Writing with Scissors

A Note of Absence

2011-09-22T17:52:00.003-04:00

For all of those who have inquired...or at least the one..."Writing With Scissors" has been on vacation over the summer as we spend time with The Teen and study for our Emergency Medicine Recertification Boards. Given that we can spend our spare hours either writing for you or studying for a paycheck, and I have yet to actually sell my book ideas or even interest an agent, I hope you'll understand my decision. Back after the first of October. See you then!

This One's For You

2011-07-07T22:19:00.001-04:00

It turns out that one of the benefits of age…although there are too few to mention, at least at my point in life, where you realize that youth was wasted on the young but have yet to assume the role of cranky yet beloved Grandpa…is that you become more comfortable not being cool.

This is why I interrupt the usual gravity of this blog to announce that not only has Barry Manilow just released his first album of all-new material in a decade entitled “15 Minutes,” but also to come out of the honeysuckled arbor and admit that I am an unabashed Barry Manilow fan. Close friends have likely suspected for some time, but only now, when I have reached the age of accepting my own inherent dweebity, do I have the strength to admit it to the world.

There. I said it. And they’re right. It does feel better to be out in the open.

I was a bit too young to be part of the first wave of Manilow Mania, being only 12 when “Mandy” hit the charts. My earliest young musical tastes centered around whatever 45’s Mike Mitchell, a grade school friend who is now an actual real live Professor of Music, played on his hi-fi (that’s how I know about The Cranberries, although of course I had no idea what “Go All The Way” was about), and by whatever Saturday morning cartoon shows were running through my head. The latter explains my continued infatuation with The Archies, The Osmonds, and The Jackson Five, as well as the fact that I still know that:

“The Cattanooga Cats don’t ever purr.
They know how, but not what fer.
The Cattanooga Cats won’t go meow, say meow.
Wouldn’t try, but they know how!
Just doin’ their thing (chu-ba-da, chu-ba-da)”

Later, the music that I knew was based on whatever teen idol’s posters my friends David Brown (grade school) and Doug Reynolds (junior high) and I could tear down from the walls of their respective sister’s bedrooms. This is why I am intimately familiar with the musical catalogue of both The Partridge Family and Bobby Sherman. As a personal note to Karen and Crary, I’m deeply sorry for my part in those episodes. Just for the record, it was ALWAYS your brother’s ideas.

(As some of you may know, Bobby Sherman later became an EMT and served as a CPR trainer with the Los Angeles Police Department, which I think redeems this bit of musical nostalgia within the ER doc’s blog.)

I came to know Barry Manilow in high school, where he was a ubiquitous part of the slow dance scene. Understand that at that age, the best thing a nerd’s hormones can hope for is a slow dance with a girl. Not any girl…there are still standards… but an actual real live double X chromosome girl with breasts that might press up against you as you danced. And Barry came with me through college. Children these days will find it hard to believe, but there was a time when if an evening was going well, three Manilow albums and half a box of wine could seal the deal.

In gratitude for his help, I’ve been a loyal follower through the years. I’m not going to say that everything he does is great. He can’t do rock and he can’t do latin. “I Made it Through the Rain” drives me crazy because I keep thinking he should get a damn umbrella. I’m not too fond of “I Write the Songs,” because I have this vision that if the first caveman who created music by banging their clubs on rocks saw Barry, they’d have turned their clubs on another target. But most of his stuff is pretty good and eminently sing-a-long-able, and some of his pieces are pretty close to perfect. “Even Now” is one of the truest ruminations on past relationships that I know. His best song ever…and one I want played at my funeral, if anybody’s taking notes…is “When October Goes,“ with music by Manilow and lyrics by the legendary Johnny Mercer. It is simply the finest musical meditation ever on aging, love, life, and ultimately the futility of it all. Flippin’ brilliant.

I’ve actually seen Barry twice. The first time was in Jacksonville when he was touring with his last album of new material, “Here at the Mayflower.” It was a good show, most notable for the fact that at one point during the song Weekend in New England…and specifically at the line “When can I touch you?”…someone in the balcony screamed out, “RIGHT NOW BARRY!” Blissfully plugged into their headphones, the band played on, but Barry himself stopped playing and started laughing as if he’d never heard that line before. (The concert also stays in my mind because I lost a bet. I figured that Barry Manilow was so popular there would be at least twenty people of color in the audience of several thousand. Turns out there were eight, auditorium staff not counted. It was like counting minority representation within NASCAR fans. But at least Barry has Oprah.)

The second time was in Las Vegas three years ago, when he was playing the MGM Grand. This was your standard Vegas show, somewhat more intimate than a ten thousand seat arena. Put simply, Barry puts on a great show. He sings what you want him to sing, he involves the audience, he screws up from time to time, he laughs and doesn’t take himself too seriously. He seems genuinely baffled that people still come to see him, and genuinely grateful that they actually still do. Most of the audience that particular night was comprised of “Barry’s Angels,” a fan club dressed in white, some with handcrafted cardboard wings duct-taped to their back. The Bride was clearly the youngest person in the audience, and even at my advanced age I wasn’t that far behind. When two of the fan club ladies asked what brought us to the theater, I reminisced about the past utility of Barry and a bottle to ensure a good night, and they nodded their heads, a faraway longing in their eyes.

The great thing about the Vegas show was that you could see Barry up close. That’s how you can tell he’s had botox. From the corner of the mouth up, he looks perfect. From the corner down, where he can’t have botox because unless Senor Wences is involved the last time I checked singing required actually movement of the mouth, he looks like an old jowly Jewish guy. Which, of course, is what he is.

(Speaking of Senor Wences, remember how he used to draw a couple of eyes on his hand, outline his thumb and index finger with lipstick, stick some hair on the whole thing and then talk to his friend Johnny? My brother got off a good line a few years back when our discussion turned to lonely guys indulging in self-pleasure. He immediately whipped out a pen, drew two dots on his hand for eyes, and made the hand say “It’s horrible! He makes me touch him! Arrrrgggghh!” Okay, maybe it was funnier at the time.)

I knew Barry was probably older than I thought, but didn’t realize until I read in the USA Today article about his new album that he was almost 68 years old. That produced a pause. Sixty-eight is only 7 years younger than my Dad, whose musical talents are limited to a few folks songs on the ukulele (none of them Hawaiian) and an enthusiastic but rousing chant of the family anthem, “The Eggplant That Ate Chicago.” And the article also said that Barry is intent on keeping his private life private, as he should. Yes, I’ve heard the rumor that maybe he’s gay, but it really doesn’t matter. Besides, as a nice Jewish boy, he wouldn’t do that to his mother. No matter where she is today, I know she’s still hoping he’ll settle down with a nice girl, have a child or two, and invite her over once a week for a nice Shabbos dinner. Trust me, it’s what they do.

And while we’re making musical confessions, let me also state for the record that I have a man crush on Tom Jones. I’ve always contended that The Lord speaks in several voices. When he’s imparting knowledge, he sounds like Charlton Heston. When he’s pissed off, he sounds like James Earl Jones. When he wants to express love, he sounds like Barry White. And when he wants to propagate the species, he brings on Tom Jones.

(For the record, I am not sexist about the Voice of G-d. When The Lord expresses either compassion or wants you to feel guilty as sin, the voice is exactly that of your mother.)

I’ve seen Tom twice, each time up close at a relatively small venue, and he is simply masterful. It’s true that women still throw their underwear at him, although some of his fans are now old enough that one wonders if girdles and support hose hold quite the same attraction as lacy bras and panties did before. Nonetheless, both his voice and his sex appeal are fully intact. So I shouldn’t have been surprised to hear a conversation at the table next to us when The Bride and I saw him in Vegas. Shortly after the first song, the wife noted that if Sir Tom beckoned to her, she was going back to his dressing room no matter what. And her husband of many years replied that he would be happy to let her, to know that someday he might also have what Sir Tom had once received. That’s not unusual, is it?

Death of a Dream

2011-07-02T08:34:00.004-04:00

Where there is no vision, the people perish. - Proverbs 29:18.

It’s a week before the final launch of the shuttle Atlantis, and I’m watching a PBS show on the Columbia disaster. The thirteen year old boy sitting ten feet away wants to know why I won’t turn it off to look at a funny internet video. I don’t know how to explain to him that retrospectives are all I have left of my childhood dreams of space. And thanks to the Obama Administration’s dismantling of America’s manned spaceflight program, he won’t even have that.

This is such a visceral issue for me that I’m not even sure how to write about it. I was a kid of the Apollo era. While the generation before me remembers the moments when President Kennedy was shot, and the one after benchmarks at 9/11, for my group our touchstones were in space. We remember Apollo 8’s reading of Genesis from space, and the grainy pictures of Apollo 11 on the moon. (Most of us can still recite the first words from the moon.) We remember that these things happened late at night, and most of us saw them with our parents in the living room or in our beds, the whole family living a moment together. We were the ones who stayed awake past bedtimes to follow Apollo 13. We saw the Challenger explode before our eyes, and felt loss a second time with the Columbia. We learned about daring, tragedy, perseverance, and triumph.

Through space, we saw a dream that we all could share. And while many of us, in our childhood ways, wanted to be astronauts, we also knew that just by being an American we were part of that dream. For those of us raised on space, who knew that our future as a nation would take us forward, upward, and outward, manned space flight was not just about boosters and capsules and lunar rocks in a Plexiglass case. For us, the space program was a fundamental part of being an American, about who we could be as individuals, as a people, as a nation. And today, where we’re all adults and our wide-eyed optimism has been tempered by the cynicism induced by moneyed interests and political hacks, watching the Space Shuttle rise from the pad was our last symbol of hope, a final sign that perhaps working together, we could be something larger than what we are.

To be sure, I’m not harboring any illusions about the space program as a whole. For a while I worked in an affiliate support role with NASA at the Kennedy Space Center in Florida, and I have friends who’ve worked in NASA facilities in both Florida and Houston. The space program has not been perfect. There have been problems with design, safety, fiscal care, and mission management. The planned Constellation program undoubtedly had issues to overcome. And while the space program no doubt accelerated technology, I’m certain that we’d still have personal computers, Tang, and Velcro even without Apollo. I also believe wholeheartedly in the unmanned exploration of the solar system and beyond, and would certainly acknowledge that there are a whole host of tasks that robots can do faster, cheaper, and more efficiently than humans.

But to try to elucidate practical reasons for the space program is to completely ignore why we go into space. We go into space because, to paraphrase President Kennedy, not because it is easy but because it is hard. We do it because it gives us something that we may not achieve, but to which we can always aspire. We do it because the infinite reaches of space continually stretch our goals and our imaginations. We do it because only by contemplating the vastness and antiquity of the universe can we address the fundamental questions of the uniqueness of humanity.

We do it because, as Americans, we explore. We expand. We learn. We go farther. And we need men and women to be our vanguard of exploration, because we can’t invest our hearts and souls in a bucket of bolts. We need people to take the risks, to go up and come back and tell us how space feels and looks and tastes and smells, people whose voices we can hear and whose hands we can shake. Space is all about aspiration, inspiration, and destiny. It’s about man.

There’s a practical, and a political, side to this as well. What the administration has done is not just to cut NASA’s budget, but also put thousands of people out of work in the midst of a jobless recovery. It’s hard to fathom that it’s okay to bail out moneyed interests on Wall Street and the auto industry in Detroit, but not consider those workers who support the space program. And if it’s not galling enough that the space program has been wrenched from the imagination of the American people, the President had the nerve to want to come to Florida to see the final launch of the shuttle Endeavor. This is hypocrisy at it’s finest. He’s making sure that he gets to see what he’ll be taking from the rest of us before it’s gone. But hey…it would also be a potential photo op with Rep. Gabrielle Giffords, the wife of Shuttle Commander Mark Kelly. From what I understand about Rep. Giffords, she’s pretty sharp. I’m sure she would have figured the politics, but scorned the posturing. (While I am not a “birther” by any means, perhaps this is one occasion when President Obama’s childhood abroad during the pivotal years of Apollo puts him out of touch with the rest of us.)

The Obama decision to defund the manned space program has utterly destroyed the idea of a national dream at a time when Americans need to unite more than ever. We’re divided politically, with honest disagreement traded for extremism and hate. Class and income gaps are widening, the standard of living is falling, and the American quilt is being torn into a raft of self-focused groups. We’re a people who find fault in other but deny responsibility, and instead of one nation under G-d we’re becoming a nation of ones unto ourselves. What could always unite Americans was a dream. First it was Liberty, Manifest Destiny, the Great American Melting Pot. For my generation, it was the conquest of space. A nation that was built on exploring frontiers, on doing that which no one has done before, now has no outlet for it’s boundless energies and no single goal to unite the country at a time when those forces are increasingly turned inward in destructive ways. Our leaders are taking from us something very real and precious, and replacing it with nothing.

And so my son is likely to be more absorbed in the world within his room more than the heavens above, engaging the universe through electrons and keyboards and not in real time, in a life devoid of real dreams and real heroes. Sadly, despite my best efforts, he’ll likely have no idea what he’s missing. But given the fundamental lack of vision from our leaders, perhaps that’s exactly the point.

Bug Season

2011-06-30T04:57:00.000-04:00

I work in an area where there’s lot of hunting and fishing, so I’ve become familiar with the “seasons of the kill.” Right now it’s between seasons in the field, but within the ER Bug Season is in full swing. Bug Season is that time of year when bugs wander into people’s ears and people wander into my domain wanting the bug out. It’s something that’s unique to early summer, and all I can figure is that the bugs, attracted to the porch light on a summer’s evening, suddenly realize they’re gravitating towards the Bug Zapper of Arachnid Doom and think better of it, ducking into the nearest dark spot they can find, knowing full well that if they think twice about it they’ll finish that run to the afterlife. (See Marty Robbins, “El Paso.”)

Those whose ears have been used as insect refuge usually drift in about two in the morning. I’ve never had a bug in my ear (other than the metaphorical one), but it seems to be one of the most excrutiating things imaginable. The skin of the ear canal is paper thing and loaded with nerve endings, so the motion of the bug causes severe pain. In addition, the wafer of skin cells lies directely on top of bone, and bone conducts sound better than air. So every little flicker of the bugs legs or wings is not only felt, but heard as a loud, interminable grating noise. So when you consider that the bug is susally still alive, feet and feelers looking for traction and wings beating against the eardrum…you can get a sense of why getting the bug out constitutes an emergency that even I, with my low tolerance for anything less than an actual acute illness or injury, would recognize as worthy of an ER visit I the wee small hours of the morning.

There are a couple of ways to do this. One is to try to wash the bug out. This usually never works, as most people have already tried it at home and if the bug was dead, it came out. They’re in the ED because the bug, having tenaciously fought the deluge, is still thriving, damper but cleaner. So you have to kill the bug, and the best way is to drown it with some kind of oil of a solution of viscous lidocaine, a thick local anesthetic gel that you squirt into the ear canal and let it sit for ten minutes or so. Then you try to irrigate out the ear again, but this time using an IV catheter and a syringe in order to get a high-pressure blast of water in there. With any luck, the bug pops out. You hope it does, because the expectation from the patient is that you will then dig in the ear for the bug. You try to talk them out of this because a) it’s painful, b) it never works, and c) you’re just going to send them to an ENT guy the next day who actually has micro bug-out-of-orifice stuff in the office. The patient will want the bug out now, so you make a couple of half-hearted blind stabs (we don’t have the kind of ear instrument or scopes that allow you to look in the ear canal as you’re working, nor tools fine enough for the work), which results in more pain and quite likely a little bit of oozing of blood form the ear as you scrape the inside of the canal. You apologize profusely, show the patient whatever you’ve gotten out of the ear (a feeler, a leg, a bit of wing, a strangely shaped piece of wax) to demonstrate some progress, tell them that all bleeding stops eventually, and refer them to the ENT guy on the morning. Which is, of course, what you wanted to do in the first place.

Sometimes bugs beat the odds, and are just slowed enough by the attempted drowning to be flushed out, but still able to make a valiant attempt to get away once they’re back in the light of day. They pop out of the ear canal into a basin of water, often in tatters, their little feet struggling to bring them up for one last breath. It kind of makes you feel for the bug, as you witness their last gasp of buggy life. I was watching this Mutual of Omaha Wild Kingdom struggle for survival and remarked, in what I thought was a fairly deep moment for someone who had eaten nothing but six Hostess Twinkies, three Cokes, and a piece of Hampton Inn Free Breakfast Sausage in the past 36 hours, that the poor creature was “drowning in the waters of his own despair.” So for some reason now all the post-ear bugs in the ED are called “Howard Junior,” and I’m wondering if it’s time to start saying Kaddish for them. But given the way I long to have things named after me, I hope it sticks no matter what the bug’s personal faith tradition might be.

A De-Funding Fallacy

2011-06-28T04:32:00.001-04:00

I’ ve always hated the abortion debate. It’s a difficult topic, involving morals, medicine, individual autonomy, and the law, and there is just no way to simplify the issue and have any kind of learned debate. But since learned debate has been expunged from our public discourse, abortion is now framed in labels and sound bites. You’re either pro-life or pro-choice, which I think are terrible labels for both both sides. Abortion is always a bad choice that may, at times, be considered necessary for a variety of reasons, but always a bad choice. And everyone should be also thought of as pro-life, in that we should want the best outcome for all parties involved in this most difficult decision.

With this in mind, I noticed recently that Medicaid officials have ruled that an Indiana law which pulls all state funding from Planned Parenthood to be illegal. As I understand the situation, Medicaid rules prevent service providers to be excluded from participating in the joint State and Federal Medicaid program based the range of services performed by the provider. Planned Parenthood performs abortions, but also provides other services such as family planning, cancer screenings, and care for sexually transmitted diseases. Medicaid can be excluded from paying for specific procedures such as abortions, but the entire agency and all the other services it provides cannot simply be struck from the provider rolls.

What bothers me specifically about the Indiana law, and similar bills passed in many states (one was proposed by Congress as well) is not it’s legal status…that’s up to the courts to decide. What annoys me is that it’s yet another example of how the exercise of partisan politics actually impedes the stated goal of those same Demagogues of Democracy.

Planned Parenthood does perform abortions. They do so out of funds that are privately raised and fees paid by individuals for care. State and federal dollars granted to Planned Parenthood are already prohibited by law for use in support of abortion services. Instead, they are used for family planning programs and screenings for breast and cervical cancer in underserved women.

So if we follow the money, we find that defunding Planned Parenthood as a political statement against abortion won’t affect abortion at all. What does get affected are those activities that help prevent unwanted pregnancy. Decreased availability of family planning services means more unwanted pregnancies, more children in single parent households, more children in poverty, and (paradoxically) likely more abortions as women struggle to cope with the consequences of unexpected pregnancy. And if we are framing the defunding of Planned Parenthood as promoting a “Culture of Life,” doesn’t it make sense that this culture would want poor women to be screened for and get care for breast and cervical cancer in the early stages while these malignancies are still curable, rather than wait until the patient has advanced disease?

I’m not Catholic, but there a lot of things I admire about the Catholic Church. One thing I’ve always found impressive is that their theology is always consistent. Their steadfast interpretation of the Culture of Life sets them against abortions, artificial family planning, and the death penalty. But it also means promoting health, welfare, and social justice for all, as we are all precious creations of God. I suppose that in America, you’re only precious if you can afford your own pap smears and mammograms.

Fitness Fanatic

2011-06-23T07:43:00.000-04:00

I have a pretty bad history with physical fitness. In fairness, I need to say at the outset that I’ve been blessed in that my life has had it’s issues, but one of them has not been a battle against weight. I was born a stick person, raised a stick person, and been a stick person my whole life. It’s not my Mom’s falt, either. While she only does two really good meals…Passover and Thanksgiving, both with all the trimmings…and she goes through phases like veal burgers and the ever-popular Sgt. Harriet’s Indiana Baked Chicken…it’s not like there were never brownies or Froot Loops in the house. I suppose it comes naturally, as my Dad was a stick person until he quit smoking in his 30’s. Since then, he’s become gradually more Santa-like, but I think he’s getting more jolly as well. So I’ve always known the weight was coming, but I’ve been fortunate to be able to avoid it until the past year, when thanks to the acute observations of my Cousin Sara the term “muffin top” has entered my vocabulary (and not in the sense that I wish it would have twenty years ago, when a muffin was a college girl and a muffin top was probably the sweater you were trying to talk her out of. Ah, memories).

As a result of my good fortune, I’ve always had a strange relationship diet and exercise. I’ve always been able to eat pretty much anything I want, and I’ll be the first to admit I’ve abused this privilege. It was at it’s worst during my public health years, the best way to get the attention of the STATE HEALTH GUY dedicated to HEALTH and HEALTHY LIFESTYLES was to present an idea with a couple of Hostess Twinkies in your hand. (I’ve since moved on. Now it takes a Suzy-Q, and in deference to the fine people in the dairy industry I chase it down with a glass of milk rather than the preferred Vanilla Coke. I’m just sayin’.) However, one of the great advantages to working in public health is the ability to justify things. So a single Starburst became a serving of fruit, and spearmint lifesavers became vegetables. Twinkies fell into the breads and cereals group, and were a way to show my commitment to the Kansas wheat growers as well as the petrochemical industry (I know the “cream filling” is actually plastic, but I do love it so.)

There is a downside of being a stick person, however. For me, it’s always been a healthy fear of the beach, the swimming pool, and short sleeve shirts. I look like Mac in the Charles Atlas ads on the back of the comic books of my youth, and he’s the one getting the sand kicked in his face. Slow dances made me nervous, because there’s nothing “hunky” for a girl to hold to. And with no upper body musculature, chin-ups and rope climbs in gym class were a nightmare. Most of my life I would have given just about anything to have another twenty pounds on me. So from time to time I would invest in a huge jar of “nutritional supplements”, mix the grainy powder in milk and drink the gummy residue four times a day. After three months I was able to pack on a whopping two pounds, and my Brother-in-Law, whom I actually like because he shoots, kills, and eats things and is my survival plan for the Zombie Apocalypse, laughed at me for trying. So that was the end of that.

I’ve had an even less successful relationship with exercise. From time to time I decide I need to work out. This usually goes well for a few weeks until boredom or pain (whichever comes first) sets in. Then l’m back to my sedentary ways for another year or two. Last year my try at fitness was to buy a Wii. I loved the thing, and for the first couple months of ownership I made sure to a seven game set of tennis every day as well as nine holes of golf. It was great while it lasted, but after six weeks I was still winded going up the steps. Since I live off instant gratification, I decided the Wii wasn’t working, so I shifted to Rock Band. (Note: Taking a top floor apartment with a cathedral ceiling so nobody’s living on top of you seems like a great idea when touring units. When a middle aged guy is dragging groceries up the steps? Not so much.)

The next step was to upgrade to Wii fit. This is a great program. Lots of exercises…cardio, yoga, and balancing work. I especially liked one of the later programs, where you had to sit quietly and unmoving for three minutes until an electronic candle burned itself to the nub. To me, this was the perfect exercise. Don’t move and get fit. And so I still do this exercise, sitting quietly on the floor for three whole minutes at least four times a week whether I need to sit down or not.

