't knows squat about patient care. But working at an urgent care clinic would be just too boring for me.

Isn't it ridiculously ironic? The hospital is ragging my case for ordering too many tests, despite that they are justified, while a patient is suing me for not ordering enough tests, despite that there were no justification for such. Cystoscopy for a UTI, oh my goodness!

What's next for this burned out doc? I dunno. Opus? I guess I can continue to blog about the cases that I've seen in the past, like good ol' Dr. Sid Schwab in retirement. I'm still too young, though, and don't have enough $$$$ to retire yet.

Taking a break

2007-04-05T05:53:00.000-07:00

I'm taking a sabatical and won't be blogging for a while. Will explain later. I've had tough days at work before but what I'm currently going through has driven me over the edge. Medicine's too depressing right now. Lawsuits to deal with, hospital politics, the usual CRAPPOLA that have sapped the energy out of me. It's all a slippery slope that I've ranted about last February. Here's an excerpt:

"Now I'm no card carrying left wing liberal who espouse socialized health care either, so don't even go there. I'm merely pointing out the fact that we have a real national crisis at hand and it seems that none of our politicians know how or even care to solve. When ~47 millions of Americans do not have health insurance, we have a big problem. When a person in America has to make a decision between food on the table or pills in a bottle to take for his/her medical problems, it is an national disgrace. When a man has to resort to committing a petty crime to land him in jail just so he can get the medical care that he couldn't otherwise afford, it is disturbing. When hospitals pass on the costs of healthcare to the public by marking everything up by 1000%, we all have to pay painfully. When doctors, who all took the Hippocratic Oath, are too fearful of litigation to take care of patients, order more unnecessary tests (shotgun CYA medicine), spread the liability by consulting other doctors and specialists to get everyone under the umbrella, or worse yet, abandon clinical privilege at a hospital...the situation sucks all around. When hospital and HMO administrators without any clinical experience or medical background can dictate what tests and studies physicians can or cannot order, the ship is being run by idiots and is doom to sink. We're headed toward disaster, there's no doubt about it. This isn't all new. Everyone knows that this health care crisis exist but our nation choose to turn a blind eye. It is analogous to knowing that the levies in New Orleans cannot withold a hurricane for decades but we choose to ignore it all the same.

Generation Gap

2007-04-03T21:34:00.000-07:00

Me to 95 y/o patient with a displaced femoral neck hip fracture and an impacted humeral neck fracture after a fall at home:

"Ma'am, are you allergic to any medication? I just want to make sure so we can get you good pain relief."

Patient (nonchalantly): "Oh, that's alright, I got Bufferin at home."

Holy cow! She was one tough lady. And sharp as a tack, too. Looked like she was 55 instead of 95. Serious!

Same night, different patient who was 22 y/o.....

Patient (moaning and whining): Can I have some pain medication? This hurts really bad! It's killing me! OMG! ...Moans some more...

Me: I pulled that little cockroach out of your ear already. It shouldn't hurt that bad anymore. Besides, your eardrum looks fine and intact. It's not perforated at all. It's not even red or inflamed. And Your ear canal has no abrasions or bleeding either. There's no swelling at all.

Patient: Well, it's killing me. (Moans even louder)

Me: Alright, we'll put some Auralgan drops in there. That should help because it's the same pain medication drops that we use to treat patients who have ear infections.

10 minutes later....

Patient (still moaning and whining): Those drops didn't help at all! I'm still dying in pain! Can I get a shot for pain or something?

Yup, it's an entirely different generation!!!

"I can't swaller"

2007-04-03T21:08:00.000-07:00

Hallway Four posted a clinical vignette about a patient who can't swallow. Many years ago, I had a somewhat similar case but with the usual Crack City twist.

I once saw a 13 y/o girl with similar symptoms of “I can’t swaller” x 3 1/2 wks. She was seen by her family doc who had diagnosed her with a “strep throat.” She had finished a course of liquid Amoxil followed by a course of Augmentin and was on Cleocin when I saw her. Examination of her throat was normal, of course (otherwise I wouldn’t have told this story). But her neuro exam showed definite bulbar symptoms. She was also ataxic, couldn’t walk in a straight line heel-to-toe fashion. She was also very dehydrated due to poor PO intake. By the time I saw her, she was drooling and couldn’t handle her secretions.

In addition to routine labs, I ordered CT scans of both her head and neck. Both were read by the radiologist as unremarkable. I first called the pediatrician on call who promptly punted to the neurologist on call who punted back to the pediatrician on call, who says that it's clearly a neuro problem and that he was not a neurologist, who whined that he was not a pediatrician, etc… Back and forth, back and forth. AAARRGH! In no damn mood for this patient ping-pong game, I ordered a brain and full spine MRI from the ED (pretty ballsy, heh?). This was 1AM in the morning on a Saturday so naturally, the radiologist called and demanded to know why. I explained the situation and the turd flat out refused to have the MRI techs called in to have the study done.