This year’s entrant into the fitness sweepstakes is going to be either P90x or the Shake Weight. P90x is the DVD-based workout program featured on late night TV, and it actually seems to work. However, it has started to fall in my estimation because it’s really hard, and my work ethic took the lottery money and is still off on vacation. In addition, a few months ago I saw a guy in the ER who had finished his first round of work and had managed to break down enough muscle tissue that we had to admit him to make sure all the newly-liberated proteins didn’t clog up his kidneys. I was almost as disturbed by the knowledge that his could happen to me as I was by the fact that he came to the ER in 30 degree weather wearing only black boxer shorts with pink and red hearts with a suspiciously open fly, sobbing while holding buckwheat pillow.

(As an aside, it was kind of funny to see how we addressed his issues. We gave him pain meds, of course…good stuff, not skimping…but he continued to whimper. At that point, we shift our internal paradigm for patient care from “poor, poor thing” to “buck up and get some balls.” Interestingly, we never ask female patients to “acquire an ovary.” No doubt a topic for further review.

Pain control is a controversial issue in emergency medicine, and in many states it’s become a political football as well. Most doctors feel they treat pain appropriately, while most patients…at least those who answer surveys… are convinced that they do not. I won’t claim to have any magic answer, or to be the perfect purveyor of pain pills and potions. A lot of it is still a judgment call based on how much pain the patient appears to have (do they look truly uncomfortable or not) and the degree to which the patient’s complaints of pain match the overall appearance. But I do have my own internal list of patients who can have whatever pain medicine they want without argument, no questions asked. You can have whatever you want if:

1) You have just broken a bone
2) You have allowed me to put a clamp, knife, needle, or tube in any orifice, place or space it doesn’t normally belong. (Routine injections, IV's and urinary catheters excluded.)
3) You have cancer.
4) You are in a hospice.
5) You have a toothache. (First visit only.)
6) You ahve a kidney stone.
7) You have a burn.
8) Your care is delayed because the doctor you really need to see, like a surgeon, is either busy in the operating room or is “operating” at home, the local golf course, or the Hotel of Illicit Gratification, hoping that flash in the background was just lightning and not a camera phone.

These criteria stand in contrast to the patient I saw last week, who came in requesting a refill of her narcotic pain medication she had received for a rib fracture six weeks before. I had a chance to look at her records before I saw here, and in addition to her three previous visits for narcotic refills, she had a repeat x-ray that had shown the fracture to be fully healed. I told her that I would be happy to evaluate her, but that I was not going to be comfortable refilling her narcotic prescription for a fracture that was no longer there. At that point I become in turn, “The worst doctor I’ve ever seen, ”the rudest doctor they’ve ever had here,” and the guy who, "doesn’t understand that YOUHAVE TO GIVE ME WHAT I NEED, AND WHAT I NEED IS PERCOCET” Seeing I was not moving from my position, she refused further evaluation and left the ED. The sad part is that it took me longer to document the encounter, dictate addendum notes, and cover my bases from a risk management standpoint than it did to examine, diagnose, treat, and write up a woman who came in just a few minutes later with a life-threatening heart condition. But in this era where medicine is business, the customer is always right, and the ER doctor is nothing more that another disposable vendor of services, dissatisfied people complain and sue. Those who are truly sick are also those who value your care. But the whiners win out in the end, and that’s American medicine.)

So I’m thinking that if a really buff person can kill his kidneys doing P90x. and then cry like a girl about it, the last thing I need is to be dragged into the ED sobbing, my stick physique and my favorite pair of Justice League underwear on full display (although the fly does lie within a picture of Superman…heh,heh,heh). But as I am now the owner of a nascent “muffin top,” I need to try again. Maybe if I downgrade to something like L45q I could pull it off. Or maybe I can use the Shake Weight that they advertise on TV, because it looks like I can do that sitting down. And if I focus on my upper body, it’ll be good to have both forearms the same size again. My right forearm is about an inch larger around than the left, a permanent reminder of several years scooping Baskin-Robbins hard ice cream in high school. Of course, nobody thinks that’s the real reason one forearm is bigger than the other. For the purposes of dispelling that rumor, let’s just say that I dress left. And well.

Another Night, A Few More Stories

2011-06-21T06:46:00.001-04:00

There are a lot of annoying sounds in this world. The screech of fingernails on a blackboard. The thump thump thump of the three year old kicking your seatback in time to "It's a Small World" all the way to Florida. And the piercing wail of the EMS radio page an hour after midnight, just at the moment the ED is on the verge of being cleared out and the pillow...or at least a Jerry Springer rerun...beckons to your tousled head.

The call goes out on to an address on Castle Street for a middle-aged female with three months of vaginal bleeding. Several minutes later, we get report from the crew. The patient has only had vaginal bleeding for two months. So it's already 33% better.

Tonight's EMS squad pairs a man and a woman. I ask the distaff paramedic...who is also one of our Unit Clerks...for patient report. Specifically, I say "I've never had a vagina, so hopefully you can tell me why someone who has one that's been bleeding for two months would call an ambulance at 1:00 AM on a Friday night."

The paramedic smiles. "I suspect it has something to do with the alcohol."

Five minutes later, I'm in the room with both the patient and the vapors of her beverage of choice, so I ask. (I have to ask questions in the "why you're here NOW" category pretty often, so there's a set script here. Mine is not the best line. The best I've ever heard comes from my colleague Dr. John Prairie, who's version is, "And what MEDICAL EMERGENCY brings you to this LEVEL II TRAUMA CENTER this VERY NIGHT?")

"I know this is going to sound rude, and I don't mean it to, but what in particular brings you in to see us tonight after two months, instead of when it started or a month ago?"

"I was bleeding so much in the bathroom that they threw me out of the bar."

I finish my history, asking about past history, medications and allergies. "I'm on medications," she says. "For my fibromyalgia."

(I saw that one coming, but for some reason I can't explain just why. I know some people who think they have "Gaydar" or "Jewdar." Perhaps I have "Fibradar.")

Her exam is completely unremarkable...no bleeding to be found...and like many patients, it's going to take longer to do the paperwork then provide the needed care. So as I'm sitting down at the desk, I hear the nurse talking to the local domestic violence shelter.

"She wanted us to let you know she was here. Are her kids okay?"

Yep, she had left her kids at the domestic violence shelter to go out to a bar. And as the story emerges from the fog of war, apparently she's there because she has a stalker. Going to a bar is always a good way to shake them from your trail.

**********
I go into Room 1 to see an older man who's been dizzy. As I start to ask him questions, his wife answers everything. This is another one of those situations where I've developed a standard script over the years. So I say, "Ma'am, I want your input, but I'd really like to hear from him how he's feeling, and then I'll want you to help fill in the gaps."

She blushed, and then the whole family started laughing. "I'm sorry. I always do that."

I asked the patient, "Do you ever get a word in edgewise?"

He shrugged. "Not often."

They seemed like nice people..fun people...so I decided to tell one of my stories. "You know, years ago I saw this little old couple when I was working in Florida. The guy was genuinely sick, but every time I asked him something, his wife would answer for him. And every now and then, when he would actually get out a word of his very own, she would put her hand on his head and say, "Shut up, Mohty. I'm tawkin to do dacotah."

They all laughed, so I figured I was on a roll. "She also wondered if I was Jewish, and if I was single. When she found out from the nurses that I was, she told me all about her granddaughter who was a college student and offerred me her phone number if I wanted to call."

I kept up the show for a good five minutes. Each laugh I got produced another joke or story. I was just on the verge of wrapping up my act by noting that I was there all week, and that you should tip the nurses and techs because they're working hard for you, when the patient finally piped up.

"Hey, doc...do I get to talk now?"

Two points for the patient.

**********
We actually saved a life tonight. A lady came in with chest pain, as we're evalauting her she becomes unresponsive. She has no pulse and is not breathing. This is the kind of stuff we live for. Within moments she's getting ventilated with a mask, receiving CPR, and having sticky-backed pads placed on her chest to give her an electric shock. A few seconds later, voltage converts her heart rhythm from disorganized chaos to a normal rate with a bounding pulse and strong blood pressure. While the nurses prepare to start medication to stabilize her heart rhythm and control her pain, I step out of the room to call the cardiologist to take her to the cath lab. While I'm out of the room the patient's hearbeat again becomes unstable. By the time I run back to the room, the nurses have already given the needed shock and the patient is brought back to life once again. Total elapsed time of hands-on ER doc care: Fourteen minutes.

Another patient came in complaining of headache. She's had neck pain and headaches for years. She's been told the headaches are related to muscle tension, and she's had a compeletley negative workup, but she doesn't believe it. She wants them fixed now. She wants an MRI. I take her history, do her exam, write orders for pain medications, and check her response. I explain to her that in the ER, when the neurologic exam is stable we generally don't do MRI's. I explain it again. I painstakingly document the encounter and the areas of disagreement in the event that she chooses to bring it up the next day with adminsitration. Total hands-on ER doc care, not including observation time to watch for pain relief: Twenty-nine minutes.

I'm sure that says something about what actually constitutes an emergency, why saving lives takes seconds but risk management takes hours, patient expectations versus clinical realities, the problems with consumer-based health care, the silliness of a health care system that promotes equally silly behaviors, and the overall state of medical practice in America. But it's three in the morning, and I've got to see more chronic back pain and kids with runny noses who's crying is keeping up their parents and people who think they might have passed out yesterday but nobody was around to see it while I hope that someone else's grave misfortune will give me a purpose for being here.

I'll let you figure out the moral of the story, because honestly I'm just trying to make it to dawn.

Speaking Frankly

2011-06-17T06:48:00.000-04:00

Frank was brought in to the ER with a decreased level of consciousness. (Our technical term is "gorked.") According to the paramedics, he had called 911 and told them he might have had a seizure. (Decreased level of consciousness after a seizure is known as a "post-ictal state. The technical term is, once again, "gorked.")

It was a chaotic night in the ER. I saw 34 patients in the first 7 hours of my shift, and at times one might have to wait over three hours just to get into a room. This may not seem like a long waiting time when compared with a busy urban ER, but around here where people expect both a slower pace and faster service, it becomes a real issue. (For me as a physician, busy times mean more than just an increased workload. Clinically, the pressure to move patients through the system means less time upfront for patient assessment and less time for teaching at the end. Rises in workload also stress the decision-making process and add an extra element of risk to care. Administratively, it also means more patient complaints about delays, which are most often interpreted by hospital administrators as "the doctor's fault." That's not fair, because delays in care are most often related to the system as a whole...not enough beds, too many patients, not enough staff...rather than to the performance of any individual physician. But hospitals are loath to admit that their systems have issues. So the easiest person to blame is the ER doc, who is certainly more disposable than admitting or specialty physicians...translated as those who make money for the hospital...or even nurses who are in short supply. There's always another body with a medical degree out there to take the job, quality beside the point.)

Because there was no room at the inn, Frank got put in the hallway just catty-corner from the nurses’ station. As expected, he was pretty lethargic on arrival. There are two ways to wake somebody up, and they both involve what is politely referred to as "noxious stimuli." The first, and most elemental, is to simply yell at them. So I did.

"Frank?"

"Hey, Frank?"

"HEY, FRANK!"

Frank would wake for a moment or two, mumble off a few words, and drift back off to Frankland.

I ordered the requisite labs and studies, and resolved to check on Frank frequently in the next few hours. What I had not realized that my voice had gotten so loud and shrill with my repeated attempts that everyone in the ER now knew there was someone in hallway named Frank and, for some reason, the doctor was very interested in saying "HEY!" to him.

As mentioned, the ER was exceptionally busy. When we get that full, we open up some extra rooms in near the back of the ER that are usually used during the day for chemotherapy and other outpatient work, but can be pressed into service. The way leading back to those rooms went right past where Frank lay asleep in the hallway. So every time I went back there to work with those patients, I took the opportunity to stop by his bedside and shout, "HEY, FRANK!"

This eventually became our collective routine. Every time someone would walk through the back hallway, they would pause for a moment by the bedside and shout, "HEY, FRANK!" This got us to giggling, and soon we were simply looking at each other yelling,"HEY, FRANK!" a behavior that made perfect sense to us but utterly befuddled the poor nurse, not one of our ER clan, called in from home to help with the load. This frantic and frenetic Frankness was noted by a highway patrol officer in the ER at the time, who introduced us to some law enforcement versions of the other kind of noxious stimuli, namely pain. I'm not going to go into detail here other than to say I never thought you could do so much with two toes and an earlobe.

(Speaking of the highway patrol, the officer was here to interview three victims of a motor vehicle accident. They were a family-to-be who was rear-ended on the Interstate. The man was a tall, thin, and pale white with a wide variety of prison tattoos, including the requisite tear drops in the corners of the eyes, skulls surmounted by a flaming cross, and the letters L-O-V-E inked over one set of knuckles with T-R-U-B read over the others. The woman was a heavyset African-American, a good foot and a half shorter and two feet wider than her fiancée, who spent of the evening rocking back and forth in a chair whimpering, "Mama, Mama, Mama." The 15 year old daughter of the woman...the most normal looking and clearly the sanest of them all...also had the worse injuries, with broken teeth and nose. All you could do is look at the three and figure Love is Blind, There's Someone Out There for Everyone or some other simple plaudit because there's really no other way to describe the group.)

Frank did wake up about 4:30 in the morning, and turned out to be a pretty nice guy. He had no idea what had happened to him, only that he recalled having a sandwich delivered from Jimmy John's earlier that night. In a bold show of camaraderie with our patients, we had also received a delivery from Jimmy John's that very evening. It gave us something to talk about, and it turns out that Frank and I both like the Hunter's Club, substituting mustard for mayonnaise. They always say you bond best over food.

In The Wee Small Hours

2011-06-15T05:29:00.000-04:00

I’ve learned that in rural Kansas, frigid cold and high winds are the ER doc’s best friend. In a world where the entire health care system seems designed to drive you to the ED so “real doctors” can see paying patients at their own pace and get their beauty rest at night, weather is one of the few disincentives to convenience care. If you come to the ER on a night where the wind chill is 30 below zero (or degrees above absolute zero, if you like to know that sort of thing), you’re either really sick or totally bonkers, which is probably sick behavior in and of itself. (Indeed, you could make a case that to come to the ED for anything short of a near-death experience on such a night is clear evidence of suicidal ideations and mental illness.) It’s a little different in the city, where cold weather brings out…or in…the homeless for a place to stay the night and maybe get a stale sandwich and a cup of juice And while I can’t prove it, based on what comes in to the ER I’d suspect that police blotters swell during cold weather, as people get themselves arrested for minor offenses to ensure their “three hots and a cot.” (The more astute ones who know the system and have a severe allergy to the stainless steel found in handcuffs will complain of chest pain and rattle off a list of cardiac risk factors, virtually guaranteeing at least a 24 hour hospital stay. By the time they’re discharged, the police have completed their paperwork and have moved on.) But in rural America, these are the nights you dream of, the nights when you look around an empty department just before midnight and think, “Tonight I get paid for sleeping.”

The problem, of course, is that you don’t sleep. You walk back to the physician’s sleep room, and before lying down you move the phone close to your bed so you can answer it when it rings. And you know it will ring, but you don’t know when. So you sleep fitfully, tossing and turning, opening an eye every fifteen minutes like clockwork; and when the phone doesn’t ring after an hour or so, you get up and wander out into the department because you’re convinced that there’s something going on that you’ve missed. And it’s doubly difficult because you’re in the middle of an argument between your body telling you to sleep and your mind noting that you’ll only wake up again and feel even worse than before.

So what do you do when you can’t sleep? Well, I would like to say I use the down time to be incredibly productive, to write on my blog, to read the latest medical literature, to conduct in-depth research about why we’re worried about air traffic controllers who work one night shift every two weeks suffering from critical fatigue and falling asleep but why we’re perfectly okay with doctors, nurses, policeman, and firefighters chronically working at night or even 24 hour shifts. I mean, all these folks do is save lives. (The air traffic controllers will now get double coverage in the towers at night and a mid-shift nap. The aforementioned groups get nothing. Yep, I’m a little bitter.)

The truth is that the last four or five hours of a twelve hour night shift is spent in a special kind of limbo that reminds me of the drug ketamine. Ketamine produces something called dissociative amnesia; the patient is awake and conscious, but not responding to words or sounds. It’s really kind of spooky to watch. The eyes are open, the heart beats, the chest rises and falls, but they just lie still like you might see in a morgue. The best way to think about it is that the lights are on, but nobody’s home. From the view of the patient, dissociation means that there’s an awareness of something going on, but no way to figure out whom it’s happening to or how you might be personally involved. (To be frank, it's the same feeling I got chewing coca leaves hiking the high-altitude Inca Trail in Peru. I was fully alert, climbing, and interacting with the guides. And I could feel someone’s heart beating fast, could hear someone with quick, raspy breathing, but I had no idea that it was me.) When you work that back half of the shift in the early morning hours, you know something’s going on but you just can’t quite place it. You know someone is awake and that someone is tired, but you nonetheless slog on through the disembodied haze. Every now and then a patient in real danger will momentarily rouse you from your torpor, but despite what you see on television in real life those moments are few and far between. Frankly, it’s hard to get excited about chronic pain or a fussy child at 4 AM. It’s lot easier to care before midnight.

(I should note that some people do better with night shifts than others, and that there are real differences in biologic clocks. Shift length makes a huge difference as well. You can rotate your schedules to simulate a “physiologic workday” in eight-hour blocks and make an 11 PM to 7 AM night shift work quite well, but there’s nothing physiologic about 12 consecutive hours of continuous toil. Personally, I have always been much more of an evening and night person than a day shift guy. I truly find the hours between 7 and 11 AM painful to work, and on days off I tend to wake up about ten AM and go to sleep an hour or two after midnight. But even as a night guy I get tired about 3 or 4 AM, and that’s where the doldrums kick in.)

So you can’t do anything useful, and you can’t sleep. So you wind up doing that which is both not useful and not sleeping and burn a few more hours of your lifespan watching television. . (The one exception to the “time wasting” is on those days when I can watch Jerry Springer, which is always a useful exercise in Social Darwinism gone horribly wrong.) It gets to the point where you can plan your shift by reruns; it’s Home Improvement from 3 to 4; M*A*S*H from 4 to 5; I Love Lucy runs 5 to 6. Every now and then the cable channels will shuffle their lineup to keep you honest, but the only real problem comes on the weekends when the regular schedule changes. During those times, you rely on infomercials to keep you occupied, and while the schedule is less predictable after a while Chef Tony, the Magic Bullet Guy, aging pop stars from Time-Life, my med school classmate Troy Burns talking about vacuum pumps, and the gaggle of well-built women (my father would call them “deep breathers”) talking about “performance” become as familiar as Tim Taylor, Hawkeye Peirce, and Ethel Mertz. Here’s an example of how familiar these things can get: One of the “performance” programs features a very blonde and buxom PhD...specifically Victoria Zdronk, PhD, "Best Selling Author and Relationship Expert"...with a small mole on the inner upper aspect of her breast. That’s not unique in itself, but if you look closely you’ll see that every other shot flips her from one side of the screen to the other in a mirror image, including moving the mole from side to side.

(Incidentally, the first time I saw my friend Troy on TV, I sent him a Facebook note about it. Turns out he did a mock interview for the show as a favor for a friend ten years ago, and didn’t realize it was going to air in perpetuity. Turns out he doesn’t get any royalties, either by the airing or by the inch.)

TV time stops at 6. That’s when some of the more early-rising administrators start to poke their heads out of the sand, and one needs to be ready to respond to questions like “How was the night?” with totally politically correct answers like, “Any night serving the citizens of this fine community is a night well spent.” (Took a week to come up with that one. I’ve got more.) So I leave my little room, but on a brave face, and count down the last sixty sweeps of the second hand.

Speaking of my room, I’ve been spending a lot less time in it lately. This is because a few weeks back, an intoxicated patient who was waiting for a ride home went AWOL. This promoted a brief but vigorous search of the area, but by all accounts he appeared to be long gone. That is, until about two hours later when he was found dozing in the bathroom adjoining the ER doctor’s sleep room, pants down around his ankles, with a pool of what was suspected to be not-yet-digested burritos in front of him and a similar conglomeration of product in the bowel behind. Yes, my friends, he had managed not only to get into the doctor’s private office and to use to toilet, but also to both barf and fall asleep in the act of elimination. And while the room was cleaned by ED staff that night and again by housekeeping the next day, I refused to go in there until at least two days had passed I was sure that one of my colleagues had used the facility. I wanted to make sure there was a layer of trusted germs in between Mr. Elimination’s use of the seat and mine.

Role Reversal

2011-06-13T05:31:00.000-04:00

The Teen is at the age where he’ll make the decision when to go to bed, but still wants me to tuck him in. He is, however, supremely embarrassed when I give him a kiss on the head and say to him as I have every night we’re together for the past thirteen years, “Goodnight, best friend. “ I’m holding on to this as long as I can, because I know the day is coming soon when bedtime rituals will be a thing of the past, and that soon the basic hygiene practices of the adolescent male…that is to say, none at all…will make bedtime more of a wave-from-the-door kind of thing.
I try to go to bed shortly after he does, in the hope that I can maximize my time with him by keeping our schedules somewhat parallel. But lately I’ve been working a lot of nights, so I’m having trouble shifting back and forth. The other night I woke up at 4 in the morning, having gone to bed at 10 the night before, and couldn’t get back to sleep no matter what. So I got up, paid a few bills, did some laundry and some dishes, worked on a few snippets for the blog, and still found myself unable to sleep two hours later.

So I started to play The Damn Game, otherwise known as Civilization IV. This is the same game that has been my blogging downfall the past two months, as noted in my piece “I Write the (Titles of) Songs” just a few days back. After a brief respite and a return to productivity, I’m back to The Game because the latest expansion pack arrived on Saturday, and I’d be remiss if I didn’t at least try out playing as the Portuguese.

It’s now about 6:30, and I hear the feet. These are the feet that, trained by years of knowing that on weekend mornings the father sleeps, know that this gives you several hours of computer and Wii time uninterrupted by parental requests to do things like “brush your teeth” and “eat breakfast at the table like a human being” and “let’s just have a meaningful conversation about what’s going on in your life because even though these moments bore you silly someday you’ll look back on it and value our time together.” The feet wake first, and as they hit the floor they send impulse to the hands to engage the power button, which then activates the eyes to open by the glow of the LCD screen.

(There has actually been some debate within our home regarding the actual timing of morning and when the feet can first hit the floor. My contention is that morning corresponds with the rising of the sun. His is that morning begins with the Rising of The Son. This dispute comes to head around those times when clocks spring forward and fall back. This leads to the invention of new time periods to describe the proximity to what I consider actually dawn, and thus delay his ability to engage the computer. Thus we have the Immediate Pre-Dawn, the Post-Immediate Pre-Dawn, the Pre-Imminent Dawn, The Imminent Dawn, The Post-Imminent Impending Dawn, Tony Orlando and Dawn, Dawn Wells as Mary Ann, and so until I run out of adjectives and yield the floor.)

On this particular morning, however, I’m at the computer first, my back turned towards his bedroom door. This causes the feet to hesitate, then shuffle. My unexpected level of consciousness is clearly a problem.

“Dad, why are you awake?”

“Couldn’t sleep. Got up at 4, couldn’t get back to bed.”

By the sound of his voice alone I can tell that the routine has been broken, and the spinning hamsters in his mind will need to come up with a new tactical plan. Like any strategy, adaptation needs with information.

“What are you doing?”

“Playing Civ IV.”

(Like he couldn’t tell by looking over my shoulder, which I know his doing by the smell of last night’s chicken curry and vegetable korma on his breath. I told him to brush last night, darn it, and when I checked his toothbrush was wet. He’s getting more clever by the day.)

He sighs and goes back into his room to read . Twenty minutes later, he’s back.

“Are you going to go back to bed?”

“Soon.” (I’m just about to send a few Portuguese knights in to knock off an Ethiopian catapult.)

My son knows me pretty well, so he knows that no matter how tired I may be I won’t vacate my game until I am assured of a win, know for sure I’m going to lose, or get a phone call from either Christie Brinkley or The Bride (not in that order). And thanks to the magic of DVD, he also knows The Big Bang Theory, which is our favorite show on TV. Sometimes he calls me Wolowitz, and sometimes I call him Sheldon. Because…well, we are.

So he decides he will solve the problem of the father being awake and potentially wanting to engage in conversation or other mutual activities that might interrupt his carefully planned morning of AdventureQuest, Neopets, and You Tube (he would direct you to “The Best Cat Video You’ll Ever See” or Parry Grip). So he adopts a strategy used by the character of Bernadette when she wants to get the socially awkward and quite literal Sheldon Cooper to get some rest after staying awake for three straight days.

“You really want to win at Civ?”

“Uh-huh.” (That’s one stubborn catapult.)

“You can’t do it unless you can think well. And what happens to our neuroreceptors when we stay awake to long?”

I look up at him, remembering the lines from the episode but not quite sure where he’s going.

“They don’t function well and they lose their sensitivity.”

“That’s right, Howard. So go to bed now, young man.”

I gazed at him, knowing that not only was he right but that this was the first step towards those days when he’ll be coaxing me to eat porridge from a spoon by making airplane noises. (Which, because I like airplanes, I will do.)

“Will you at least tuck me in and sing the “Soft Kitty” song?”

“I’ll give you Bob the Giraffe to sleep with and pat you on the head.”

Fair enough. So I did.

Snippets

2011-06-11T06:45:00.000-04:00

There's a young woman we see often in the ED. She has spina bifida and is in a wheelchair, and also has problems with migrane headaches and urinary tract infections. She’s' a pretty frequent user of the ER, but she's just so darn pleasant and easy to care for that we really don't mind.

Sometimes our familiarity with her makes us forget her disability. I'm sure that's what she would want. But I wonder if it she caught it when the unit clerk out front asked her to "Take a seat in the Waiting Room, and we'll be right with you," or when I said after finishing her care, "Let me do some paperwork, and we'll get you rolling." Ouch.

**********

While I wear black scrubs, and most male nurses and techs wear solid colors, women will often wear scrubs with different prints and designs on them to add a bit of color to their working lives. This is why one of the ER nurses was wearing a scrub top with a collage of squares from Monopoly. Given that I have no internal filter, it was a given that at some point...specifically 9:28 on a recent Sunday night...I would ask if it meant anything that the square for Community chest was located atop the left breast, while the one for Luxury Tax was over the right. No telling if there are any strategically placed "Go," "Chance," or "Go to Jail" spaces elsewhere in the print.

**********

We're able to hear the calls that go out from the County Dispatch Center to our local fire, police, and EMS services. Here are three calls out in the past week, literally transcribed:

"Medical Emergency. A woman says a light bulb fell on her head."

(Hearing this, one of nurse remarked, "It must have been a bad idea." She was transported to the hospital at her request, found to be exceptionally whiny, and discharged with alacrity.)

"Medical Emergency. Man is slumped over the steering wheel of his car beside the exit ramp."

(Turned out he was asleep, and none too happy at being awakened. At least when I sleep on the side of the road, I lean the seat all the way back so they can't see the body. If they think it's just an abandoned car, I'm not disturbed.)

"Medical Emergency. Man found unresponsive on the front porch. Pizza delivery found the patient, not sure if he was breathing. They left the pizza and called from a different location."

(There's a way to get free food...feign death. On arrival the EMS crew woke the patient, who refused care. He did not refuse the pizza.)

Rich 'Ol Me

2011-06-09T06:26:00.000-04:00

I’ve heard that President Obama wants to raise taxes on the wealthy. Much to my surprise, it turns out I’m one of them. It’s not that I didn’t know my income. Every month when the bills are due I do the multiplication, (dollars per hour) x (hours per shift) x (shifts per month). Nonetheless, I had no idea I was wealthy. When I think of the wealthy, I think of folks playing golf and sipping cocktails at the club, living off investments and inheritances. I think of CEO’s and shrewd financiers; I think of Wall Street folks counting their cash, looking down on us from their penthouse views. I think of Robber Barons and Paris Hiltons, of reality stars, Bridezillas, and anyone named Kardashian.

When I think of the wealthy, I don’t think of a guy who’s pushing 50 and still working in an ER, mixing up his days and nights, spending more time in a Hampton Inn and eating instant oatmeal that in his own bed sipping a cup of tea served by a white-gloved valet. (The reality, of course, is that I make my own cup of tea, carry it to the bedroom, and then fight off the cat who just wants to share.) I don’t think of a guy who’s upside down on three mortgages and doesn’t want to default because of some antiquated sense of obligation (thank you, Wall Street…and you enjoy those record profits). I don’t think of someone living paycheck to paycheck with back taxes (from retirement accounts cashed in when the market first crashed…thanks again, Goldman Sachs); with child support and student loans still not paid off over twenty years after med school. I would be perfectly happy to be considered “wealthy” if I actually got paid for everything I do, but given that in some surveys half or more of all ED care is actually “given away” and not reimbursed, I am not so fortunate. And we won’t even get into the questions of liability I face for my actions, problems unknown to attorneys, investment bankers, or policymakers.

As a former professional bureaucrat, I really don’t have a problem paying taxes. What I object to is being labeled as “wealthy” and taxed at a higher rate simply to satisfy someone’s idea of class warfare. There is a clear difference between the “wealthy” who bust their butts to earn their keep, and those for whom the money simply rolls in. For the latter, a higher tax rate is a mere inconvenience; for the former, it’s a form of punishment, a clear message from the government about the value…or lack thereof…of hard work and effort. And the tax code is so convoluted that any sense of fairness is gone…it’s pretty clear that the “wealthy,” at least as I think of them, also have the resources to avoid the biggest tax bites.

But as my father told me some years ago, it’s not enough to have an opinion; you have to know why you think that way and what you would do about it. So here’s the Rodenberg Plan:

First, individuals are taxed at a consistent, graduated rate. The current numbers we have, with a top tax rate of 25%, works for me. Medicare, Social Security, and Medicaid taxes continue as a fixed percentage of income to a maximum rate. There are a minimal number of deductions, such that the tax code can be summarized in an hour-long Power Point presentation. Deductions can apply for dependents, mortgages, taxes paid to states, and student loans. There should be new deductions for those who pay child support and alimony; the recipients of these funds should have to pay taxes upon them as income. Other than that, your tax is your tax. Individual sate income taxes should follow a similar model.

(For the record, I think that if a piece of legislation cannot be fully explained to a lay audience in a sixty minute Power Point presentation…including cartoons and jokes…the legislation is too complex and needs to be thrown out.)

Second, corporate taxes should be based on a graduated but fixed percentage model as well. Tax credits or deductions could be granted for investments in infrastructure, employer support of employee benefits, or the creation of actual, filled jobs. Tax shelters in the form of offshore accounts and domestic loopholes need to be closed.

Finally, entitlement programs need to be means-tested. If I’m fortunate enough to live well in retirement, I’m willing to forego my Social Security payment as the dues I pay to have lived in an affluent society. I have a similar feeling about Medicare benefits; if I can afford my own insurance, I ought to do so rather than taking more money from the public purse. Again, it’s my personal sacrifice for the benefit of having been successful in life. And I believe that within Medicaid, services must be limited on the basis of medical necessity and cost-benefit ratio.

I think this plan has something for everyone. Democrats will like the emphasis or corporate taxation, and making the “wealthy” pay their own way rather than using public funds for a golf-centered dotage. Republicans will appreciate lower individual tax rates and a simplified tax code. Of course, special interest on both the left and the right will find reasons to trash these ideas, just as they will any ideas the real politicians may choose to propose. (This is assuming that the politicians don’t find reasons to trash each other’s idea first.)

Meanwhile, I’ll have to start learning to be wealthy. Maybe next time I drive through Kansas, I’ll rent the Full-Size Car rather than the Compact. And if only I could get the folks at the Hampton Inn to have room service…

To Be or Not To Be

2011-06-08T04:28:00.001-04:00

Mr. Rowley was brought to the ER by his son for a drinking problem. Drink was no stranger to Mr. Rowley, nor Mr. Rowley to the bottle. He had been in a detox program in 2003 that had kept him sober for two years, and afterwards had been able to limit his drinking to a glass or so a day. But in the last few weeks he had lost his job, and the drinking returned in force, to the count of a couple pints each day.

I tend to think that alcohol brings out the real person under the everyday veneer, albeit it in an exaggerated form. That’s why every intoxicated person is different. Some are nasty and mean with a few shots in them; some get deep and philosophical, while others are funny and raucous. Some turn out to be just decent people, polite, respectful, who just seem to be drinking to numb the pain of the day. Mr. Rowley was one of those.

Mr. Rowley recognized his drinking was a problem, but he was not interested in detox; he figured he could do that on his own. What he wanted help with was the depression that led to the drinking. Not only had he lost his job, but also his means of support for the three children he loved dearly, as well as the ability to maintain his obligations to his ex-wife and to care for his pets. He felt he had nothing left, that everything meaningful to him as a man as caretaker and provider were being taken from him, and the only way out was suicide. He knew exactly how he was going to do it as well, at home in the backyard with his shotgun. (And being a man who’s been in similar circumstances in the past, I’ve known exactly how he felt.)

When someone states they have thoughts of suicide, and especially when they have a well-thought plan, they inadvertently trigger a set of clinical and legal interventions. Clinically, we make sure there are no medical problems which might be responsible for these dangerous thoughts. Legally, we are obliged to hold the patient in the ER for their own safety until evaluated by a mental health professional. If the psychiatric screener feels the patient represents a clear danger to himself, we are then obliged to continue to hold the patient for formal psychiatric evaluation. While larger communities often have a local set of mental health services, at the rural facility where I work that means transfer to the State Psychiatric Hospital an hour and a half down the road.

Mr. Rowley had made it clear that while he wanted help with his depression, he didn’t want to be admitted to the State Hospital. He wanted to get some therapy, maybe get on some medicine for his depression, then go out tomorrow and look for a job. But he couldn’t have realized that once the process is set in motion, it can’t be stopped. His statements to me meant that he needed psychiatric screening. His statements to the mental health worker mandated further evaluation at the State Hospital. The fact that he was under an involuntary hold meant that he would need secure transport by law enforcement. And knowing that he didn’t want to go meant that we couldn’t tell him what was going to happen, as if he knew he would leave and short of using force there would be no way to stop him.

So we ended up playing this game of buying time with sandwiches and sodas, telling him we wanted to make sure he was sleeping off his alcohol before letting him go, until all the arrangements had been made and the police were here for transport. It’s my job to tell him what’s going to happen, and I did so as softly as I could, for I felt for this man. Polite, reserved, dealt a bad hand in life, and about to be dealt an even worse one by policies and procedures far beyond his control or mine. He tried to negotiate, but there was nothing more to do. The die was cast.

So here’s this proud man, who is a likeable and decent citizen, getting escorted to the State Hospital by police, and not even with the last piece of cake we’d gotten for him out of the hospital kitchen. Short of going in handcuffs, it had to be the most humiliating thing we could have done to him. All of it was legal, and all of it was exactly by the book. And while I really hope we’ve done something good here, and gotten him some care that can help him find a reason to go on, I can’t shake this feeling that all we’ve really done is let him know that the next time he feels this way, asking for help only makes it worse. I wonder if we’ve made suicide a more inviting option, because at least you go out on your own terms. And I wonder if, as noted by Albert Camus, “There is but one truly serious philosophical problem, and that is suicide,” we’ve just helped him answer the question.

Motivators

2011-06-07T04:27:00.000-04:00

One of my favorite moments in political history was during the Nixon Administration, when an obscure Federal Judge named Harrold Carswell was nominated to the Supreme Court. In defense against charges that Carswell was "mediocre", Senator Roman Hruska of Nebraska (Republican, Nebraska) stated:

"Even if he were mediocre, there are a lot of mediocre judges and people and lawyers. They are entitled to a little representation, aren't they? We can't have all Brandeises, Frankfurters and Cardozos."

Given how our standards for public life have fallen in the past forty years, I suspect Judge Carswell would have an easier time of it today, at least as long as he believed whatever the current Chair of the Senate Judiciary Committee believed about abortion. But there was a nugget of truth in the good Senator’s statement. Given that a few of us are geniuses, a few are total duds, and most of us lie somewhere in the middle, perhaps we’d all be happier if we strove for the median instead of the top?

We’ve actually discussed this late at night in the ER, and we’ve come up with the following potential morale-building internal slogans:

“Striving for Mediocrity”
“Defining Adequecy.”
“We Aim for the Middle.”
“At Least We’re Better Than Jetmore.”

I think there are lots of advantages to this kind if system. First, as we are a pretty decent hospital, we’re sure to meet our goals. There’s satisfaction in that. In addition, we know that third party payers and government agencies are always looking for outliers, and cast their investigative net accordingly. Being average lets you fly under their view. Finally, it’s the kind of thing that everyone can buy into, because we really are better than Jetmore. We think.

Acuity Axioms

2011-06-06T05:20:00.000-04:00

While I won’t claim to understand physics, I do appreciate the way mathematics is used as a constant, objective language to describe the universe. Therefore, you can understand why I’ve always been intrigued by ways in which human behaviors can objectively described by math. Until Hari Seldon comes along to develop the science of psychohistory, the world will simply have to limp along with my brief attempt at such an effort, a few musing which I have modestly termed Rodenberg’s Universal Laws of Inverse Acuity.

1) The severity of the presenting illness or injury is inversely proportional to the number of decibels generated by the patient in registering their discomfort or displeasure. If you’re able to exert that much effort at complaining, there can be very little going on sapping effort from your vigorous noisemaking.

2) The severity of the illness of any one family member is inversely proportional to the number of family members who have accompianied the patient to the emergency room, or to the number of family members to seen by the emergency physician for various medical problems during the same visit.

3) The severity of any one patient complaint is inversely proportional to the number of complaints exhibited by the patient at the triage window. If you are stable enough to think exhaustively about all the things wrong with you, there can be very little really wrong.

Nobel Prize nominations humbly, but gratefully, accepted. Thank you.

Brighter Than You

2011-06-03T03:35:00.000-04:00

They say the title does not make the man, and that’s also true in medicine. There are plenty of people out there who are book smart but lack common sense, and some of them carry the title of physician. It's like the old joke about what they call the guy who graduates last in his medical school class. The answer, of course, is “doctor.”

I have an ego as much as the next guy, and I like to think that I’m a reasonably bright citizen. But I also like to think I know my limitations. I know, for instance, that despite reading the CDC guidelines I will not survive the Zombie Apocylaspe, as I’m fairly certain the ability to sporadically blog and complete paperwork for maximum reimbursement pales compared to the ability to kill your own food and build your own fortress. (This is why my son already has reservations to live his post-Apocylatic days with my sister and brother -in-law, who have these qualities in spades.) I also know that I have trouble keeping my shoes tied, like to drive in the left-hand lane, think recording ATM withdrawls in the checkbook is only an option and not a requirement , and am a relatively poor parallel parker.

So I’m fully aware that there are folks in medicine who are a lot brighter than me. That opinion isn’t based on what you might think, like who’s a “specialist” and who’s not. The truth is you get be a “specialist” not because you’re the best at what you do, but because you’re willing to slog away, overworked and underpaid, for umpteen extra years for others who, by dint of seniority and not by quality, have you to do their work for them. And it’s not that hard to become a specialist. If you’re willing to go anywhere, there’s always a training spot somewhere. (A significant reason that I’m an ER doc and not a plastic surgeon is simply that I didn’t want to get beat up for five years of general surgery and two or three more of plastics when I could sail through relatively unabused in three years of ER. A powerful work ethic has never been one of my strong suits.)

My personal view…and one, I suspect, shared by many ER docs…is that most specialists can’t work their way out of a paper bag. They are very, very good at dealing with the handful of things they do routinely (and at high cost). But you’d be stunned at the number of “collegial” phone calls I get from doctors wanting to know what to give their kids for a cold (“Tylenol” is always a good start) or what’s the best thing to do for a sprained ankle. In fact, that was one of the things that first attracted me to Emergency Medicine, as it seemed that ER docs were the only people left who actually knew how to do all those basic things you always thought a doctor…well, at least a doctor on TV…should do. Twenty-five years in, I recognize that was poor basis for a lifelong career choice, and I recognize that the inability of other physicians to take care of the simple things means there are an infinite number of reasons for “real doctors” in their offices with normal hours, the ability to control their workload, and the benefit of actually being reimbursed for the patients you see to use the ER as a convienent whipping boy. But the optimism of youth won out, and now I’m too old with too many mortgages to do something else.

One of the more pleasant discoveries of working ER in a more rural setting is that, in fact, there was a reason you were in the top half of your medical school class. Out here I’ve seen both the best and worst of medicine. There’s the best, because I truly believe that the single most difficult thing to do in medicine is to be a good family physician in a rural area. You’ve got to be able to manage the greatest spectrum of care with the least support, and do it to the same standard as the guy at a teaching hospital with specialty backup for each gonad. There are a lot of these unsung heroes out there, doing the right thing every day in a manner I can’t even approach. But there’s also the worst, as rural communities starving for medical care take whatever they can get, and sometimes it’s that guy at the bottom of his class who’s still called “doctor.”

The problem is trying to figure out how I should respond to the baboon (and, as Groucho Marx notes in “Duck Soup,” that’s an insult to the rest of the baboons) who calls in the middle of the night to transfer you a patient that either don’t want to deal with or they’ve clearly mucked up. Most of the time you grab the phone with righteous indignation, determined to spit out in no uncertain terms exactly what you think of their clinical skills and to suggest that they get a new job selling door-to-door ham, where at least the product is already beyond help. However, after a few seconds reality sets in, and you figure that at least the patient is better off at a hospital that knows what they’re doing (that’s a polite turn of phrase for “get them out of there before someone kills them.”)

Purists…basically those academics, policymakers, and ethicists who exist in a sheltered world…might say that when we come across these scenarios, it’s our duty as physicians to turn in our less capable colleagues to the State Medical Boards. But doing so doesn’t help hospital volumes, and less patients mean less revenues. Making your concerns known in the public record so that the other doctor’s referrals go elsewhere does nothing but get you relieved from your job. Sorry, but that’s the real world. No matter how justified or correct they might be, squeaky wheels in the employ of another get no grease. They get fired.

(Interestingly, while there are always better and worse physicians in a community, I don’t see the same breadth of quality of care in more urban areas. I’m not quite sure why that is. Perhaps it’s because physician practice groups are larger and there are more doctors to “ride herd” on one another, and because hospitals have medical staff and administrative structures to ensure the quality of care. When you’re the only game in town, quality…or lack thereof…is what you say it is, and there’s no one to argue otherwise.)

Needless to say, I’m not about to tell you which physicians I’m thinking of as I write this or what exactly they’ve done. I’m fortunate that at the facility where I work, we have a pretty good record of getting patients out of the hole dug for them by their own doctors. But I can tell you one story that just gives you a sense of some of our referrals.

A middle-aged male was sent to us for evaluation after an intentional overdose of Phenobarbital. Phenobarbital is used mostly as a medicine for seizures, and in large doses it can cause sedation. Management of these overdoes is actually pretty easy. Make sure the patient’s breathing okay, and let them sleep it off. This patient, however, became angry when aroused and started to swing at folks. So rather than simply letting him sleep, the doctor at the other facility decided he needed to be transferred to us. He was apparently loaded into an ambulance with difficulty. He was unloaded with no difficulty at all, because there’s nothing like the steady drone of tires on interstate plus a heapin’ helpin’ or barbiturates to induce a nap.

I checked him out, fully expecting to see what had been advertised…a guy who needed to sleep. What nobody had mentioned…and I’m giving the other doctor of the benefit of the doubt by saying they didn’t know enough to look, because to take the other tack is to call them a liar…is that he also had the snot beat out of him, with multiple abrasions and bruises all over his head and face. That’s a pretty good reason to be agitated, don’t you think?

A few x-rays later (the same x-rays I know they have at the other hospital), we were back to Plan A, and he was admitted to sleep off his mischief. Maybe the other doctor just knew our beds were better for therapeutic non-intervention. But I can’t fault the other doctor entirely for knowing the patient had a better opportunity for competent care at our place. This was proved later that night when he got mad about not being in his hometown ER anymore, and decided to roam about the room flinging chairs and pulling towel dispensers off the wall. The hospitalist on the case decided that the best course of action was to bandage his cracked and blistered feet.

You’re probably asking, as did I, why that was the preferred method of care. Was it out of compassion and understanding, a desire to build trust within the physician-patient relationship? Perhaps it was a show of humility by the physician, a bold statement of service with a Christian precedent?

Turns out she did it because it was smart medical care. With his feet wrapped in gauze, he couldn’t get any traction on the slick, freshly waxed hospital floors. So when he tried to get up, he’d slip back onto the bed. Sure, he could still yell, but hospital property was no longer in the air. It was a flippin’ brilliant move.

See, there’s another doc who’s brighter than me.

Gone Fishin'

2011-06-02T04:43:00.000-04:00

Tonight’s notes from the You Can’t Make This Stuff Up Department:

A thirteen year old boy was playing on the banks of a local creek in his bare feet when he stepped upon a dead catfish. As you may know, catfish are so named because they share several qualities with their land-based counterparts, including “whiskers” on the front of their face and an utter indifference to the presence of humans, with the possible exception of when you throw some pellets into the water at a feeding pond. The “whiskers” are actually cartilaginous spines that stay moist and malleable when the catfish is alive and in the water. When the catfish has washed up on the bank of the creek and dried out a bit, the spines become small barbed weapons that tend to get stuck in things. Things like the unshod foot of a thirteen year old boy, who showed up at the front door of the ER with a catfish spine stuck in his foot. Which was, in turn, still attached to the head of the disembodied catfish.

Many people think of medicine as a delicate art. It’s not always. But it was worth the ol’ med school try, so I numbed up his foot and tried to gently remove the catfish head. I made a small incision at the base of the wound hoping to find room to free up the barbs so I wriggle it out with minimal tissue damage. This, of course, didn’t work. Enter the vise-grip pliers, a backward pull, and a lot or torque, which did.

The patient did well and is now home, having negotiated a stop at McDonald’s with his grandmother before leaving the ED.

The catfish head resides in a small specimen cup currently sitting on the desk of the ER Manager.