“She’s been having this for over 3 wks for crying out loud! Why can’t she have it done as an outpatient on Monday? Besides, her CT’s were negative. I read them myself!”

“Fine,” I replied. “Just come into the ED, examine the patient and put a note in the chart to document that you don’t think she needs an emergent MRI done.”

“Hell, no! You can’t do that to me! That's bullshit! I won’t come in, and I won’t put any note on the chart! From what you’re telling me, there’s no indication for an emergent MRI in the middle of the night! I’m not authorizing any MRI to be done! The other 2 guys can admit her and have it done as routine inpatient orders on Monday.” Click. The bastard hung up on me.

So there I was, stuck in the proverbial ED creek without a paddle. And the boat was sinking fast because of a bunch of lazy ass consultants who refused to do what’s right for this poor kid. The child’s family doctor, of course, had no admitting privilege at our hospital, nor anywhere. Yes, one of those! Technically, the lazy ass radiologist was right, it is bullshit. The MRI could’ve waited. But without a definitive diagnosis, I couldn’t get neither the pediatrician nor the neurologist to stop playing patient ping-pong.

Bulbar symptoms she definitely had. Botulism? Nah, too rare and no risk factors in the history either. And not for over 3 wks anyway. Myasthenia? Multiple Sclerosis? ALS? Tough case. I had to consult Tintinalli on this one for a full differential that night.

Here’s a trick on how to disposition difficult pediatric cases when you can’t get anybody with balls enough at your institution to care for these kids. You call Children Hospital! Ta da da da…Children’s to the rescue! My Hero.

I had the child transferred to Children’s several hundred miles away. She underwent MRI imaging through their ED. Guess what they found…BRAINSTEM TUMOR!

So I called the pediatrician, the neurologist, and the radiologist up the following morning after checking with the fine folks at Children’s.

“Hey lazy ass, guess what the kid I called you about last night had…brainstem tumor!” Click! I hung up on them all after that short line.

I called her family doctor, too…just to rub it in. Politely, of course. The guy never did a rapid strep nor a throat culture on the kid or anything. Just looked at it and kept on pushing antibiotics for weeks.

Who's The Boss?

2007-04-02T07:52:00.000-07:00

Drug seeker of the night:

Patient: Can I have some Demerol and Phenergan for pain, it's the only thing that works for me. That and Dilaudid.

Me: (in a surprised tone) But I only had to put a li'l Dermabond glue on your arm to close that tiny cut.

Patient: I'm dying in pain here! I need some pain medication, man!!

Me: Aren't you exaggerating a bit? C'mon, that cut wasn't even that deep. It didn't even go into the fatty layer. Demerol or Dilaudid? Dying, really?

Patient: (In escalating, louder voice now) You don't understand, I usually have a very high pain tolerance, but this hurts really bad! It's killing me! I need something for pain!

Me: It ain't but a 1/4 inch cut, for goodness sakes! High tolerance you say, huh? Killing you? C'mon!

Patient: Yeah, but you didn't numb it up when you cleaned it and glued it.

Me: I didn't think it was necessary for such a minor superficial cut, not for skin glue. I've had paper cuts that are worse than that.

Patient: You are an uncaring doctor!!! I wanna talk to the person in charge of this place!!! (Screaming as loud as she can) I don't want this mf'ker, I DEMAND to see the person in charge!!!

Me: (pointing to myself) That would be me, ma'am! I'm in charge of the Emergency Department.

Patient: I don't wanna talk to you! I want to talk to your supervisor!!!!

Me: Um...That would be me, again. I supervise this place..

Patient: (screaming like a feral banshee now) Then I want to talk to your boss!!!!

Me: Um...That would be me, too. I AM the boss!

Patient: I WANT TO TALK TO THE PERSON THAT PAYS YOUR SALARY!!! Ooh, I'm going to have your job, you son of a bitch!!!!

Me: The person who pays my salary? That would be you, ma'am! You can talk to yourself. Unless, you won't be paying your hospital bill, in which case you'll have to talk to all the real tax paying...Aaawh, forget it...If you're unhappy, you can always ask for your money back. Buh bye, now. Security!!!

Patient: I'M GONNA SUE YOUR ASS AND EVERYONE IN THIS PLACE. YOU'LL BE TALKING TO MY LAWYER!!!!

Me: (outloud to nurses and techs) I got 3 minutes and 48 seconds on my watch before she said "lawyer"! Who won?? (I placed my $1 bet for under 2 and a half minutes. Damn, too overconfident of my own abilities!!)

I can't resist:

Alyssa's so hot.

Ode To A Butterfly

2007-03-21T08:23:00.000-07:00

Sweet Barbados Butterfly, you are so missed! I click to your blog everyday, ever hopeful for your return. Saddened. Then I started an ode, just a few lines, but found this much more eloquent one by Thomas Wentworth Higginson.