CITation

2011-06-01T05:58:00.000-04:00

The Teen is going to Claymation Movie Camp this year, and since it’s his third summer in a row he tells me he’s going to be a Counselor-in Training, or CIT. Which reminded me that one of the nurses was having her 30th birthday a few weeks back, and she mentioned that she was going to be a puma. “A puma?” I asked, not seeing where this was going. “Yes,” she said, “a puma…a CIT…Cougar-in-Training.”

Tickle Me Emo

2011-05-30T06:35:00.002-04:00

One of the benefits of a job in the ER is that it keeps you up to date with pop culture. So over the past few years I’ve learned what it is to be Goth, and now I’m become familiar with those we call Emo. I’ve even had occasion to write an Emo poem, at the request of one of my finer compatriots in the emergency care system of our fine nation, and thought I’d share it with you here.

(PS: Larned and Chattahooche are the locations of some of our country’s most desirable pieces of psychiatric real estate. Thought you should know.)

I cut my wrist in joy
For the bloodletting is freedom
And death my Valhalla.
If only my girlfriend notices
And I can avoid going to Larned.
Or Chattahooche.

My blood runs black
Black like the despair that fills my soul
Black like the curtain of worldly evil
That shatters the glee even of my pain
Caused by fibromyalgia.

Black like the bile of medieval times
Spawned by malevolence
Causing disease
Pestilence
Death
Black like the smell of melanotic stool.

Black like the color of Snooki’s hair
She of the Jersey Shore
A testament to the unfairness of all
And that I need larger breasts in order to attract media attention.

And what I want to say to you
You who demands my happiness
You who insist I value this pointless existence
This accident of fate
In a universe less a deity;
This struggle for life,
Only to end in inglorious pain,
Going nowhere and leaving nothing behind, is:

Leave Brittney Alone.

Food Fact

2011-05-29T00:18:00.001-04:00

Here’s a thought as to the obesity epidemic, especially among the poor and disadvantaged. I went to a coffee shop the other day. I had something called veggie hash, which was a small bowlful of roasted potatoes mixed with seasoned vegetables and covered with a slice of cheese. I was a bit of a doubter, but actually very tasty. Price for large order: 3.50. Add in my large hot tea for a buck-fifty more, and I’ve got a reasonably healthy 5.00 breakfast.

Breakfast at McDonalds the day before, 2 hash browns and a large soda. 2.00

See a connection?

Revisiting Breakfast

2011-05-28T10:24:00.000-04:00

I owe the Saab dealership $1400 to fix my car, and in order to facilitate collection they sent a driver to fetch me from the Orlando airport. (They call it Customer Service, though I suspect it’s actually a way to make sure I come back to pick up and pay for the vehicle.) I’m talking with the driver, and when he finds out I’m an ER doc he mentions that once upon a time he wanted to be a paramedic. He bailed out on that career because he didn’t think he could stand the sight of blood, and didn’t believe a friend who said he’d get used to it. Personally, I’ve never had a problem with blood, especially when it belongs to someone else. But as I’ve previously noted in these pages, I have a real problem with gastrointestinal fluids (vomitus and feces, or barf and poop.) So I explained to him that he was right, that you never really get used to it. Which is why I’m the guy flying out of the room when the retching starts, ostensibly to find a nurse with a plastic pan or to write some orders for medication to help, but really just to get out of there faster than spit. Granted, there’s probably some therapeutic value in standing by the patent’s side offering words of comfort and a reassuring hand on the shoulder, but I try not to stick around long enough to find out.

That’s why I’m so very grateful that my son is not a barfer. Some kids barf at the slightest provocation, mine has a stomach like iron. He comes by it naturally. I myself have done so maybe eight times in my whole life, and with only two exceptions they’ve all been from the excessive use of alcoholic beverages and therefore eminently preventable. (By way of contrast, The Bride is a barfer, but she does so with such charm and grace that I’ve actually thought about holding her hair back if she needed me to. But because she is wonderful, she knows not to ask.)

So it was quite a surprise last weekend when I was sitting happily at the kitchen table and heard an “urping” sound coming from his room. The fact that he was in his room at 9 AM was curious enough…he’s usually well engrossed in the computer by then… but he had told me he felt tired and wanted to rest, and I just figured it was some of his father finally coming through (weekends are sleep-ins for the ol’ man). I didn’t know what to make of it at first, as the only urping noises I’m used to hearing around the house come from the cat having a personal moment with a hairball. So I didn’t think much of it until I heard the sound of liquid on solid, which sounded suspiciously like…well, like what it was.

I have to hand it to the young man; he really kept his cool. No screaming, no crying. It was Spartan barfing. I waited a few seconds or so to give him his dignity, and then heard this small, embarrassed voice say, “Dad?”

I walked in to his room to find a slide full of blueberries. His bed is up on posts about five feet high, with a military décor. On the foot end of the bed is a ladder to climb up; just on the right side, next to the head, is a slide which allows for a fun exit in the morning. It’s also an excellent surface for the collection of vomitus, and to direct it away from the bed toward the carpet, where the blueberries currently resided in an intense pool where the slide met the floor.

Here is what I’ve learned by having my son barf a pint of blueberries:

1) Revisited blueberries are a lovely deep blue, and don’t smell bad at all. Therefore, while I would always encourage you not to engage in vomiting, if you must do so I highly recommend that blueberries be involved.

2) Blueberry hulls don’t deteriorate in the stomach. Although the juicy contents have been extracted, the hulls themselves stay relatively intact. (See “corn.”)

3) When you mop up the mess, the blueberry hulls stick to the towels.

4) When you wash the towels, soggy blueberry hulls stick to the fabric during the spin cycle. In the dryer, they will separate from the linens and lodge in the lint trap.

Here’s what my son has learned:

1) Don’t eat a pint of blueberries all by yourself during a single two-minute block of commercials.
2) Be sure to wash the blueberries before you eat them.

3) Don’t wash them down with a warm Coke.

Barfing in the ER is pretty easy to deal with, and it’s actually kind of fun to manage. It’s an instant gratification sort of thing. You can make the barfing go away, the patient feels better, the horrible retching noise stops, and everyone is happy. The process usually involves tossing the patients a few bags of IV fluids to aid in rehydration and to dilute out the ketones that have built up, chemicals which themselves can induce the Technicolor yawn; and giving some antiemetics, medications that work to suppress the Vomiting Center in the brain. (I’ve always wondered how they figure this stuff out…keep poking a rat in the brain until it ralphs, figure out where it landed, and call it the Vomiting Center? And yet science marches on.) The disposition process is pretty easy as well. If the patient keeps vomiting, they get admitted. If they get better and can keep down some Gatorade or juice, they can go home. There are lots of pills for vomiting out there, but I’ll usually prescribe a suppository on the theory that while you can barf up a pill before it has a chance to get absorbed, it’ll take a very special effort to bring up a suppository.

Barfing at home is different. The usual solutions include ginger ale, Seven-Up, and soothing noises uttered to the afflicted while cleaning up, all the while silently praying they never never NEVER make you do this again. And you can also…

(I was going to write more, but even thinking about this makes me feel a bit unwell…I’m breaking into a sweat, and starting to salivate. No, really I’ll be fine. Just leave open the door to the bathroom, and please be sure not to block my way. Can you hand me that Sprite?)

Turf the Bear!

2011-05-27T00:07:00.000-04:00

There is a stash of small stuffed animals in the back room of the ER that we give out to young children or physicians who are scared of getting their employer-mandated flu shots. (This is why I have a new giraffe named Bob). So it's not unusual to see these toys floating about the nursing station. But what was strange was finding a stuffed bear with a tear in the joint between its head and neck taped to a clipboard and stuck in the "To Be Seen" rack with a note on the chart that says "Help me, please...I'm losing my head!"

This prompted a discussion of the best plan of care for the small smiling ursine. While we can and do sew up lacerations, the location of the tear and the extrusion of fluff from the rent suggests the possibility of deeper injury that goes beyond my expertise. In fact, as the bear does not react when I talk to it, nor does it have effective movement of its limbs, severe head and spinal injuries might be present. Maybe he needs transfer to a neurosurgeon:

"Hi, Dr. Smock? Hey, it's Howard Rodenberg out here in the ER. I've got a patient I hope you can give me hand with tonight. His name is Theodore Bear...last name's B-E-A-R...and he's an unknown aged male with a large laceration to the back of the head, almost like someone tried to decapitate him. When I first saw him his eyes were open but he was unresponsive, not moving his arms and legs, and not reacting to voice or pain with an overall GCS of 6. So far I've got a CT of the head which shows only a "white-out" homogenous pattern with obliteration of the normal anatomical landmarks that radiology is reading as diffuse cerebral edema with increased intracranial pressure. I've tried to intubate him for airway protection and hyperventilation but I'm unable to get his mouth open to intubate him despite using paralytics...it's like his mouth is sewn up tight. I've tried to get a nasal tube in him instead, but I keep meeting resistance and can't get it placed. That being said, his vitals have been unchanged throughout his ER stay. I'm thinking that because we're having airway problem, it's best to get him there by air. We'll make the arrangements with the helicopter if that's okay with you."

You don't know how much I want to make the call, because I'm nearly positive that if I talk really fast at three in the morning I can probably pull it off. I probably would do it, too, but neurosurgeons generally have the same sense of humor as Newt Gingrich. Oh, wait...that's wrong...heck of a prank he pulled off last week about that whole Presidential thing. Well, played, Mr. Speaker...well played.

I Write the (Titles of) Songs

2011-05-26T02:33:00.005-04:00

It’s often hard to remember that other people outside of The Bride and The Parents actually read this blog. I know this because I was reminded of such by one Katelynn Ralph, an ED tech who hails from the lovely town of Beloit, Kansas. Beloit is not particularly renowned outside of North Central Kansas, but I have been in Beloit during my tenure as a State Health Officer visiting the Mitchell County Health Department. I learned that the people of Beloit are, well, quite Beloitful, but also that they put out a spread of cookies that included the most remarkable pecan tarts. When most places simply open a bag of Oreos and sugar wafers, you remember stuff like that.

(I have done some more research on Beloit and have also discovered that according to the Definitive Authority on All Things…and by that I mean Wikipedia…that “legend has it that the local Indians advised to locate the town at a certain bend of the Solomon River to protect the town from tornadoes. To this date, downtown Beloit has never been hit with a tornado.” I have also discovered that Beloit was once home to Gene Keady, former Purdue Boilermaker head basketball coach who was despised by my parents (both Indiana grads) for decades of coaching against The General and really bad choice of hairpiece.

(You may laugh at the whole Indian thing, but they clearly knew what they were talking about. In Topeka, for instance, city planners were warned not to build a water tower on Burnett’s Mound, long thought by native peoples to protect the city from tornados. They did, and a tornado came right over the top of the mound in 1966, killing 16 and doing over $100 million dollars of damage. I also have it on good authority that Lima, Peru was sited directly in the middle of a malarial swamp, as the Spanish were advised to do by the not-so-savage-and-really-pretty-darn-acute native population.)

Katelynn had asked why I had not blogged in the past few weeks. To be honest, I hadn’t really thought much about it. I blog when I blog, and some weeks I do better than others. I do recall that the last time I blogged I was having problems with line and paragraph spacing on the BlogSpot site, and that whatever I tried to post came out as one long run-on sentence. That’s probably reflective of how I actually talk, but not really good for reading. So I remember thinking that I’d give the system a week or so to figure itself out, and then I’d go on-line again.

Then I made a discovery…or, more accurately, a re-discovery…that steered me away from my writing tasks. This was called Civilization IV, a game where one’s nation starts in the Stone Age and your task is to emerge victorious by “The End of History,” which the game reckons to be the year 2050, a full 39 years after last weekend’s aborted rapture. It’s an older game, and I’ve had it for a couple of years. It had been dropped from the standard repertoire of time-wasters for Age of Empires III, then for Starcraft II, and finally Civilization V. Civilization V, however, was so little fun…and I mean that in a playing sense, not in the sense that I stand no chance above the merest beginner level, nor in the sense that I won’t play on-line because I’m tired of having my butt kicked by teenagers who have no life and can’t spell, because that’s a given…that I decided to give Civ IV another spin in the CD drive.

This was, to put it mildly, a mistake. Civ IV has become an all consuming passion for the past six weeks, and while I’ve done some writing it’s usually started out in with a phrase like “I saw a patient in the ER…” and ends up a sentence or two later with “…and what I really need are a few Giant Bunnies with Chainsaws to take out those stupid Barbarian Axemen.” Needless to say, I like the game. It lets me create people who do whatever I want them to with no regard for themselves. I can name cities after particularly noxious individuals in public life or in my own personal and professional sphere, and then utterly destroy them with nuclear weapons. I can make an entire culture put up monuments to ME. It’s horribly addictive, and to be frank it wasn’t Katelynn’s question, nor the continued urgings of The Bride that brought me back to my keyboard. It was the fact that I’ve been able to win on Warlord level six times running (don’t get too excited for me…it’s still the third easiest out of the eight levels of play) and Amazon.com has yet to send me the next expansion disc. I figure I have a ten day window (standard shipping) to write.

So Katelynn, here is your blog. As you requested, it’s about soundtracks. A few weeks back, a few of us (Katelynn, Aminda and I) were sitting around thinking about the music you hear in the background at stores and when you’re on hold. What if different places in the hospital had their own piped-in music? We came up with a brief list of tunes we thought should be in the background for these many different units. Here’s a sampling, edited for taste:

Intensive Care

“Every Breath You Take” (The Police)
“Breathe” (Faith Hill)
“Knock Knock Knockin’ on Heaven’s Door” (Bob Dylan)
Anything by Air Supply

Urology

“Bridge Over Troubled Waters” (Simon and Garfunkel)
“Goodbye Yellow Brick Road” (Elton John)

Labor and Delivery

“You’re Having My Baby” (Paul Anka…because he had His Way with you)
“Baby, Baby, Baby’ (Justin Bieber)
“Born to Be Wild” (Steppenwolf)

Cardiology

“My Heart Will Go On” (Rene Angelil’s incredibly rich Child Bride)
“Heart of Glass” (Blondie)
“I Can Feel Your Heartbeat” (The Partridge Family)
“Achy Breaky Heart” (Miley Cyrus’ Dad…didn’t he used to be somebody?)
“Heart Attack” (Olivia Newton-John)

Emergency Room

“Urgent” (Foreigner)
“Need You Now” (Lady Antebellum)
“You Can’t Always Get What You Want” (Rolling Stones)
“Alcohol” (Brad Paisley)

Plastic Surgery

“Barbie Girl” (Aqua)
“California Girls” (Katy Perry)
“Baby Got Back” (Sir Mix-A-Lot)

Operating Room

“The First Cut is the Deepest” (Rod Stewart)

Psychiatry

“Crazy” (Patsy Kline)
“Crazy Train” (Ozzie Osborne. FYI, you can get rabies from eating bat heads.)
“Man of Constant Sorrow” (Soggy Bottom Boys…also see Urology songs.)

Pediatrics

Anything by Justin Bieber or Billy Ray Cyrus’ kid (Didn’t she used to be somebody?)

Neurology

“You Shook Me All Night Long” (AC/DC)

Transfer Center

“We’re Not Gonna Take It.” (Twisted Sister)

Radiology

“Underneath Your Clothes“ (Shakira)

Pastoral Care

“Living on a Prayer” (Bon Jovi)
“Don’t Stop Believing” (Journey)
“Jesus Take the Wheel” (Carrie Underwood. I have long thought there should be a song called, “Moses, Invest my IRA,” but no one seems to want to record it.)

Ophthalmology

“Eye of the Tiger” (Survivor)
“Eye in the Sky” (The Alan Parsons Project)

Anesthesia

“High on You” (Survivor)
“Mister Sandman” (The Chordettes)
“Hit Me with your Best Shot” (Pat Benatar)
Anything by Michael Jackson (can you say propofol?)

And a special tune for those with any two or more totally unrelated problems, each encompassing a time span of greater than three months that needed ambulance transport between 1 and 5 AM, asleep upon physician arrival but awakes to find they are still in severe pain, is accompanied by at least three family members or any number of assorted pets, reminds you that they are “not a f…ing prisoner” when you tell them it’s against hospital policy for them to go outside and smoke during their care, and says they know someone in administration:

“Here’s a Quarter. Call Someone Who Cares.” (Travis Tritt)

As always, your contributions are welcome

(Hey, Katelynn…yes, I did write most of this at the Laundromat.)

Photo Guy

2011-05-25T06:17:00.001-04:00

I will be the first to admit that in I can be a bad tourist. I try very hard not to be an Ugly American, with all the baggage that implies. But I do think I wind up being an Amusing Japanese, as I have this tendency to take pictures of everything I can find. This is especially true of things like animals, as for some reason I believe that stray dogs in Peru are fundamentally unlike stray dogs in the States. Probably has something to do with it’s political ideology, or the fact that it ages siete anos cada ano instead of seven years for each one as our dogs do. And clearly this difference has to be documented for posterity.

Nonetheless, I was startled last week in the Orlando Airport to see what, by all indications and accents, were normal, red-blooded Americans taking pictures of a Starbuck’s. With the possible exception of selling china cups emblazoned with the name of the state of residence, I cannot figure out what unique quality of this particular caffeinated outlet would cause anyone would do such a thing. A Starbuck’s is a Starbuck’s, and they’re all the same, equally good or bad, unless we’re talking the Starbuck on the original Battlestar Galactica who was a much better character, but a lot less hot then the buxom female Starbuck on the 2000’s version who is probably best known for sharing a bathtub with the Big Bang Theory’s Howard Wolowitz. But I try to be understanding, because during my traveling days I was working on a photo montage called “The McDonald’s of the World.” Guess it’s a case of the exposed film calling the photographer black.

How Aboot a Ski Trip, Eh?

2011-03-30T07:08:00.004-04:00

The Teen, The Bride, and I just returned from four days in Canada. You may have heard of Canada. It’s the big country to the north that plays hockey and stubbornly refuses to become a state. Before this trip, what my son knew about Canada came from my copy of Jon Stewart’s “America: The Book,” where a demure Samantha Bee periodically interjects in the discussion of our political life to ask “Would You Like the Hear How We Do It In Canada?” The Bride, who went to college at 14 and so never studied things like high school geography, knew Canada was not anywhere near Belgium. She also never took high school biology, but she has learned where babies come from, which is probably why we’re not having any.

This was my third trip to the frozen north. The first was almost twenty years ago for a medical meeting, which really involved no tourism. The second was supposed to be a week-long excursion with someone I was dating at the time, a girl who actually spoke Cajun French so we wouldn’t be totally lost in Montreal. She backed out at the last minute but I went anyway, and spent most of my time in Ontario mourning my romantic misfortune. However, on the train from Ottawa to Quebec I met a most charming and beautiful woman from Trois Pistoles by the delightfully melodic name of Natalie Chantal Lavoie, who spoke such wonderfully accented English that the fact that I could barely understand her seemed superfluous at the time (To be honest, it seems kind of superfluous even today. She’s number two on the “Where are you now?” list. And don’t pretend you don’t have a list, because everyone does.)

So essentially I still have the same understanding of Canada as most Americans, which is the following:

Hockey.

Canadians are more witty then we are but without the inherent bawdiness and occasional cross-dressing on the English. They listen to pop groups like “5 Neat Guys.” All televisions shows start with the traditional “Coo-roo-coo-coo-coo-coo-coo! “Coo-roo-coo-coo-coo-coo-coo! (I watched SCTV.) They shoot rubber chickens at things for fun. People from Canmore are silly. (I watched the Royal Canadian Air Farce.)

Canadians are handy. They can wear overalls and flannel shirts without being thought of as lesbians. Even the men. ( I watched Red Green.)

Canadians speak English and French. This means they understand all the words to “Lady Marmalade.”

Hockey.

The Royal Canadian Air Force Snowbirds fly smaller planes than the Blue Angles, but more of them. That’s very cool.

The dollar coin is called a looney, which is funny.

Gordon Lightfoot is from Canada. Bob Dylan is from near Canada. Both sing as if suffering from severe intestinal distress. Coincidence? I think not.

Canadians can probably look over Sarah Palin’s house all the way to Russia.

Hockey.

Draft dodgers used to go to Canada. I can’t judge if that choice was right or wrong. But when you match up swamps, bullets, and the Viet Cong against bacon, beer, and Tim Horton’s donuts, it’s pretty clear why some folks jumped the border. (Speaking of which, wouldn’t the perfect Canadian food be a Tim Horton donut with apple filling and bacon sprinkles? I’m just sayin’.)

Canadians are multicultural, highly taxed, have cheap drugs, and unfailingly polite. They have universal health care that is either a glorious ideal of care and compassion or a satanic assault on our individual freedoms, depending on whether I’m watching MSNBC or Fox News.

The Queen is still officially in charge of Canada, and if she really wanted to she could just dissolve their whole government lock, s tock, and barrel and replace it with the an amalgamation of the Hudson’s Bay Company and some disgruntled pilgrims, installing a scandalous relative who needs to be out of the UK as Governor-General.

Hockey.

*********
One of the most interesting things about Canada…or at least about Whistler, British Columbia, the small resort town north of Vancouver that was our final destination…is that a lot of Canadians aren’t. The place was rife with young workers from New Zealand, Australia, England, and South Africa, with a fair number of Japanese and Chinese thrown into the mix. In talking to them, I got the impression that it was considered routine for them to spend a good part of their twenties living abroad, working small service jobs to make ends meet while seeing the world and having one heck of a good time. This seemed almost anathema to the American experience, where we tend to get plugged into career tracts just after college and a semester abroad is considered enough international exposure for any one person. It reinforced to me why Americans are often seem small-minded and xenophobic, because we voluntarily and willfully restrict our exposure to the rest of the world. And while plenty of Americans travel abroad, travel itself teaches very little. Life is the real professor.

********
For my souvenir, The Bride purchased a pair of red and white boxer shorts emblazoned with the Maple Leaf of State. I presume this is so one day when I am in the nursing home, the aide can prepare to change me and suddenly exclaim, “OH CANADA!” (Which has got to be the oldest line in the Great Joke Book of the North.)

********
I have decided that I want to live in a town called Squamish. It’s about 40 km from Vancouver and another hour down the road from Whistler. It’s a beautiful area, with mountains on one side and oceans nearby. The indigenous people of the region have a strong heritage, and from what I understand Squamish is particularly popular in summer with rock climbers. (This sounds like job security for an emergency physician.) Squamish has those things you really need: A Wal-Mart, a London Drug, a Canadian Tire, and a Tim Horton’s Donut Shop. But I think I’m most intrigued by trying to figure out if, after the Great Migration, I would be known as a Squamite. Or Squatter. Or Squamanian. Or Squamapolitan. I could have fun for the rest of my days with this problem alone.

********
I was a little hesitant about taking The Teen skiing. This trip was something I had always wanted to do as the ultimate family outing, but still I knew that at age 13, I would be trying to cultivate enthusiasm against the potent opposition of the Sullen Years. He ended up having a really good time but, true to expectations, immediately after telling me that a run was “AWESOME!” he returned to form when I asked him if now he liked skiing. “It’s okay, I guess,” he replied, catching himself before enthusiasm got in the way of his image.

He did really well for his first time out. His skiing ability is best thought of as a controlled standing fall, with the skis in a snowplow vee all the way down. Turning, when it happens, is a slow and deliberate process, so speed control on the steeper slopes can be something of a problem. But point him the right way on most of the easier green slopes and he takes off like a small helmeted rocket.

The weekend was chock-full of those proud father moments that you can’t describe in words, though every father knows what I mean…when he went down the first beginner slope all by himself, when he told me he was skiing on ahead because he didn’t need me alongside to back him up. But there was a big ol’ honker of a father terror moment as well.

We had hit a steep patch on a slope that was difficult for Brendan, and he fell in a ball of powder and ice. Fortunately, he had already perfected the “crucifixion” fall, which is where you lay on the snow with your legs together, throw your arms out to the sides, and yell loud enough to remind everyone how you’ve been forsaken.

To get him back up, he needed to take off his skis; and as I was ten yards ahead of him I needed to take mine off as well to get up the slope and help him back to his feet. He stood up, and I held him steady by the boots as I lay on the snow and told him to meet me at the bottom of the hill, about 100 yards down in plain sight. This plan would have worked out fine, except that it took me a while to get my own skis back on. When I did, I looked to the bottom of the Hill and he was GONE.

Dread took hold of my heart. I was pretty sure nothing major had happened…he’s a pretty loud kid when he needs to be, and if he had gone off the trail I was certain I would have heard something. So while I had some trepidation in my heart, I was doing okay until the two guys from the ski patrol came whizzing by.

Now I’m officially terrified. My kid has gone off a cliff or broken something that is best left intact. There’s no doubt in my mind that something awful has happened. So I finally get my skis back on and get down the hill as fast as I can. I still don’t see him. Panic rises. I speed up and he’s still not there. I kept going, now in my old creaky guy version of a racing crouch to go even faster. But as my knees screamed at me to stop, I started to notice that even though the slope was getting steeper, he wasn’t down there in the snow. For that matter, neither was the ski patrol anywhere to be found. The only thing I could hear was the wind as I sailed down the hill, and not the shrill cries of a child in pain. So I started to relax, and as I took a deep breath and sighed I saw in the distance a small figure in a gray plaid jacket and red ski boots, snowplowing his way gamely down the hill, cautious but confident, eminently on his own. Another proud father moment revealed.

Next year we work on turns.

********
Because The Teen is…w ell, a teen…bodily noises and products are never far from his mind. So when we went into the local rock and gem shop to hunt down a souvenir, he was naturally delighted to discover that one could purchase a coprolite. (For those who lead normal lives, a coprolite is fossilized dung.)

Some time later, we’re in a hotel restroom. He’s taking an awfully long time. I try to take it in stride. After all, he is an adolescent boy. Is he on a journey of self-discovery, looking at his body and marveling at the changes that occur as he goes from boy to man?

A few more minutes pass by, and I’m just a bit concerned. So I ask through the door, “Hey, what’s going on in there?’’’

He answers. “I’m making the coprolite of the future.”

(This line of conversation was followed the next day while having dinner in Seattle at a Chinese place that overlooks a row of houseboats. We were talking about what it would like to be to live on a houseboat, and especially what we would do with our dogs. Do you have to walk them all the time, or do they just kind of learn to put “parts” out over the edge as needed? The Teen had the ready answer. “Just send them to the poop deck.”)

********
Overall, we had a great time. The Teen learned to ski, The Bride got to jump off things (it’s called “Zip-Lining”), and I felt like a genuine Head of Household befitting my tax status. And as we came back to the US on the Amtrak Cascades (business class is brilliant fun) one memory that will stay with me is the stark contrast between the old but well-maintained Central Station in Vancouver and the decrepit King Street Station in Seattle. You could actually start to see the difference in route. Just like in America, Canada has older infrastructure. And the United States certainly has no monopoly on rusty trackside containers parked outside of warehouses or fenced-off vacant lots. But somehow things just seemed more orderly, more organized, the mess somehow arranged with care. And when we got off at the station, to go from four days of people going out of their way to be nice to having to persuade the baggage handlers to actually give you your bags that you can see on the cart before slamming the steel door on your hand, and being harassed in broken English (broken American?) by taxi drivers from nations you’re pretty sure would be perfectly happy to eliminate you and your co-religionists from the earth, it was even more clear what Canada got right.

I’m sure that there are a host of sociologists who can wax eloquently about the sociocultural factors that have made Canada different than the US. Whatever it is, it seems to this admittedly superficial observer that while America may still offer more economic opportunity than anywhere in the world, Canada excels at the business of life. Which is why, at some point in the future, I might really need to ask if BC will have me. I think I’d make an excellent Squamite.

ED One-Liners

2011-03-28T12:36:00.010-04:00

It’s seven AM and the morning crew is coming in. Jason Fawver (he of Gravity Storm fame) is trying to decide where to go for breakfast. After ample discussion and soul-searching, he opts for the “One-Legged Restaurant.” It turns out this is IHOP. And what’s the waitress’s name? Eileen, of course. And be sure to tip her.

********
I’ve got a deaf patient with a leg injury, and I’m trying to get her to wiggle her toes so I can make sure all the nerves to the foot work okay. She can’t read lips and I can’t sign, so it’s becoming a more difficulty proposition by the moment. Finally I get the idea to take off my shoe and place my stockinged foot next to hers, demonstrating for her the desired action. The nurse working with me deadpans, “Good thing you’re not doing a pelvic exam.”

********
The young adult make says he’s had rectal pain for the past three weeks. “And,” he notes,“ I’m getting pretty tired of this crap.”

********
The ambulance is called out for an elderly man with Alzheimer's Disease complaining of chest pain. The overworked but nonetheless insightful nurse says, "Give him five minutes. He'll forget all about it."

********
A man from the state mental hospital comes in becuase he's been...umm...inserting things into places they don't belong. Notably, a deodorant stick has made it's way up his back passage. Says the nurse, "I guess that mean his s..t doesn't stink."

Puzzlers

2011-03-28T12:36:00.006-04:00

Signs that pop culture has finally penetrated the middle aged crossword-addled troglodyte brain:

34 Across: “Little Hooters”

I’ve been to the restaurant. I understand that the calling card is not hot wings. So I have no idea why the puzzle folks think “owlets” is the correct answer and “titties” is not.

14 Down: “Cougar”

Granted, “puma” is also four letters. But that doesn’t mean “MILF” is wrong.

"Most Eager for Fame"

2011-03-24T22:34:00.004-04:00

As much as I would like to firmly believe in the afterlife, I have to confess to some moments of existential doubt. This is not something I feel particularly guilty about…if nothing else, I figure I’m in pretty good company with virtually all theologians of note. And like them I’m usually able, albeit in a crude fashion, to reason myself out of these insecurities. That being said, I’ve always thought there was also something to be said for the Anglo-Saxon heroic ideal personified by Beowulf, that one lives on through fame, the deeds performed and the treasures won.

The limits of fame are that while deeds are easy to record, thoughts are not. It’s fairly easy to mythologize anyone based on their record. It’s much harder to know what they actually thought. So when someone asked me why I try to keep up with a blog (with admittedly varying degrees of success), I think that maybe the need to document my thoughts as well as my deeds is part of it. It’s part and parcel of my own shot at fame, even if fame for me is nothing more than my descendants reading this stuff and wondering why they ever let Great-Grandpa out of the asylum.

Along with the blogging, my hope is to write a few books before Grendel takes me down. One is collection of essays about life in the ER, focusing on what really happens, the daily grind, rather than just the glory and the pathos. A second explains how a public health approach is the best way to address health and health care in America. The third is the Great American Novel (or at least The Great Novel Within The Local Zip Code) about a guy who thinks he has special powers but is actually handicapped by living exclusively in the moment on “dog time.” The latter is very much still in the conceptual phase, and I fear I’ll only fully understand my idea after I’ve put myself on copious doses of antipsychotics for a few months and then go through an abrupt withdrawl. This means that I’ll have to wait to write it until I’m done practicing medicine, and given that The Teen has now decided he wants to be a veterinarian this project is clearly fifteen years and multiple tuitions away. (The Bride has read this and wishes it to be noted that she paid for her own damn graduate school, thank you very much.)

The process of writing the blog, let alone a book, has given me a much greater appreciation for those who write. Writing is genuinely hard work, and my personal schedule of working twelve hour ED shifts at all times of the day or night certainly doesn’t help. (I’ve noticed that since I switched to doing twelve hour shifts instead of eights my output has decreased dramatically, as most days you’re simply too tired or have too many tasks of “normal living” to do.) It’s no wonder that many authors are either professional journalists or copywriters who know how to write and to write fast, or academicians who are essentially paid to take empty time and fill it with authorship. Having tried even just this blog, I have a much greater admiration for people like former high school English teacher Stephen King who wrote his first book on a TV tray between dinner and bedtime. I also think that as a writer, I suffer from a normal upbringing. Being raised in a nuclear, upper middle class, reasonably functional family in the Midwest is unfortunately not great fodder for thinly disguised fiction nor inspirational look-at-all-I’ve-overcome memoirs. I’ve pleaded with Mom and Dad on this one, but they refuse to change their non-alcoholic, non-abusive, monogamous ways. They’re not much help at all.

Despite these handicaps, there are still untold numbers of reasonably normal people like me who want to have their lives on paper. Even within the ED crowd, I know a nurse who’s working on a book, and one of my former physician colleagues is compiling tales of patients with rectal foreign bodies he has seen entitled “In Through The Out Door.” It’s probably a good thing for him. Like most of us, he undoubtedly could use a creative outlet. And his personality most assuredly resonates with the topic.

SOB

2011-03-15T06:26:00.002-04:00

We’ve recently changed our terminology in the ED. Medical terminology is it’s own topic (and has been previously on this blog), but I don’t think I’ve really touched on the acronym. Acronyms are those abbreviations we use to simplify communication, and are certainly not unique to medicine ( LMFAO). But we do have our own special ones for ED use. There’s TMCTC (Too Many Complaints to Count), VND (Veak und Dizzy…accent intentional), OTDHTB (Out The Door, Hit The Bricks), III (Insurance-Induced Injury), and AMFYOYO (Adios My Friend, You’re on Your Own.)

But one of our most beloved and useful acronyms has fallen on the junk heap of political correctness. SOB (Shortness of Breath) has been replaced by SOA (Shortness of Air). Apparently some folks objected to seeing the term “SOB” featured prominently on the front of their charts. In truth, I’m not sure how you can be short of air. There’s a lot of it around, and as far as we know it’s not running out any time soon. You can actually run out of breaths, so SOB seems to be more clinically accurate.

With SOB in mind, it is true that the terms we in the healing professions use to describe a small minority of suboptimal patients are not always as polite as they might be. In the ED, we try to be as culturally sophisticated as we can while still conveying the essential message, preferring to use terms such as “oxygen thief” (one who steals perfectly good oxygen from the atmosphere at the cost of CO2 production and global warming). And as far as SOB goes, well, sometimes the patients just are.

Strangely enough, it’s not our habit to note when someone is a decent citizen, simply because most people are. I don’t know why that is. Perhaps it’s for the same reason that Man Bites Dog is a headline while Dog Bites Man is not. So we tend to reserve the terms “good” and “nice” only for people for people who are genuinely sick or in a bad situation. For example, the patient with end stage lung cancer whose wife has been trying to take care of him at home and brings him to the hospital because she literally can no longer care for him are “nice people.” They’ve done all they could and then some, and failed. And they qualify as nice because of the immutable ED law that Nice People Get Bad Disease and Dirtbags Live Forever.

The one exception seems to be our frequent use of the word “pleasant,” often as part of the phrase “pleasantly demented.” Of course, not all patients with dementia act particularly pleased about it. Many are angry or agitated, but for whatever reason I can’t ever recall saying that someone was “really teed-off demented.” I wonder if this is because I have this belief…unsupported by fact, of course, but it seems to work…that when your higher mental functions and processes are stripped away, you really present as the person you always were. And because dementia is a rotten thing to have, we try to somehow make it more palatable by rewarding a cheerful demeanor. It’s another manifestation of the immutable Law of the ED. If you’re pleasant now, you were probably pleasant before; and dementia is a bad disease. Consistency matters.

Cat Nips: The Sequel

2011-03-09T01:02:00.000-05:00

The lonely man with the bad heart and social isolation (see “Cat Nips," February 5th) has returned three times in the last six days. I saw him on his third visit, when he developed chest pain after receiving an injection of a blood thinner. His workup was negative, but given his history he was admitted to have his blood tests and EKG checked once more the following day before declaring him free of acute heart damage and sending him out to return again, probably after he has another shot the following day. For, as one of the nurses pointed out, “He’ll have chest pain with the shot. He’ll have chest pain without the shot. He’ll have chest pain if you get the shot.” And while I’m trying to suppress a snicker while I’m doing the paperwork…because I do feel kind of badly for him, given that he says he likes it when I take the time to talk to him in the ED and the fact that he’s going to die sooner rather than later…I’m presented with a prescription to sign. It has his name on it, and it reads, “Cats. #8. Feed as directed.”

Cafe Colon

2011-03-08T00:19:00.001-05:00

While the Doctor’s Lounge here at work has a virtually unending supply of Pepsi products, every now and then I prefer a real honest-to-goodness Coke. Fortunately, the c cafeteria features a genuine Coke machine to satisfy these periodic cravings, and it was pushing midnight when I headed down the terraced steps leading to the vending machines.

Hospital vending machines usually offer more fare than the usual soda, candy, and chips. That’s because health care is twenty-four hour industry, but food services are not. So there are machines that feature more substantive foods such as burgers, sandwiches, and salads. In this particular cafeteria, these kinds of treats are in a machine that has tiers of rotating circular trays. The trays bring the food to the front where they can be pulled out through small plastic windows.

I’m sure that someone checks what’s in the machine and doesn’t leave anything in there for an inordinate amount of time. However, because the food is often under continual lighting in the cafeteria and has been frozen, thawed, and frozen on any number of occasions, the color and consistency is often just not right. Because these morsels are sometimes questionable, the machine is known popularly as The Wheel of Death. And acquisition of a meal from The Wheel has become its own kind of triage tool in the ED. For example, two nights ago I saw a young woman complaining of severe abdominal pain while munching on a vended hamburger of uncertain character. It was a given that if she could stomach that, there could be nothing serious going on.

(As an aside, the ability to eat just about anything in the ED…but especially Fritos, Doritos, french fries, or chicken nuggets…while complaining of nausea, vomiting, or abdominal pain will automatically downgrade your ‘emergency” problem to…well, whatever we decide it is. The same goes for your severe level of pain or discomfort if I walk into the room and need to wait five minutes for you to get off the cellphone.)

The walk to the café is actually one of the most pleasant journeys you can take within our institutional walls. The hospital has built an indoor atrium with a rock garden full of real water, plants, and dirt complete with pre-recorded songbirds. The steps that lead form the main floor to the cafeteria descend through this arboretum. It’s a place where I always pause for just a moment to smell the freshness of the greenery within the bosom of antisepsis, or feel the warmth of the sun at the height of the day. It is not the kind of place you expect find a giant stuffed colon. Which is exactly what happened.

It turns out that the display was part of National Colon Health Month. It needs to be noted that I am in favor of treating your colon right. I recognize the need for balanced diets including the liberal intake and fluids, fruit, and fiber. I know that screening for colon cancer, including testing of stools for occult blood and colonoscopy, is one of the most cost-effective tools we have for the successful treatment of bowel cancer. I am also the guy who believes so strongly in colon awareness that at the Kansas Department of Health and Environment employee picnic, I dressed up in a polyp costume. (In retrospect, I may have actually taken the role too far. Convinced that my costume needed a personality, I decided to be an angry polyp and walked among the staff, pointing at plates of burgers and chips and yelling “MORE FIBER!” Yes, there are pictures somewhere. No, you cannot see them.) All this being said, I had never really considered the possibility of what do to when confronted with a giant twelve-foot-long stuffed fabric colon cascading through the atrium suspended from two metal uprights.

So I did the only thing I could. I became inspired by the display, and decided to dedicate my life to being an advocate for colon health. Everywhere I go I’ll carry small cards and a bottle of chemicals to test the stools of random passers-by for blood. I’ll stand on street corners and espouse the cause. I may even take the giant stuffed colon and wrap it around my shoulders to wear as a boa, bringing my message to the swankiest nightspots, or perhaps I’ll use it as a rope to tie myself to the White House gates and demand…well, I’m not sure yet, but it’ll come to me.

The above paragraph is, of course, a lie. The only thing I could really think of to do was get my picture taken with it. And so now in my cellphone there is a picture of me standing under the colon; one where I’m standing on top of the rocks in the atrium with my head seen above the colon, and a third with me pointing at the colon in a most solemn and Galenic manner. Fortunately, one of my nursing colleagues felt the same sense of wonder as I, so I also have a picture of the two of high-fiving under the colon, smiling with thumbs up under the colon, and a high-fashion photo of each of us posing, looking indifferently off into the distance, hands on our hips, our respective profiles set off against a background of fabric-filled ascending bowel.

I can barely wait for Breast Health Month.

Dispatches from the Front

2011-03-04T20:06:00.001-05:00

A few thoughts to share from a Midwestern night shift:

I had always assumed that the grocery business was relatively safe. And even if there were some jobs within the supermarket that might be more prone to injury than others, I never would have put the dairy staff in this category. (We are intentionally ignoring the perennial concern about fingertips in the deli slicer, and in doing so get to avoid making a strained analogy between sandwiches of tongue and hoagies of digits. Although I will note that two decades ago I sewed back on the pad of a finger lost at Gates and Sons BBQ in KC, and for the next twelve months gratitude upgraded my Beef on Bread to a Beef and a Half.)

Last night I sewed up the thumb of a young woman who had been injured by eggs. Well, maybe not the eggs themselves, but by the knife she was using to cut open a box of eggs. The funny thing is that this wasn’t her first ovolaceration. Two weeks ago she had cut her face when the knife hit a snag in the box and flew up against her cheek. Which made filling out her workplace accident report quite fun in trying to resist the urge to put under the heading of work restrictions, “May Open Egg Beaters Only.” Which is an urge I may, or may not have, given in to. Only Worker's Comp knows for sure.

*************

Two ambulances are called to a domestic disturbance. During the spat, one of the protagonists had a seizure. Watching the seizure, a second combatant had an anxiety attack.

The first patient came to ER and promptly demonstrated her seizure. She tensed up her whole body, holding her limbs rigid and trembling while producing a constant, undulating moan. She did, however, follow me around the bed with her eyes when I entered the room. You can’t do that with a seizure. So I told her it was okay to stop, and she did so immediately, letting out a large sigh as she slumped back into the bed.

The second patient was unresponsive. She was so unresponsive that when the nurse began to do a sternal rub, she immediately opened her eyes and said, “Stop doing that!” In conversation, both the patient and her boyfriend recalled that while she had been unconscious at home, she had full recall of the paramedics talking to her and rubbing on her chest. “It hurt!’ she noted. You can’t do that if you’re unconscious. (For the record, a sternal rub is not as nice as it sounds. There’s no rhythmic caress with Vapo-Rub and a nice warm, fuzzy feeling. It’s driving your knuckles into the heart of the breastbone, a painful maneuver sure to provoke some kind of response. And if there’s truly no response, there’s a real problem.)

What happened at home is that the first patient, a middle-aged female homeowner, got into an argument with the second patient’s boyfriend. The second patient’s boyfriend is also the first patient‘s daughter’s not-yet-divorced husband. The son-in-law and his girlfriend are currently living rent free in his mother-in-law's home. She's upset because they don’t pay rent and eat all her food, and the fight was a result of her attempt to evict them while they were all sitting together watching a movie. Police were called when soda cans and laptop computers began to fly through the air.

The nurse and I agreed this was a Jerry Springer moment, and we’ve decided that a good side business would be to start an ED based Jerry Springer Talent Search. For a finder’s fee, we’ll drop the names of potential guests to the Springer production staff. Could pay off a few credit cards faster than spit, for in our line of work there’s a virtually inexhaustible supply of material.

Honestly, you can’t make this stuff up.

**************

One of the tricks of working at night is getting medication for patients when there’s no 24 hour pharmacy in town. You can write a prescription, but after 9 PM (6 on the weekends) there’s no way for the patient to get it filled until the following day. The hospital inpatient pharmacy does not want to be (and in fairness, probably should not be) in the business of filling outpatient prescriptions. So there’s this stopgap scheme where we can put a sticker on a sandwich baggie and dispense enough medication to get the patient through until the next morning when the pharmacies reopen.

Occasionally, this requires a bit of math as you try to determine if you need to give the patient one or two doses of medicine to help them through the night. Last evening, it was also a reminder that working in a small town ER has its benefits. So when I was trying to figure out if I needed to give a patient a second dose of narcotic pain medication, I was told not to worry about it. The nurses knew he'd just get another dose from his mother.

****************

There was a call from an outlying ED about a patient who had swallowed a prickle. These are the little burrs that stick to your shoes and socks when you walk through an ungroomed field or a path through the woods. Anyway, she had apparently tried to pluck one off a mitten by nipping it with her teeth, and then swallowed it by accident.

There’s something about the atmosphere in the ER that resolves certain medical problems. Mostly this happens with children, whose fever of 134 degrees, gasping for breath, and inability to drink without barfing immediately disappears once they get within The Healing Walls of Health. (More than likely, it’s because the Tylenol has kicked in, popsicles are tastier than Pedialyte, and the cool night air has eased the cough. But there’s still enough voodoo in medicine that I’m willing to attribute some magic to the ethers.) Which is why, after a two hour drive in the dead of night, the patient arrived, coughed twice in the lobby, and promptly hacked up a slimy, mucus-encrusted plant burr. Treatment consistend of placing it in a specimen container, affixing a label inscribed “Mr. Prickly,” and taken home for display.

****************

An example of how the health care system works…or doesn’t…and of the Law of Unintended Consequences:

A patient came in early in the day with seizures. To get the seizures to stop, she required the use of multiple medications. Her seizures were not new…they had been fully evaluated, and she had been under the care of a neurologist, and she was already on medications. And it was known that when she had a seizure, she had a prolonged “post-ictal” state. (This is the presence of an altered level of consciousness that follows a seizure, a phase of lethargy and slowness of thought that clears over time.) Most people are back up to speed in 1-2 hours after a seizure; in her case, it had been noted that it often took twelve hours or more.

For the patient’s comfort and to keep the ED bed open, it made sense for the patient to be admitted to the main hospital to watch for resolution of her lethargy and confusion. We spoke with the admitting physician on call, who determined that if the patient had a neurologic problem, he was uncomfortable caring for her without neurologic consultation. Unfortunately, there was no neurologist available on call, so we would need to find someplace else for her to go. We found a referral facility willing to accept the patient, but could only gain her acceptance if she needed admission to the ICU. So half the battle won.

Normally she’d take the hop down the interstate to the next big city by ground. However, of the four ambulances in the county, two were broken and the other two needed to be kept in the service area. So the only way to get the patient to the referral center was by plane. It took time for the plane to arrive, for the patient to taken from the ED to the airport, to be flown to the referral center, and to be unloaded at the airport and taken to the hospital. And of course, by the time she arrived at her final destination, she was already starting to wake up, and everyone looked kind of silly.