Ode to a Butterfly

THOU spark of life that wavest wings of gold,
Thou songless wanderer mid the songful birds,
With Nature's secrets in thy tints unrolled
Through gorgeous cipher, past the reach of words,
Yet dear to every child
In glad pursuit beguiled,
Living his unspoiled days mid flowers and flocks and herds!

Thou winged blossom, liberated thing,
What secret tie binds thee to other flowers,
Still held within the garden's fostering?
Will they too soar with the completed hours,
Take flight, and be like thee
Irrevocably free,
Hovering at will o'er their parental bowers?

Or is thy lustre drawn from heavenly hues,--
A sumptuous drifting fragment of the sky,
Caught when the sunset its last glance imbues
With sudden splendor, and the tree-tops high
Grasp that swift blazonry,
Then lend those tints to thee,
On thee to float a few short hours, and die?

Birds have their nests; they rear their eager young,
And flit on errands all the livelong day;
Each fieldmouse keeps the homestead whence it sprung;
Burt thou art Nature's freeman,--free to stray
Unfettered through the wood,
Seeking thine airy food,
The sweetness spiced on every blossomed spray.

The garden one wide banquet spreads for thee,
O daintiest reveller of the joyous earth!
One drop of honey gives satiety;
A second draught would drug thee past all mirth.
Thy feast no orgy shows;
Thy calm eyes never close,
Thou soberest sprite to which the sun gives birth.

And yet the soul of man upon thy wings
Forever soars in aspiration; thou
His emblem of the new career that springs
When death's arrest bids all his spirit bow.
He seeks his hope in thee
Of immortality.
Symbol of life, me with such faith endow!

Thomas Wentworth Higginson

I miss you dearly, Sweet BB.

Why?

2007-03-20T23:09:00.000-07:00

"Ma'am, your grandmother is dying. She fell and has a head injury. She has some bleeding in her brain, a subdural hematoma, it is small in size for now, but being on a blood thinner doesn't help matters much. She must have fallen hard because she also broke her right hip. But I think the reason why she fell, though, is because she has an overwhelming infection that has spread throughout her body. She is in septic shock. The severe infection has caused her blood pressure to be extremely low. She's unresponsive, comatosed in fact. She has severe pneumonia in both lungs, what we call multilobar pneumonia. She's not breathing and not oxygenating well at all. She is also severely dehydrated. She is in kidney failure and has a very bad urinary tract infection as well. She is GRAVELY sick. She also has rhabdomyolysis, which is severe muscle tissue breakdown, probably from lying on the floor undiscovered for so long. Rhadomyolysis can result in kidney failure. Your grandmother is very sick. She is unlikely to survive this hospitalization and will die very soon..."

"I want everything done!"

"Ma'am, she's 95 years old. I know that you have Power of Attorney over these matters, so I must...."

"I want everything done! Yes, I want everything done!"

..............................................

"Mr. and Mrs. Smith, have you established any advance directives for your son?" I tactfully alluded.

"What do you mean?" they replied.

"Have the both of you ever discussed that in the event your son ever becomes gravely ill..."

"No, is it that serious now?"

"Yes, it is extremely serious now. Your son is in shock from a severe lung infection that has resulted in multi-organ failure. He has an empyema, or in layman terms, a very large collection of pus in his chest causing complete collapse of his right lung. He has a very bad urinary tract infection as well. His large bed sores, or decubiti ulcers, are very extensive and look infected in the sacral area because I see pus oozing out of there. He is not breathing well and has only shallow gasps. His blood pressure is extremely low..."

"We want everything done!"

"Can you tell me about his past medical history and surgeries again, please? I need to jot them down," I asked deliberately so that they could hear themselves torturing this poor 4 years old child.

"Well, at one and a half years old, he got bacterial meningitis that spread to his arms and legs so they had to amputate everything. From then on he's been pretty much like this. He'll look at ya when ya to talk to him but doesn't respond much other than that. He don't talk any. He's got very bad scoliosis, his neck is always twisted and contorted to the left like it is now, so they had to put that tube in to help him breathe some time back. He's got a feeding tube in his stomach too 'cause he can't eat. And he's got that suprapubic cathether...Since he's got no arms or legs, he's got the life port in his chest for any needed medications."

"Let me go over that again to make sure. At the age of 1 and 1/2...And you want everything done."

"Yes, we want every thing done!"

"Full life support and a ventilator. He'll need a chest tube to drain the pus and re-expand his lungs, of course. I'll need for you to sign a consent form for the procedure...Afterward, we'll have to transfer him to Children's Hospital because we don't have any pediatric critical care intensivist at this facility..."

"Yes, we want everything done!"
..........................................

I kept on asking "Why?" all night long. Clueless me.

Through A Child's Eyes

2007-03-16T09:11:00.000-07:00

THROUGH A CHILD'S EYES

(I got this in an email, I couldn't resist)

My absolute favoritest (just as my daughter would say it):

I hope you enjoyed that as much as I did.