I tell this story not to blame anyone. Taken in isolation, each piece of the story makes perfect sense. The patient should not be subject to 12 hours in the ED, and admission was clearly warranted. You shouldn’t force any physician to care for a patient when they’re uncomfortable with that level of care, so the patient needed to be transferred someplace. You can’t take needed EMS units out of a community, so other transport resources need to be utilized. And things take time, and time changes things. Two wrongs don’t make a right, but in this case multiple rights surely added up to a wrong. But that’s health care in America.

***********

It was a good night. Never too busy, patients pretty straightforward. Got to sleep in the wee small hours and didn’t wake up ‘til sunrise. And it’s the kind of shift you dread when you leave at 7 AM, because you know that the Law of Averages means you’ll pay for it tomorrow.

Shrimp Tale

2011-03-02T23:30:00.001-05:00

There was a Medical Staff Meeting the other day, but I didn’t attend. ED docs don’t often go to Medical Staff Meetings. Except for the Medical Director of the Department, we’re often not as invested in medical staff issues. We come to work, get paid by the hour, and go home. And given that medical staff meetings occur at hours when we’re either still at work, getting ready to come to work, sleeping off the prior shift, or keeping our private time private (one reason why many of us went into ER…no office, no call, no pager), it’s not all that surprising. (My own rationale for missing the meeting was to grab every wink of sleep until the last possible moment before my twelve hour twilight journey.)

That being said, I was able to sneak down towards the meeting room and steal a plateful of shrimp cocktail before heading up to the ED to start work. I put the plate in the break room, figuring that anyone who wanted could share in the feast. Which led to the following conversation, overheard between two nurses:

“You know, those look really good. I really want to eat one even though I shouldn’t.”

“I don’t know. l really don’t like them very much at all. They always seem so flaccid and small, and taste so fishy.”

“I like them large and really stiff. You know, like Dr. Rodenberg's.

They were talking about shrimp, I swear to God.

Changes

2011-02-28T12:53:00.005-05:00

The best care in the ED is often tough love. Tough, as in severe and confrontational, with no chance of marshmallows by firelight and the sonorous hum of kum-by-ya. This knowledge no doubt will cause grave issues for medical sociologists. Medical sociologists are those people who tell us how, in the ideal world, physicians should provide clinical care. And a minority of them are genuinely helpful, like when they give us insights like always sit down when providing care. (It puts the patient at ease, allows you to communicate with them at eye level, and they perceive that you’re spending a lot more time with them then you are. It’s also fun to wheel around the room on a roller stool, and if you have enough roller stools you can play a mean game of floor hockey in the wee hours of the night just after housekeeping has waxed the floors.)

The rest of the medical sociologists are totally useless. They remind us to ask open-ended questions and to give the patient plenty of time to express their hopes and concerns. This, if course, is the absolute antithesis of the ED focus on determining if there is an actual emergency or not within a minimal amount of time. They also note that we should think of patients as individuals with life stories and cultural variances, and not as “The Chest Pain in Room 5.” This is probably the right thing to do, but given that I can get hit with up to 40 people I’ve never seen before in a single day (and if it’s someone I know, it’s usually a repeat customer for all the wrong reasons), my choice is to either get to know them or individuals or do what I’m paid to do, which is to get them through the system in the safest and most efficient way I can. It’s a lot easier to do that if I can categorize them by illness or injury and implement a standard protocol for care; and all the patient goodwill in the world can’t excuse excessive throughput times.

But their lack of relevance is most pronounced when they talk about healthy behaviors and “theories of change.” Let’s say that Bob the Hittite (because there are no more Hittites, I run no risk of offending anyone) decides he wants to quit smoking gazelle. Most of us would think that, having come to this conclusion, Bob would flick the ashes from his last antelope limb and, with a heavy sigh and one last long inhale, set aside his vice for good. It would be a rough few weeks and he might gain a few pounds, and need to chew a few crocodile sinews in the process, but eventually he would feel better and learn to substitute a more healthy habit like idol worship.

A medical sociologist, however, would tell you that this isn’t what happens. According to Prochaska’s Transtheoretical Model of Behavior Change, here’s what really went on:

Stage 1: Precontemplation – “not intending to take action in the foreseeable future.”

This stage represents those happy years Bob smoked those gazelles before he coughed up a hoof and thought there might be a better way to enjoy his leisure time between hunting and gathering.

Stage 2: Contemplation – “intending to change with the next 6 months.”

Bob plans this out carefully, making sure that he quits when gazelle is out of season. Besides, dried gazelle is nowhere near as tasty as fresh.

Stage 3: Preparation – “intending to take action in the immediate future.”

Time to smoke up that stash of illegal Cuban antelope you’ve hidden under the rock out back…assuming the jackals haven’t gotten to them first.

Stage 4: Action – “making specific overt modifications in lifestyle.”

The gazelle is gone. It’s a tough day in the cave.

Stage 5: Maintenance – “working to prevent relapse.”

Because chewing on hamster just doesn’t do the trick.

Another particularly useless contribution of medical sociology in the ED includes the belief that all medical problems (and for the true believer, it really means ALL) are really a reflection of social ills. The latter principle led to one of my favorite memories from my Master of Public Health course. I will be first to admit that for one with free-thinking tendencies such as myself (I’m much better now), an MPH course is as close as you can get to living in a house inhabited by members of the Students for a Democratic Society. Everyone is very strident, and it’s made clear that non-believers are verboten.

We were doing a group project where we had to identify the social factors that led to eye disease in patients with diabetes. The usual candidates were trotted out…access to care chief among them…and then the breakdown of contributing factors kept moving along. Maybe access to care was a function of lack of transportation to offices and clinics. It could be the maldistribution of eye physicians in poor inner city and rural areas. Perhaps it was the lack of money to purchase private insurance in a world where physicians are reluctant to see patients on Medicaid. It could be a lack of health literacy, the inability of patients to understand how to properly use their medications. All of which are absolutely valid, but not entirely reflective of the ED world in which I live.

So I asked, “How about if the patient doesn’t want to take their medicine, or chooses to spend their money on something else?”

“You mean they have to spend their money on things like food and housing because they’re disadvantaged?” came to predictable reply.

“I was thinking more like beer and cigarettes.”

“They only do that because they haven’t been appropriately educated about the risks of alcohol and nicotine, and they lack the resources to find more healthy substitutes.”

I like to think I’m an educated guy, and the powers that be have given me enough initials after my name to prove it. But even I know that while I’m supposed to take antibiotics for a full ten days, I stop them after Day Five when I’m feeling back to normal. And I haven’t yet met a smoker who contends that cigarette use leads to better health. People know stuff, but choose not to act upon it. If I had been clever, I might have even said these individuals are permanently stuck in Pre-Contemplation.

Unfortunately, I am not that clever, and my internal filter fails me on more occasions than I care to admit. So as memory serves, my response came out as:

“So you’re telling me that those guys who drop into my ED every week, whose usual weekend routine is to go out, get drunk, and get their face bashed in with a pool cue, do so because society gives them no other choice? That it’s a lack of education that makes them decide that staying home and watching reruns of The Golden Girls is not a better, and less painful, option?”

(Yes, I really did use The Golden Girls as an analogy for alternative behaviors. I’ve been meaning to apologize to Betty White for years.)

What I learned from this experience is that medical sociology is done only in controlled settings, because real life might upset their expectations. This is why the only people who ever really listen to medical sociologists are other medical sociologists; advocates who can find unlimited support for their views that the problem d’jour is a function of the medical profession, the health care system, society as a whole, or anything except personal responsibility; and certain nurse practitioners whose academic training is focused on holistic care to the exclusion of actually getting anything done. (This is not to say that nurse practitioners cannot be a valuable adjust in the ED. It is to say, however, that it takes about three years for them to unlearn how to be a nurse and figure out how to be a practitioner.)

So the medical sociologist would be opposed to the “tough love” approach in the ED, because it does not value the patient as a unique individual with autonomy, who needs to both accept the physician’s advice while rejecting his or her paternalism, and who must be given time to go through the process of change. Tough love places blame solely on the individual and not on society, and the individual is the one who pays the price for their behaviors. And medical sociologists would vehemently disagree with the concept of “punitive therapy.” Punitive therapy is that medical care, while clearly directed towards helping the patient, is also designed to teach a lesson and inform future behaviors. For example, if you come to the ER with certain kinds of sexually transmitted disease, I can either give you oral medications or an injection. If you were the passive recipient of an STD or you seem genuinely repentant for your role in transmission, you’ll get the pills. If you are a repeat offender or appear to be without remorse, it’s the shot for you. Both clinically valid methods of treatment, and you can even make the case that with the shot, you insure patient compliance with care in someone who might not be motivated to complete their antibiotic course. But it’s also quite clear which approach carries a message.

The interesting part about punitive therapy is that most of the time, the patients leave you no choice. If you arrive with an overdose, you will need a dose of liquid charcoal (it is what it sounds like) to get whatever you’ve taken out of your system. I will ask you to drink it form a cup with a straw. If you refuse, I will have to ask a nurse to put a tube down your nose into your stomach to get the medicine into your gut. I will also need to get a urine sample to get a better idea of what’s in your system. (While I trust you, faithful reader, sometimes patients lie about what they’ve taken. Go figure.) You can pee in a cup, or I can have a nurse put a rubber tube up into your bladder, restraining you if needed in order to accomplish the task. And if you are drunk or otherwise unable to control your agitation without a valid medical reason to be so, and you take a swing or spit at any member of our ED family, I will have you restrained until you have either sobered up and have to face your family who has come to pick you up, or until law enforcement takes you away. And in all these circumstances you’ve done it to yourself, probably with a minimum of Contemplation.

Punitive therapy is not always physical. Sometimes it’s informational, as when you remind the intoxicated college student of the legal drinking age; or when you tell the alcoholic, on his fifth ED visit in two weeks and in early liver failure that there’s nothing you can do for him unless he’s willing to go to rehab. (His response to this information was to look at me and use a phrase similar to “Duck Foo,” indicating that he was still in Pre-Contemplation.)

And sometimes it’s therapy by omission. If use the ED for the purpose of acquiring narcotics, I am under no clinical obligation to accede to your wishes. I am under a legal duty to assess you for an emergency medical condition, and to treat you in an appropriate fashion. This treatment may include an explanation of my concerns about your use of pain medications and suggestions for follow-up with your own physician; I may offer you a non-narcotic medication to help you until you can follow-up or even a referral to a detox facility or short-term medication to ease your withdrawal. (You’d be surprised how many patients ask for ”just a few days” of pain medication to manage their withdrawal until they can get to detox….and the appointment is always the following week.) Your “punishment,” if you will, is that you don’t get what you want.

(This scenario illustrates that good medical care does not necessarily equal customer satisfaction, and the customer is not always right. It’s also why health care, when provided by independently licensed professionals at high risk of liability, cannot work in a pure customer-driven, free-market model. My job is not to meet the expectations of the customer. My job is to render high-quality, clinically appropriate medical care. While the vast majority of the time doing so means customer satisfaction, no matter what you do there will be a small percentage of times that what is medically appropriate is not what the patient wants. This fact is lost on the majority of high-level health care pundits, who assume that all patients are reasonable persons with reasonable thoughts, and that health care providers are simple line workers at a task. Come spend a Friday night with me.)

No physician I know wants to harm a patient, and most of us strive for complete patient satisfaction if we possibly can. And while the medical sociologists would disagree about the “paternalistic” attitude I’ve exhibited in making decisions for patients, and deride me for not achieving a “partnership” with the patient to achieve “mutually beneficial goals,” sometimes the role of the doctor is to act like Mom and Dad and insure that actions induce consequences.

Clearly, I’ve been Contemplating this for a while.

The Yu-Gi-Oh Blues

2011-02-11T11:32:00.001-05:00

I am fortunate that The Teen, while beginning to assert his independence in increasingly annoying and odiferous ways, still likes to hang out with dear ol’ Dad. We go to movies together, have Boy’s Night Out, and deal the cards for poker. We play miniature games like Heroscape and blast away at Lego Batman on the Wii. And, God bless him, he still wants me to play Yu-Gi-Oh.

For those of you who are blissfully unaware, Yu-Gi-Oh is a trading card game from Japan. If Hello Kitty is penance for the Doolittle Raids, then Yu-Gi-Oh is retaliation for Hiroshima and Nagasaki. But like in-laws and cockroaches after nuclear fallout, it never goes away. Bakugan came and went, the Mighty Morphin Power Rangers have fought their last battle, but Yu-Gi-OH is the Energizer Bunny of nerd-based commerce.

After three years of patient tutoring by The Teen, here’s what I know about Yu-Gi-Oh:

The cards in a Yu-Gi-Oh game are used to duel with an opponent.

There are Monster, Spell, and Trap cards.

These cards are combined to make a deck. Decks have themes. Some of the themes are Arcana Force, Ancient Gear, and Gladiator Beast.

Decks are played on an expensive piece of flexible plastic called The Field.

Someone someplace gets paid way too much money to think of names for cards such as “Blue-
Eyes Toon Dragon” and “Obelisk the Tormentor.”

The wording on the cards is too small for an adult to read.

I lose every time.

While I don’t understand Yu-Gi-Oh, I try to be understanding. I think it’s probably his version of my comic book collection or my fascination with Star Trek (TOS…because there was no Next Generation) at about the same age. And I’m glad it’s something that gets him off the computer and out of the house from time to time to play with others at local card shops. The only thing that bothers me is that most of the cards are “dark” in nature. Characters with names like Ghost Knight of Jackal, VWXYZ Dragon Catapult Cannon, and Judgment of Anubis course freely throughout decks of Chaos and Zombies. The iconography probably doesn’t mean much, a function of the battling nature of the duel coupled with the game’s cultural origins, interesting translations from the Japanese, and marketing to the seething hormones of adolescent boys. But it still disturbs me a bit.

Here’s an example of what I mean. The Teen made me a practice deck for me. Knowing that I’m not too hot on the “darker” side of the world, he built a Dinosaur theme card set. Here are some of the cards in my “tame” deck:

Black Tyranno
Goblin Out of the Frying Pan
Super Conductor Tyranno
Mad Sword Beast
Ultimate Tyranno
Super-Ancient Dinobeast
Dark Diceratops
Hyper Hammerhead
Tyranno Infinity

I understand that in dueling, you have to fight fire with fire. I would never tell my son to go up against someone playing a deck full of Gladiator Beasts armed only with Penguin Soldier. That being said, I would like to see a see a market out there for nice Yu-Gi-Oh cards:

Genial Whale
Happy-Go-Lucky Earthworm
Polite Bunny
Playful Dolphin
Friendly Wombat
Smiling Soft-Coated Wheaton Terrier
Squealing-With-Delight Dacshund

But why stop at cuddly critters? Maybe we can use Yu-Gi-Oh for instructional purposes:

Well-Mannered Child
Homework-Doing Pre-Teen
Regularly Showering Adolescent
Boy Who Limits His Television Time
Admired Father
Glorious Father
Father Automatically Wins

(On several occasions in years past I really would play this card. It was when The Teen was still The Child and I would play Pokemon, essentially a younger child’s version of Yu-Gi-Oh without the rage. As opposed to Yu-Gi-Oh, I could play a fair game of Pokeman and generally pull my weight. This frustrated The Child, so he came up with these things called “Invisible Cards” that would defeat anything I could ever play. So I came up with an invisible card called “Daddy Automatically Wins.” Which is undoubtedly why he switched to Yu-Gi-Oh shortly thereafter.)

Anyway, last weekend I took him to a Yu-Gi-Oh tournament at a local card store. To be honest, I was a little on edge about this…he usually plays the game against kids who are less experienced and have less cards than him, and consequently he almost never loses. Besides, he comes from a line of bad losers. (That would be me.) So I wasn’t certain how he’d react if the cards turned against him. Sure enough, I was watching from a distance when I heard him exclaim that he wasn’t going to play anymore, and saw him cup his head in his hands with a gesture of despair.

Me (adopting deep paternal voice): “What’s going on?”

The Teen: “I always lose. Why should I play anymore when I just lose?”

Please note that I am a father ever-alert for the teaching moment.

Me: “It happens. Deal with it.”

This was apparently not the right answer, because I heard the unmistakable grumble of early adolescence rise up from his chair. But he sat and played, which is what socialization is all about, while I sat in an adjoining room watching a game of Warhammer and listening for the next yell of exasperation that blessedly never came. I’m sure the fact that he won the next three matches helped. I’m a much more gracious winner, too.

(Interestingly, I was actually the only parent there. All then other parents dumped and ran. For which, having suffered through five hours of Gladiator Beasts and Arcana Forces and Magic Cylinders and the like, and not a single Friendly Wombat, I don’t blame them one bit. And in fact, when it came time to run out and get the child lunch, I was able to get down a beer while waiting for our hot dogs at the local Parrot Cay. I’m not proud of it, but as a parent you sometimes do what you must.)

I am really hoping that Yu-Gi-Oh is a phase, not a lifestyle, and that at some point it will go away. Sort of like when I gave The Teen advice about one Justin Bieber:

Teen: “Dad, can I ask you a question?”

Dad: “Sure. What’s up?

Teen: “Why do all the girls talk about Justin Bieber?

Dad: “Who’s Justin Bieber?’

(A brief pause. The conversation resumes after a quick visit to the Internet and 3 minutes 45 seconds of “Baby” that makes even Richard Harris’ rendition of MacArthur Park sound like Placido Domongo. Which, incidentally, would be a very cool version of MacArthur Park, especially the part where he would sing “Oh NOOOOOOOOOOOOO!”)

Dad: “Justin Bieber is like when I was a kid the girls talked about with David Cassidy and Bobby Sherman.”

Teen: “Who?”

(Cut to YouTube.com video of “Easy Come, Easy Go.” Teen rapidly loses interest as I exclaim about the quality of the song. He sits, glaring and bored, as I then watch the video for “Seattle” and the Opening Credits for “Here Come the Brides.” Conversation resumes.)

Dad: “You know, maybe it would make sense if I said it was like the girls used to talk about Michael Jackson?”

Teen: “He did Thriller. Now he’s dead.”

(Pause to regroup.)

Dad: “Okay, here’s the bottom line. They’re going to talk about Justin Bieber for about three years. Then he'll go away and they’ll talk about something else. It’s what they do. Get used to it.”

Another teaching moment found...and lost.

Strip Search

2011-02-09T02:02:00.002-05:00

On the airplane this morning from Kansas City (Slogan for Today: “We’re Colder Than Your Ex”), I learned from a fellow passenger that Dallas’ main problems during Super Bowl week were not ice, snow, and ticket fiascos. They were actually critical shortages of limousines…and strippers.

The problem with the limos did not strike me as funny. The shortage of strippers did, given that stripping is essentially a spectator sport (at least in the public arena) and any one stripper can theoretically entertain any number of viewers. However, it is true that as opposed to football or baseball, where a view of the entire field is critical to understanding the ebb and flow of the game, the area of focus is really an on-stage cylinder extending six and a half feet from the floor and within arm’s reach of a centrally located pole. (To be frank, I suspect that most spectators are concerned with an even more narrow area of focus, but I may be wrong. It might really be all about personality and intellect. See “The Whore of Mensa” by Woody Allen.) So given the narrow range of interest, distance becomes an issue, and either an excess of strippers or telescopes are needed to maintain the required proximity. Besides, it’s awfully hard to toss dollars down from the cheap seats.

Anyway, the Super Bowl Stripper Shortage got me thinking about a conversation held a few weeks ago in a western Kansas ED. One of our nurses was complaining that her husband had gone to a strip club in Salina rather than joining a group of ER folks for a night on the town. This was news to me, because I really never saw Salina…while the home of the first girl I ever saw non-clinically unclothed…as an epicenter of adult entertainment. True, it is just twenty miles down the road from Exit 272 on Interstate 70, known popularly as the “Exit of Sin” because off the north ramp is the Lion’s Den Adult Supermarket and just to the south is the Russell Stover Factory and Outlet Store. It’s an efficient way to knock out nearly a third of your deadly sins in one stop. And just in case the gravity of your offense is lost on you, as you get back on the westbound road there is a large billboard reminding you that “…the EYES of the LORD are upon YOU.” (Interestingly, there is no such sign as you get back on the highway eastbound, which probably reflects the thought that if you’re headed towards the land of the heathen liberals, like Topeka, you’re a lost cause anyway.)

I was thinking about the odds of having a strip club in Salina, and then recalled that this would not be so unusual given that I had seen a “Gentleman’s Club” in Great Bend. Great Bend is a town of about 10,000 people located on the Great Bend (gentle turn) of the Ar-KANSAS River (mostly dry). The main landmark is a ten story tower public housing project in the middle of the Town Square. The strip club is located in a steel building on Kansas 183, and was noticeable only because it was across the street from Braum’s Officially Delicious Ice Cream.

This got the mental wheels working, and I think I’ve figured out how to resolve any future stripper shortages at major sporting events. Strip clubs need to be organized into farm systems. Places like Great Bend are the rookie leagues; Salina is A ball, and Topeka (where the parking lot outside of the strip club always seems much busier during the legislative session) is AA. Larger places, like Kansas City and Denver, represent the AAA level, just before the majors such as New York, Miami, LA, and Dallas.

You can see how this would work. As strippers in the majors get injured, go on the disabled list, age out, droop, or sag, their places are taken by those brought up from AAA. This progression moves through the ranks, opening up new opportunities at the entry level. Organizations can even offer coaching along the way to improve individual performance and bottom line revenues. (Yep, I really said that). Plastic surgeons can serve as Team Physicians. I see nothing but a growth industry here. (I really said that, too.) And when there’s a shortage, like during Super Bowl week, just call folks up from the farm system.

I can barely wait to buy my team jersey.

********************
One other quick airplane note: On Southwest, they give out crackers shaped like little airplanes. Instantly regressing to the guy who dissembles animal crackers by having the run around the table, then biting off the limbs followed by nipping at the head (I’m sure a psychologist can have a field day with that one), I took the crackers and had them soar around my seat, accompanied by the obligatory “swooshing” sound.

After a minute of play, I bit off the engine. The cracker went quiet, then plunged to the floor.

There were no survivors.

Cat Nips

2011-02-05T16:44:00.000-05:00

There’s an unfortunate man who comes to the ED a lot. He has terrible heart failure, and isn’t a clinical candidate for a heart transplant. Most of the time he stays alone in his room, keeping to himself, simply waiting for his time to end. When he feels especially lonely, he calls EMS and comes to see us. It’s what passes in his life for a social call.

So we’re trying to figure out what we can do to help this man, to help him build a relationship with someone or something other than the health care system of this fine community.

“He needs a kitten,” says the Unit Clerk.

The Tech shakes her head. (Brace yourself, and remember we are in the ED, not a place for normal humans.)

“No, that’s a bad idea. When he dies, the cat’ll eat him.”

This was new knowledge to me. I had no idea that cats ate dead people. That being said, the story of Oscar, the cat that sits by dying residents in a Massachusetts nursing home, makes a lot more sense. Oscar’s not there to provide comfort to those heading towards the Great Beyond. Apparently, he’s out looking for a snack.

Because this is the ED, however, the conversation doesn’t stop just because it’s breached the limits of decency. The Nurse pipes up next.

“You know, if he got several cats, he can save on funeral expenses.”

“So he would be consumed by pussy,” says the Tech.

Metaphorically, I hope.

Counting Down

2011-02-04T00:03:00.000-05:00

Some years ago I learned that if I count backwards, visualizing the numbers while I count and matching each number with a deep full breath, I can often get myself to sleep. It doesn’t always work, and if I hit 70 before feeling that disjunction that happens just before nodding off I usually give up. Patience has never been my strong suit.

(Numbers are easier to count than sheep. I used to try to count sheep, but when I did my tangential thinking…helped along by The Bride…meant that suddenly the sheep were being given names, and personalities, and life histories. There was Alice the Sheep, Betty the Sheep, Charlie the Sheep, and so on. The brown sheep was named Pedro. The black sheep was Shaft.)

You would think that counting backwards would be a pretty easy thing to do, and it used to be quite routine. But since I got back into full-time clinical medicine, I notice that no longer do I count down routinely from 100. Some nights it’s everything I can do to not count backwards as follows: 300, 150, 100, 75, 60, 50.

Forty self-esteem points for the reader who can tell me why.

Goin' a-Courtin'

2011-02-02T06:35:00.002-05:00

You may have heard that earlier this week, a federal judge in Pensacola has ruled the new Health Care for All Act (or The Job Killing Socialist Manifesto, depending on your political stripe) as unconstitutional. The basis for the ruling, as I understand it, was that there is no constitutional allowance for the federal government to mandate that private individuals purchase a specific product (like health insurance).

I can’t say I’m really upset by this interpretation, especially as the government-subsidized purchase of private health insurance it made very little sense to me. It seems an inherent contradiction that the same insurance companies that have been labeled as significant contributors to the crisis in health care...and reaping massive profits as a result...should be rewarded by an infusion of public dollars. Of course, both Republicans and Democrats were perfectly happy to give public money to the large Wall Street firms that drove the current recession, so I guess I shouldn’t be surprised. And I recognize that both the subsidy and the individual mandate are political compromises made to garner support for passage of the law, and that compromise is the essence of policy. But I’m still not thrilled with it. If health care coverage for all Americans is as critical as we are told (and I personally believe that it is), then the logical solution is to establish a baseline, no-frills, economy-class, bring-your-own-snacks level of care for all. If the private sector can add services on top of this baseline, and individuals choose to make those purchases, so be it.

Commentators on television and radio have made it clear that no matter who won this round in Federal Court…and so far the score is tied at two decisions apiece…the battle won’t be over until the issue hits the Supreme Court. While I understand that the Supremes have an unpredictable streak (and have ever since Diana Ross left to pursue her solo career), unless there is a sudden retirement on the bench the chances are a conservative court will at least hold the individual and employer mandates within the act as unconstitutional. And while technically the rest of the Act could still be legit, in reality the financing for the entire scheme falls through if the individual and employer mandates are not in place.

What I know for sure is that these court decisions are pure theater, much like the show put on by the Transportation Security Administration. They obscure the real issue, which is an irretrievably broken system of care. Nobody has ever denied that fact. I can’t think of any voter who is unaffected by a lack of access to care or runaway costs, nor a policymaker of any stripe who will say the status quo is just fine, thanks for asking. Nor can I, despite all the posturing about keeping government out of health care (and right now between 45- 55% of all health care costs in this country are borne by governmental agents), can I find anyone willing to forgo their own Medicare or Medicaid benefit, nor any policy maker willing to take them away.

(And for the record, and because with my fetish for linguistic accuracy it drives me nuts when people say it, government funded healthcare programs are not evidence of socialism. Socialist health programs involve government ownership and control of all elements of care. Nobody has ever threatened to nationalize the hospitals or make all health care workers government employees. Even the subsidies for health care coverage within the new law go to support vibrant private sector insurance companies. So get over it.)

Last November, Republicans were able to whip up the public against health care reform with a large helping of clever rhetoric and a side of fearmongering. But if the health care reform law is declared unconstitutional, people have a right to expect something else to be offered in it’s place. The GOP may have owned the last election and are drawing even in the legal war. But without a real plan of their own, one that enhances access to care while controlling costs, they are sure to lose the war. Either that, or we as people in need of care most assuredly will.

Mystery Meat

2011-02-01T04:23:00.000-05:00

It’s lunchtime, so between patients I skip down to the Doctor’s Lounge for a bite. At this particular hospital, the cafeteria brings up some trays of hot food to supplement the usual assortment of sandwiches and chips.

I walk up to the food bar to find one of our surgeons, a fairly bright guy, looking uneasily at something chunky, pink, and breaded. Hearing my footfalls, he turns and gives me a quizzical look.

“What do you think this is? Chicken or fish, or something else?”

Now let’s get this straight. This is a guy who cuts into flesh for a living, while in general I only look at it from the outside. And he can’t figure out what kind of meat they’re serving for lunch?

I had a piece of cheese and a Coke.

Newton's Tempest

2011-01-31T22:37:00.001-05:00

You may have heard several weeks ago about the 5,000 red wing blackbirds who died in a mass extinction event in Arkansas on New Year’s Eve. According to the Arkansas Game and Fish Commission, the official explanation is that they all perished form “blunt force trauma,” which is the clinical way to say they were “…flying into stationary objects such as trees, houses, windows, power lines, towers, etc." These crashes resulted from the fact that, “Arkansas blackbirds have poor eyesight and don't normally fly at night. The AGFC said the birds were probably disturbed by "unusually loud noises" and flew lower than normal due to New Year's Eve fireworks. The rare night flight was even recorded on radar data.”

Personally, I figured that perhaps they had become communally frustrated by the fact that they had been told that they could not migrate north for another few months and were just supposed to wait it out in The Natural State, and so they all flung themselves out of the trees from sheer boredom. (As a loyal Kansan, as especially as I write this on the sesquicentennial of our Sunflower Statehood, I feel bad for the birds. They could either spend the winter in Arkansas, or move north to Missouri. Not a good choice either way, if you ask me.)

However, my ED colleague Jason Hawver has made me aware of a new and even better theory of what did in our feathered friends. It’s called the Gravity Storm, and it’s so common I can’t believe it’s escaped the notice of science until right now. Gravity storms pull people to the ground without provocation. They appear to be localized phenomena, and just as tornadoes show a predilection for trailer parks, gravity storms seems to erupt at nursing homes. They also have a tendency to occur at specific hours, most notably sometime between when the resident was put to bed and when they failed to report for breakfast the next morning.

The results of gravity storms can be serious. Bruises and minor lacerations are common; hip fractures may result as well. I think this is worthy of further investigation, and I’ll need a federal grant to do a proper study. The grant will need to cover the costs of a theoretical physicist, an experimental physicist, an astrophysicist, and an engineer. Oh, and we’ll also need a blonde actress/waitress to provide snacks and a link to the real world. Which is my argument for including a late-forties, vaguely amusing emergency physician within the cast of the Big Bang Theory. And in comparison with the salaries negotiated by the cast in their new contract extensions, I think they’ll find my rates surprisingly reasonable. I’m my own agent. Call now!

Satellite Love: Update

2011-01-29T23:46:00.002-05:00

My sister has provided me with an update on my blog about the Top Songs of First Love. She has informed me that Katy Perry’s “Teenage Dream” fulfills the criteria from a female standpoint:

“Let's go all the way tonight.
No regrets, just love.
We can dance until we die.
You and I, we'll be young forever.

We drove to Cali and got drunk
On the beach.
Got a motel and built a fort
Out of sheets.
I finally found you,
My missing puzzle piece.
I'm complete.”

I would argue with her that:

1) Katy Perry is a teenage DREAM, not a real girl actually doing it, so the song doesn’t count; and that

2) Building a fort out of motel sheets is a chaste activity (see Clark Gable and Claudette Colbert, “It Happened One Night, 1934); and that

3) These two kids have a RELATIONSHIP and are in LOVE; and that

4) Katy Perry is from an era of music I don’t listen to, so it doesn’t count, no matter how hot Katy Perry is nor how much I am convinced that while she married Russell Brand and I wish her happiness, I know it’s only because she didn’t meet me first; and that

5) Anybody who sings with Elmo is automatically too pure of heart for this list.

So there.

First Love by Satellite

2011-01-27T18:42:00.005-05:00

For those who drive long distances in rental cars, satellite radio is a truly wonderful thing. There is a virtual cornucopia of channels attuned to your specific interests with minimal commercial interruptions and a minimum of chitchat, and if you happen to not like the song that’s on at a given moment it’s easy to flip to someplace where you’re sure to find something you enjoy. Satellite radio also proves The Bride’s contention that I have no concept of music after 1990, as the moment I’m in the hired transport I preset the Sirius channels to 40’s on 4, 50’s on 5, 60’s on 6, 70’s on 7, 80’s on 8, Sinatra, and Laugh USA. The fact that I do not listen to music from the 90’s or the present century also lets me transiently forget most of the Clinton and Bush Administrations, and that’s not a bad thing either.

Because of the nature of the channels, I tend to think that they are likely independently programmed. That being said, every now and then you’ll find some strange overlaps, like the programmers got together and decided on a daily theme. One I was headed down the road in Southeast Missouri and heard “In The Navy” by the Village People, followed closely on another channel by Diane Renay’s “Navy Blue.”

(I may have already told this story, but it bears repeating that my Midwestern naiveté made sure I was well over thirty before I had any clue that “In The Navy” had any other meaning than thinking it was cool to be on an aircraft carrier or destroyer. They’ve got planes, they’ve got missiles, they’ve got torpedoes, and if they work right things blow up. Like there’s any other reason to join?)

So the other day I’m doing an early morning drive across Kansas and heard “This Girl is a Woman Now” by Gary Puckett and the Union Gap” followed by “Tonight’s The Night” by Rod Stewart. This, of course, made me think that the theme for the 5 o’clock hour was “Losing Your Virginity.” Tangential thinker that I am, I then came up with my top eight songs of this genre. Here they are, listed in ascending order:

8. “Girl, You’ll Be A Woman Soon” Neil Diamond

This song should probably be ranked higher, if for no other reason than The Bride, who is both an audiophile and a Neil Diamond aficionado (two things I would have thought were mutually exclusive), will chastise me if this song is not included on my list. That being said, it is ranked lowest because a close examination of the lyrics reveals that while the singer is not imminently about to join his girlfriend in a biblical way, he is making certain to be the first, by dragging her away from the competition if need be:

“Girl, you’ll be a woman soon.
Please, come take my hand…
Soon, you’ll need a man.”

Marking your turf is always a good first step. Just watch out for the claim jumpers.

7. “Summer (The First Time)” Bobby Goldsboro

It turns out that there are two subtypes of this lyrical mode. The essence of the first is "I'm talking you into doing me." The second is exemplified by this song, where the innocent lad is schooled in the ways of love by an older, experienced woman. Here young Bobby is strolling down the beach, having just, “…told Billy Ray, in his red Chevrolet, I needed time for some thinking.” (The rhyming of a proper name and an automotive brand is priceless.) Turns out there was a woman on the beach who gave him a few more things to think about, and “…the boy took her hand, but I SAW THE SUN RISE AS A MAN.” There is no record of if Billy Ray ever stopped back by, or if the now slightly older and much wiser Robert ever got back to town. The song is sappy, syrupy, and incredibly pubertal as he drops his voice to sing the final “AS A MAN.” (The Oedipal issues will remain untouched.) It is also stuck in my brain because I went through a phase in junior high where I was a huge Bobby Goldsboro fan, and I confess to owning his Greatest Hits Volume 1 and 2 on CD. And for this, I’m truly sorry.

6. “That Summer” Garth Brooks

It gets hot in the Midwest, and especially so for a widowed rural wife with a young, sweaty teenaged farmhand. Teenagers are also cheap dates:

“'Til she came to me one evening
Hot cup of coffee and a smile
In a dress that I was certain
She hadn't worn in quite a while
There was a difference in her laughter
There was a softness in her eyes
And on the air there was a hunger
Even a boy could recognize.”

Needless to say, a good time was had by all. Which probably explains why Colby, Kansas, a town of 5,400 people 200 miles from nowhere, has it’s own Starbuck’s.

5. “War is Hell (On the Homefront, Too)” T.G. Shepherd

Another in a series of summer adventures. This time she’s lonely because her man is off fighting for God, Country, and the ability to spend his leave watching the trajectories of ping-pong balls in the military-friendly Phillipines. At some point these songs begin to read like a Penthouse letter. “I never thought this would happen to me, but…”

(T.G.Shepherd gets an extra nod for “Do You Want To Go To Heaven,” where “…those preacher’s words were barely heard as sweet Bunny Lou gave in.”)

4. “December 1963” Frankie Valli and the Four Seasons

Oh, what a night indeed. But have you ever noticed that everyone to this point, with the exception of Frankie Valli, gets laid in the summer? I think it has something to do with a link between the cremasteric reflex (where the testicles move towards the body when exposed to cold) and the timbre of Frankie Valli’s falsetto, but I’m still working that out.

3. “Tonight’s the Night” Rod Stewart

I can’t even talk about this song without cringing. Rod Stewart actually does a nice job on his latest versions of The Great American Songbook. But here, Rod sounds like a chain-smoking drunk trying to seduce my daughter before he hocks up a loogie. And I don’t even have a daughter. I understand Rod Stewart does. I’ll bet he regrets this song now. Maturity brings wisdom.

2. “This Girl is a Woman Now” Gary Puckett and The Union Gap

Up until now, every song has used some assemblage of code words to disguise what is happening, or has a strategic omission in the narrative serve an informative role. This song nears the top of my list for it’s sheer lack of pretense:

“This girl tasted love, as tender as the gentle dawn.
She cried a single tear, a teardrop that was sweet and warm.
Our hearts told us we were right, and on that sweet and velvet night.
A child had died, a woman had been born.

This girl is a woman now; she's learned how to live.
This girl is a woman Now. She's found out what it's all about
And she's learnin', learnin' to live.”

Yeah, I’ll bet she’s learned how to live. Of course, one can’t help but wonder if this is the same Young Girl that Gary sent away before, and if she’s hit 18 by now.

1. “Paradise by the Dashboard Light” Meat Loaf

There are so many reasons I love this song. The driving rhythm and the rocking melody are exquisitely attuned. The lyrics are perfect. The baseball call is priceless. The film version, with The Loaf’s intensity rising as he lifts the microphone stand over his hand, is brilliant metaphor. Even the GoPhone commercial based on the song is worth playing again and again. And it is one of the few songs that my sister and I can sing…badly…together, which greatly distresses my father. I think this is less based on the subject matter or the fact that I sing it with my sister than because he never had that much fun in high school and resents us acting like we did. (I am aware that the fact that I sing this with my sister might have a totally different connotation in Arkansas.)

Have you noticed that all of these are songs are performed by men, either bragging about their prowess in bringing women into the world or proclaiming their newfound status as an adult male through participation in the coital act? You never actually hear woman sing, “Please Deflower Me,” or “I’m Going to Make You a Man. (The only song I can think of with the latter lyric is from the Rocky Horror Picture Show, but this involves an entirely different kind of relationship and also takes a week to complete.) Perhaps this is because women tend to discuss these things quietly with friends rather than proclaim them to the world. Or maybe because as men, we’re just so darn glad to get any that it becomes a red letter event, especially when we’re old enough that singing about it is often the best we can do, and even when luck comes our way a three minute song lasts longer than our maximal effort. And while we’re at it, why are there no songs from the male side that say, “I Really Want to Know You Better as a Person Before We Engage in Intimacy, Because If We Don’t Share a Foundation of Mutual Respect Our Relationship Cannot Move Forward in a Positive and Productive Manner,” while the female literature is rife with them, notably Janet Jackson’s “Let’s Wait a While?”

Oh, wait, I know the answer to that one, too.

Calling Rampart

2010-12-30T12:08:00.000-05:00

Growing up, I wanted to be an astronaut, a United States Senator, and a doctor, preferably all at the same time. As fate would have it, the chance to be the latter came first. I was a senior at Shawnee Mission East High School just over the state line from Kansas City, Missouri, and there was a new and innovative medical school on the Show-Me side that took you in after high school and six years later sent you back out with a medical degree. And during my interviews I was asked the inevitable questions of, "Why do you want to be a doctor?'' The problem was that I didn’t have answer, and still don’t. It’s not like I was impacted as a child by some friendly family physician that came to my bedside, nor was my life saved by the swift intervention of a skillful surgeon. I was not born into a medical family. The only things I ever remembered (or at least haven’t suppressed) about going to the doctor's office were shots, being bribed to get shots with butter cookies, and reassurance that yes, someday he will hit puberty (it did happen, and last week was a life-changing experience, to be sure). About the best I could do was recall drawing arteries and veins on a Valentine’s Day heart, causing the girl across the street to say she'd never play with me again, and absorbing all the reproductive details in the Better Homes and Gardens Baby Book the adoption agency sent home with my brother. So I gave the admissions folks the honest answer, "I really don't know. It's just something I've always thought I should do.” The answer, no matter how truthful, provoked frowns all around, and I was sure it was time to pack up the bags and head to the closest state university with a drinking age of 18 willing to give me some scholarship cash. (I did have some standards.)

(Frankly, I also had crap answers to other questions the interviewers would ask. One of them, a female psychologist, would have you tell a story about something that happened, and then say “Tell me more.” On several occasions I had to say “There isn’t any more. The story’s done,” which seemed to displease her. A second interviewer, who was an older African-American pediatrician, asked if I ever had any experience being a minority. The only thing I could think of to say was, “Does being a Jew in Kansas count?” Apparently it did.)

So how did I get into medical school? Truth be told, I have no idea. I‘m not sure I would have taken me. Nonetheless, the official reason would be that they saw my potential as not only a physician, but as a person, and wanted to help me fulfill my destiny. To this day I’m convinced that the real reason was simply dumb luck. The University of Missouri-Kansas City School of Medicine was designed to turn out primary care doctors for Missouri, and it had always taken exclusively Missouri residents. However, there was a small, never used clause somewhere in the Admissions Manual that said every year, they could take up to four kids from the Kansas side of the metropolitan area. (Kansas City, Missouri and Kansas City, Kansas, are just across the Missouri River from one another; the Kansas suburbs of KC are separated off from the main city by a two-lane street called State Line Road. When Kansas was a dry state, the police used to sit just over the Kansas side, watch cars with Kansas plates go into liquor stores on the Missouri side, and bust the drivers when they came back into the Sunflower Realm.) The year I applied, the daughter of one of the Vice-Chancellors of the University, who happened to attend high school in Kansas, also wanted to go to medical school. So the clause was dusted off for her, and a few other Jayhawkers were let in for show. They sent me a letter of acceptance, I called my parents who were on vacation in the Caribbean (the message they got from the hotel operator was “Mr. Howard’s in the hospital”), and a mere thirty years later I’m writing about it all.

I have the same difficulty in describing why I chose emergency medicine as a specialty. It just seemed like something I was always supposed to do. Now, with over twenty years of practice under my belt, I can think of a number of reasons I stay in it (and a few more to get out, but until I can convince my son that trade school would make him happier than a four-year college and a graduate degree, I’m still at work.) The truth is I still don't know why I do this, except it makes me happier than anything else in clinical medicine. I suppose that happiness is the only reason you should do anything for a living, and it probably doesn't matter if you know why you're happy or not.

But since there’s a requirement that everyone has to have an anecdote about why they chose to do what they do, here’s mine:

I remember watching the show “Emergency!” when I was eight or nine years old. “Emergency!” was about a group of LA County paramedics who saved lives and stamped out disease. Their medical base was the fictional Rampart General Hospital. Rampart is the only hospital I’ve ever known that was staffed 24 hours a day, 365 days a year, with two physicians (Kelly Brackett, MD FACS and Joe Early, MD FACS) and a single nurse (Dixie McCall, RN), complete with starched white cap and dress. (The nurse, I mean.)

I can remember not being terribly interested in the paramedics. Roy DeSoto was a boring guy, and Johnny Gage was always chasing girls. Who has much use for that when you’re eight? My girl issues back then consisted of making sure I had the requisite shots against cooties. But the doctors really impressed me, mostly because of the initials after their name besides the usual MD. At the time, I though the more letters you have, the cooler you are. I didn't know that FACS meant fellow of the American College of Surgeons, which in turn means you allowed yourself to have the personality sucked out of you during five to seven years of surgical training in exchange for the ability to rummage around someone’s innards, and that you then get to pay a large chunk of money in dues each year for continued use of the letters. And there was no way to know they were surgeons, for they weren’t ostensibly arrogant and could occasionally relate to patients and admit mistakes. But I knew that someday I wanted lots of initials after my name.

I think that the drive to work in the ED was solidified the day that Kelly and Joe saved a goat. For some reason that escapes my memory, Johnny and Roy had brought a goat to the hospital. I suppose the goat was dying of some dread goat thing, and needed immediate goat surgery to save its bleating little life. So they've put the goat under, and Kelly has his hands somewhere within the goat's entrails, and Joe is about to administer some sort of goat drug to do some sort of goat thing when suddenly Kelly has what can only be described as a veterinary version of an LSD flashback. "Wait!” he cries to Joe, who is busily keeping the goat asleep with anesthetic gases and chewed up tin cans and soothing goat noises and such. "Don't give that drug!” Whereupon Joe replies calmly, holding up an uncapped syringe, "Don't worry Kelly. I just remembered my animal physiology."

That was it for me. I can save people and goats, too. If the people didn't make it, I could still have food. And in retrospect, I got my initials. I became a Fellow of the American College of Emergency Physicians, or FACEP. That is, until I got tired of paying over $700 each year for the initials that nobody asked about, and when I realized they were best pronounced in a rhyme with “duck up.”

So with all this being said, what’s the main reason people go into, or stay, in emergency medicine? I think the bottom line is that emergency medicine is fun. We have the wildest stories, the closest sense of family, the highest highs and the lowest lows, the most food per capita of anyone in the hospital, and more laughs per hour than an episode of “Scrubs.” It’s like being in a perpetual amusement park. Sure, you spend a lot of time waiting in line for the fun, but the ride at the end of the queue is worth it. The risk of barfing when it gets too fast or twisted adds excitement and mystery. And always stay away from the deep fried Pepsi.

Bak to Skool

2010-12-20T16:42:00.002-05:00

A while ago I went to my 30th Anniversary High School Reunion. I had only been to one previous gathering, the 10th, and had a rotten time. The people who wouldn’t talk to me in high school still wouldn’t talk to me, depriving me of any chance to engage in condescendive posturing at my early successes in life and my collegiate-aged growth spurt. It was also the night that I got a phone call from one Florida girlfriend saying she had run into the other Florida girlfriend asking which one I wanted to keep. In retrospect, I gave the wrong answer, which was confirmed not only by short-term loss of relationship and long-term demolition of any chance of reconciliation with said blonde, but also because I learned that it’s not a good sign when you come into your apartment after a weekend away to find a stuffed brontosaurus hanging by the neck in a noose made of a silk tie, swinging a lazy circles from a ceiling fan. I also fumbled a lingerie-scented pass from a beautiful woman I had a crush on for years, but had suffered in silence while she dated one of my friends. So I really don’t have good memories of the experience at all. The only moments that I enjoyed were found sitting at a corner table with one Laurie Thornton who, while not really close friends in high school, I now had a common interest: I was an ED doc, and she was an emergency veterinarian. So we talked quite avidly about various organs and body fluids possessed by various two and four-legged species, and drove away everyone else at the table. (I personally think it was the topic of why cats hiss when you intubate them that did it. Incidentally, this is why you can always tell the ED people eating breakfast after a night shift at Cracker Barrel. In a room full of tables, theirs is the one that nobody wants to sit next to. )

Anyway, I hadn’t been back for any of the other reunions, but the Magic of Facebook got me in touch with some folks from high school, and though it took some doing I got talked into going. I’m glad I did. If it was pretty clear that if the 10th, 20th, and 25th reunions would be about keeping score, this one was more about survival. We’re all on the back side of forty, pushing the half-century mark. Now it’s all about rejoicing not in our achievements, but simply in our continued presence on this earth.

Overall, it was a very nice affair, and I’m very glad I went. I met up with a few friends for a drink beforehand…Jim Cramer, Roger Ramsayer, Missy Webber, Bill Koch… and we all thought we looked pretty good. This was a test hypothesis, or course, but as we came into the hotel ballroom to see the whole group I was glad to see it was generally true. We did look pretty good, for folks older than our parents were when we got out of school. The only thing that could have been better…and this is a very minor and quite selfish point, for the Planning Committee did a great job…is if they had music and dancing, so this nerd could finally sidle up to the hot chicks. (Would have done it, too...had permission from The Bride to flirt my brains out to make up for lost time.)

Later in the evening I’m talking to Brian Youll, who was very close to a good friend of mine who didn’t make it to the party, and up comes Laurie Thornton. It’s wonderful to see her. She looks great. And within ten minutes, we’ve done it again. We start talking our stuff, soon we’ve been left alone, somehow the traffic pattern has pushed us into a corner, and we’re having a grand time. Later in the evening, we get into a conversation with Steve Silbinger, a former classmate who has made his fortune in direct-to-TV products such as Urine-B-Gone. As clinicians intimately acquainted with the bodily fluids of various species, we were probably his most appropriate audience. (Neither of us remembered it, but it also turns out that Laurie and I sat next to each other in the class picture taken in the gym 30 years ago. So maybe it’s fate, and not just fluids.)

A somber part of the evening came with a slide presentation of the dozen or classmates who have already attended the Celestial Graduation. It was very well presented…high school pictures followed by photos of them later in life as well. A few of the people I knew peripherally, but one I knew quite well. You know how in high school you can have people who are your best friends for a month or so, and then you just drift apart, no harm, no foul? For me, Jeff Serrault was one of those guys. Jeff always carried a brief case to school, and we were all convinced he was going to be wildly rich the right way and we would all come beg him for money. He was the one who took me to get my driver’s license one afternoon my senior year. He passed away, and nobody knows where he was or what happened to him. It’s pretty sad.

But given that there’s humor in everything, a curious pattern began to emerge. With several of the deceased…including my friend Jeff Serrault…they showed old photos of them involved in school activities, such as sports teams or the yearbook. And in every photo they showed, whether it was the Literary Society, Student Council, of the Chorus, someone in the “Roll of Gone Before” was sitting next to Ann Lowry. As was I at that very minute. Coincidence? Maybe. I shifted in my seat.

Ann was my “friend who was a girl but not my girlfriend” in high school, although by all rights we probably should have been (and we were, for about three hours one post-pubertal night in college, but even that only went so far. I mean, it was ANN). Both student council nerds, both literary nerds, both short, both cute as a button. I often went over to Ann’s house to pick her up to do stuff together because, well, we could. Her folks were always great to me, and I still remember they had a small dog named Taffy that, as best I recall, barked and nipped and did very little else, at least while I was around. And so when the plans were made to meet up for the reunion, of course Ann was there, and of course I was going to be sitting next to her, which meant I had unwittingly placed my backside in the Hotel Banquet Chair of Doom. This was confirmed when they handed out a copy of the last issue of the student newspaper of our senior year and there was Ann once again, signing her choral heart out next to another decedent. And as I’m soaking up this tidbit of fate, the evening’s moderator, in a wistful moment, notes that “We’re getting older, so look around because next time some of us won’t be here.”

I had a great time, and I have concluded that I would very much like to attend my 40th high school reunion. But when I do, Ann had better be on the other side of the table.

Washday Blues

2010-12-18T07:28:00.002-05:00

This piece is coming to you from the Non-Creepy Laundromat in Hays, Kansas. Hays actually has two laundromats. One is down by the Student Ghetto of Fort Hays State University (home of the Tigers, another school celebrating an animal native to it’s environs just like the Pittsburg State Gorillas) and has been labeled by the natives who are advising me on washday destinations as Creepy. The Non-Creepy one is in the north part of town, where the hoi polloi…such as can be mustered in Hays (one hoi, two polloi)…dwells in placid isolation from the cares of student life. It’s a fairly nice place to spend an hour washing your scrubs, especially if you’re able (as I am) to work through the fact that it’s a Sunday evening of hunting season, and the parking lot is full a pickup trucks with gun racks and men washing their cammos clean of blood and feathers before they bring their outdoor gear into the house.

Anyway, this evening I’ve come to realize that the great paradox of the laundromat, and probably a money- making scheme in it’s own right, is that it’s hard to get stuff out of the washer to the dryer. Here’s what I mean. When you wash a load of clothing, things get tangled together, right? Pant legs get caught in the arms of shirts, socks get meshed inside of sweats, and the whole thing becomes a jumbled mess. It’s nearly impossible to extract one article of clothing from another. And it’s not like the washer and the dryer and next to each other like at home, so you can simply scoop stuff from one appliance to the other. At the laundromat, the washers and dryers and physically separated, washers along one wall, dryers on the other. So when you try to remove the wet and wadded ball of clothes from the washing machine and cart it the ten feet across the room, something invariably trails behind in the tendrils of fabric and falls to the floor.

If this is your floor, the floor at home that you’ve kept immaculaltely clean, or at least has your personal dirt on it, this is no problem. But this is a public floor, full of anonymous sticky stains of God knows what, into which your favorite pair DC Comic Heroes underwear had fallen, and now you have to think if you’re willing to put them in the dryer with all your nice clean non-floor contaminated clothes and get those sticky-old-soda-I-think-but-what-else-could-it-be-after-all-its-hunting-season germs on your other stuff, and then go ahead and wear them knowing that maybe-they’re full-of-disease-and-I’m-pretty-sure-the-dryer-isn’t-hot-enough-to-kill-the-plague, or buying another small box of detergent (75 cents, more for bleach), putting another three dollars in quarters into the washer, one more buck in the dryer, and killing another hour (and $1.25 for a Coke and a stale Lance Peanut Bar) in order to have pure underwear.

Well worth it, I say. Aquaman’s colors have never been so bright.

Eyes Wide Shut?

2010-12-13T01:30:00.000-05:00

Best moment of my ER night: A transfer patient arrived from an outlying hospital. He had multiple facial injuries from a motor vehicle accident, and among these were deep abrasions to his eyelids , to the extent that the local facial surgeon thought he might require a skin graft. And where might you get such a graft, he wondered aloud? Perhaps the skin of the penis, he reasoned. It was the only skin thin enough to be appropriate for the eyelids. He even had a real medical word for the procedure, but to be honest I was too busy working through the implications of the procedure to remember what it was called. A phallograft, perhaps. That sounds good.

Anyway, think how this works. You see a hot girl, and then your eyes stay open, unblinking, for a long time. In the short term, you’re a sure bet to win any staring contest. But if your eyes stay open for more than four hours, please call your physician.

Aging with Style

2010-12-12T22:56:00.001-05:00

In the past I’ve been guilty of ageism. Before I hit the age of 40, I tended to view my elders as something different than me…not worse, by any means, but just different. Not as up-to-date. Not as funny. Not as earthy. Certainly not as hormonal. Which is why I could never figure out why one of my Dad’s mother would laugh uproariously at my Saturday Night Live Cast Album. I mean, she must have been all of 55 at the time, and we all know that’s old.

I think what finished this illusion once and for all was hanging out with my other grandmother. Grandma Theresa was a social animal, and for a while she dated a gentleman from Belgium we’ll (respectfully) called Nick the Frog. Old Nick wasn’t much to look at, hence his epithet; but Nick had bucks and wasn’t afraid to use them, and Grandma wasn’t afraid to benefit, either. He was good to her, to be sure, and having lost two previous husbands to cancer Lord knows she deserved everything she could get. But it was still kind of…well, creepy…to think of Nick the Frog kissing my grandmother. So one day, when I was in one of those intergenerational-bonding-question-moods, I asked her how she could stand kissing Nick the Frog. “I wouldn’t know, really,” she said with a wink. “He tires easily.”

Theresa was the kind of Grandma who would set me up on a date the same night she had one. Usually her date would come pick her up before I took her car, so I played the role of the father, inspecting the date before she left the house. (And yes, I did reject one.) Before she would leave, she would turn to me and say, “Now don’t do anything I wouldn’t do.”

One night I decided to call her bluff. “And what exactly is it that you do?” I asked.

Her eyes sparkled. “A hell of a lot more than you think.”

Date nights would end when we both got home, drinking hot tea laced with peppermint schnapps. She would complain about how all the men her age were sick with something or another and just wanted someone to take care of them. I would wonder how in the world she could think it was okay to set me up with a seventeen year old no matter what her fake ID, kissing abilities, and breast size had said otherwise. (The answer, of course, is that she was Jewish.)

My grandmother’s comments came back to me a few weeks ago as I went to examine an 87 year old woman who had suffered a fall. The right side of her face black and blue, with a bruise going from just above her eye down to the girlishly prominent cheekbones.

“Hello, ma’am, I’m Dr. Rodenberg. What happened to you?”

With a smiling face and a knowing look, she answered. “Rough sex.”

There was no comeback. I stood there stunned for a good thirty seconds as she laughed out loud and her family stared at her with horror. Finally, I looked at her with all the compassion I hold for those elders who are the kind of old person I want to be: Crotchety, independent, and racy as hell.

“Ma’am, if I was 40 years old I’d date you.”

She eyed me up and down, with special attention to the waistline.

“And then you’d see what I mean” she answered back.

Middle Ground

2010-12-09T22:30:00.000-05:00

I’ve often heard the phrase, “If you’re young and you’re not a liberal, you have no heart; and if you’re old and you’re not a conservative, you have no brain.” And I do believe there’s a certain amount of truth to it. One of the reasons I chose Emergency Medicine as a career was that I liked the “White Hat” part of it all…I was the one guy who would take care of anyone at anytime. The Stetson has been solied, however, by years of reality, and so I have begun to morph from what I like to call the Hard Rock Café of Medicine…Love All, Serve All…to a more nuanced view that while there are both people we absolutely need to help and some totally beyond redemption, that personal responsibility is on the wane, and that nobody quite understands the concept of an “emergency,” in general people earn what they get out of life. That’s why I’ve become increasingly fascinated by pundits and politicians, as well as ordinary citizens, who are able to state with metaphysical certitude (thank you, John McLaughlin) that the solution to our social ills is to either throw handfuls of money at more government programs to positively impact more people or to slash every entitlement program out there and let people fend for themselves. They find no room for compromise in between. I have no idea what world they’re living in.

(If you and I are “ordinary” citizens, it’s important to note the policymakers and pundits are not “extraordinary” because, like Superman, they possess “powers and abilities beyond those of mortal men.” Instead, I like to think of them as extraordinary in a Twilight Zone sort of way, as “not like us” but resembling extraterrestrial fully willing to devour the heart and soul of their fellow humans while quoting “To Serve Mankind.” IT’S A COOKBOOK!)

So here’s what I think I’ve figured out. It’s really easy to be an extreme liberal if you live well and don’t see the poor, the abused, and the homeless. It’s easy to see them as the victims of racism, xenophobia, substance abuse, and rampant capitalistic greed. And it is equally easy to be a radical conservative under the same circumstances, except now you see them as abandoning the work ethic that built America for an entitlement mentality and draining the fiscal and cultural life from the land. What they know of the social ills of this land they know mostly from clever statisticians and reinforcing media, supplemented by “listening tours” and the occasional goodwill visit. Both sides are perfectly willing to manipulate the dispossessed as political tools and voting blocks to advance their own agendas. And after their obligatory daytime hours spent in tearful condemnation of or strident fury against the system, they go home to nice neighborhoods, full larders, kids in good schools with every chance to go to college, health coverage, and paid vacations.

The whole thing seems a little hypocritical to me, and I say this fully aware that I’m one of the ones who’s not worrying about my next meal. But if I don’t know how to live in poverty, at least I see it every day. Sometimes I’m sympathetic with what I see, and want to do all I can to help someone; sometimes it makes me furious, and I’m equally enthused about wanting to tell another that they’re abusing the system and they can expect no further handouts from me. But at least I know something of which I speak, and I have some “stake in the game,” as it were. Improving these social ills makes my working life easier. But when problems get fixed, politicians and pundits are out of work, and special interests cease to wield power. So it’s in everyone’s interest to keep the system going exactly as it is. Everyone’s, of course, except those in true need, and those rare individuals in public life actually interested in making positive change.

So what’s really out there? Based on my totally unscientific observational study of the socioeconomic needs of people who drop through the ED. About a third of folks are truly in distress and need all the help we can provide. A third are abusing the system. A final third really have no clue where they fit in and are just trying to get by the best that they can. And as a result of these observations, I have come to believe that our system does often entitle people to services that are undoubtedly excessive, but also places significant roadblocks in the way of those who truly need additional help.

I fully recognize that this subtlety…also known as reality…goes against the current “sound bite” dialogue we’ve come to expect in our public policy debates. And we accept that lack of substance, because these issues are hard to think about and even harder to solve, and if Americans have been trained to do anything in the media age it’s it avoid independent thought. Which is clearly one thing we excel at.

Where in the World?

2010-11-27T20:27:00.001-05:00

As some of you may know, I’m currently spending some of my time as a “locum tenens” physician. What this means is “Rent-a-Doc.” There are any number of agencies out there that recruit physicians for short-term assignments in ER’s across the country, and as one of a relative handful of residency-trained, board-certified emergency physicians I’m fortunate to be a relatively hot commodity. This is why, after posting my resume online a few months ago, I had forty-three different recruiters from thirty-one different agencies (believe me, I counted) all vying to be my new best friend. Nice for your ego, but still you can only tell the same story so many times.

As far as I can tell, job requirements for a physician recruiter include amiability, persistence, and an ability to guilt the recalcitrant physician into working places he or she would never care to go. (See Palms West Hospital, Loxahatchee, Florida). The other thing that’s interesting about the process is that knowledge of geography is apparently not part of the job description. I had stated in my profile that I was interested in jobs in Northeast Florida, within about an hour driving distance from Daytona Beach. As a result of this detailed geographic preference, I have been told of opportunities in Ft. Lauderdale (241 miles), Tallahassee (258 miles), Pensacola (451 miles), Alabama, Indiana, Missouri, and Ohio. But perhaps I’m being harsh. After telling one of the recruiters that Miami (260 miles) was not really worth a daily commute, he honestly admitted, “We’re based in South Florida. We don’t get around very much.”

(Interesting note: If you do a MapQuest search for directions from Daytona Beach to Miami, step 13 notes “Welcome to the UNITED STATES,” which pretty much confirms everything everyone up here north of I-4 always suspected about Miami. And while we’re on the subject, a real geography story. Jim Cramer, an old high school friend, posted on Facebook that the soccer team from The Netherlands had a particularly hard road to the World Cup finals because they had to play two extra games against Holland and the Dutch. I’ve had to explain to any number of folks that it’s all the same place. I was not, however, able to pull off a follow-up story telling the same folks that people from Albania are known as Albinos, although on occasion I have been able to stress that people from Belgium are known as the Belch.)

So if you’re a frustrated physician who’s had a rough few weeks and needs your ego stroked, by all means put your name out there on the internet. It’s amazing what will turn up...and that on closer examination, there’s often no place like home. At least you can find it on a map.

"Strictly Speaking"

2010-11-25T17:12:00.000-05:00

(Edwin Newman, the former NBC newsman best known for his insisitence on the proper use of the English language, recently passed away at the age of 91. His most popular written work, "Strictly Speaking: Will America be the Death of English? reached Number 1 in the New York Times Non-Fiction Best Seller List.)

I have been known to take things far too literally. For example, last week I was told by a paramedic that a patient’s chief complaint was “being unresponsive.” I couldn’t help but wonder how you did that. It’s not like you can be comatose, suddenly regain consciousness, politely note, “Pardon me, but I am unresponsive.” It’s one of those questions I didn’t think you could possibly answer with a “yes,” like “Are you asleep?” But I’m always surprised in this line of work, and I have seen patients who, when roused from their substance-induced slumbers and holding a rudimentary knowledge of medical terminology, have angrily reminded me, “WHAT’S WRONG WITH YOU? DIDN’T YOU HEAR THEM? I’M UNRESPONSIVE!”

Here’s another one. A paramedic called in saying the patient has chest pain “times 0600.” Now, I know, and you know, what he really meant. But that’s not what he said. So I figure if the patient has had chest pain x 0600, it must be 0600 times worse than anybody else’s chest pain. (I’m not sure how to multiply that one out.) It’s like when the paramedic finishes his radio report with “Do you questions or orders?” and you ask them to name the capital of North Dakota. They never said it had to be a medical question, right? And I’m proud to note that during my tenure a decade ago as EMS Medical Director for Volusia County, Florida, the Paramedic State Capital Identification Ratio was the highest ever recorded in the illustrious annals of prehospital care.

Finally, on a somber note, someone recently asked me the “signs of suicide.” I gave the answer that was needed about the risk factors for suicide, but inside I was fighting the urge to say, “The only really definitive sign of suicide is being dead.” And years ago, during my life in public health, I recall being asked to attend “a conference on suicide” and wondering, based on the way the question was asked, if we were for or against it.

(While we’ve been talking syntax, let me share with you the single most annoying grammatical error in American popular culture. In the song “I’ll Be There,” young Michael Jackson wails:

“If you should ever find someone new
I know he’d better be good to you.
Cuz’ if he doesn’t
I’ll be there.”

Five extra credit points, and full permission to burn the Mariah Cary version with a butane torch, if you can spot the problem.)

Praying for Safety

2010-11-17T22:53:00.003-05:00

Every now and then you see something that may have escaped your notice for years. I had one of those moments at the Orlando Airport this week. It turns out that the airport has a very nice chapel. It’s located after you go through Security, on the side of the airport that leads to Gates 1-60.

I am aware that many different faiths use intermediaries between man and God. Catholics can pray to the saints to be intercessors for them before The Father, and Hindus worship different manifestations of the divine in order to approach him. But I was not aware that in America, one also needs to get through the Transportation Security Agency to get closer to God. And if you’re departing from Gates 61-150, you may as well just surrender to fate.

Also, I don’t know if you’re run into this yet, but the latest annoyance provided by your Transportation Security Agency ("Needless Obstruction Since 2001") is the full body scanner. I ran into this in Kansas City. You walk in between two, large metal towers and are instructed to literally put up your hands in a position of abject surrender. Surrender to the feds. As if the process already wasn’t as intrusive, politically correct, and totally unscientific or efficient as possible. It’s enough to make me want to start drinking tea.

Light My Fire

2010-11-16T16:38:00.002-05:00

Last week I saw a woman who had apparently fallen into a campfire at midnight. Arriving in the ER about two in the afternoon, she said she only came in because once she woke up and loked in the mirror, she realized it was kind of bad. (Another testament to the amazing anesthetic powers of alcohol.)

She didn’t need to see anyone immediately…there was very little to be done other than make sure she got the right kind of follow-up…and so while we were finishing up her paperwork, she walked out of the ED saying she needed to smoke a cigarette. No, she was careful to explain, she wasn’t addicted to nicotine. It was a “hand and mouth kind of thing.” Which is good for her, because I thought she was addicted to the flames.

Bathday Perils

2010-11-15T01:08:00.001-05:00

Let’s face it…we’re not all neat freaks. While the United States may represent the most overwashed, overshaved, and nit-free society the earth has ever known, there remain significant variations on the theme. It’s not politically correct to say that some patients stink, so we have our own set of euphemisms to describe their condition. Terms like “earth-centered” and “someone really comfortable with themselves” are examples of these covert comments. Over the years I’ve favored noting that someone was “allergic to soap,” conveying the hygiene message in a way that medicalizes the condition to free the patient from confronting their real problem, like we do with other stuff such as fibromyalgia (meaning “depression”) and metabolic syndrome (meaning “fat”).

Recently, though, I’ve had to reassess my use of this phrase. Witness the allergy list on one particularly aromatic patient I saw in a small hospital in Missouri (transcribed verbatim, including spelling):

Allergy on Medicine

Asprin
Pencillion
Demroal
Dervect
Sulfer
Keyflex

Other allergies

Tomatoes
Strawberries
Purex
Dail
Joy
Palmolive
Irish Spring
Milkweed
Wasp, bees, misquites, tick bites
Pine sole

Avoiding hives is the best excuse ever for not washing. I stand, adrenaline in hand, corrected.

Musings at McDonald's

2010-11-13T17:06:00.000-05:00

I’m sitting at McDonald’s waiting for the car’s semi-annual wash and detail. I’m trying to write, but without much success, for as far as I can tell the soundtrack playing above my head seems to intersperse “Do You Wanna MAKE LOVE or Do You Just Wanna FOOL AROUND?” in between other, perfectly reasonable songs. I’ll hear Journey sing “Faithfully,” or the perennially underrated Lou Rawls will croon “Lady Love,” and all will be right in the world, and then I’m suddenly back in college and trying to decide exactly where the fine line is between making love and fooling around, and exactly how many Long Island Iced Teas it will take at Harry Starker’s on the Country Club Plaza in Kansas City to get the date d’jour to consider the same question.

Oh, wait, the music just changed. Now they’re playing a medley of tunes…and I use that term metaphorically at best…by Bread. I wonder if I can poke out my brain with a spork?

(Sorry to interrupt, but the corporate lawyers at McDonald’s just called. They would have me remind you a spork must be handled with care in order to prevent injury, that the points are sharp, and that if you have questions about the use of the spork you should ask your wait staff for help, call our customer service number at 1-800-OK-SPORK (and rest assured that “spork” is pronounced the same in Bengali), or review the instructions found at www.bereallyreallyreallycarefulwithyourspork.com. If you have any concerns that are not addressed, DO NOT USE THE SPORK. They would also have me remind you that McDonald’s properties do not actually distribute the spork, but that this utensil is available to the public at Taco Bell, KFC, and other PepsiCo-owned entities, and that the McDonald’s corporation would be happy to provide support for your spork-induced injury suit against these dastardly PepsiCo corporate pirates who put their profit before your health and safety. After all, if they cared about you they’d spend the extra dime and get you a separate fork and spoon, right? Let’s get ‘em!)

World Cup Farewell

2010-11-02T19:12:00.002-04:00

(This was written during my self-imposed hiatus, so it's a bit dated. But it does provide important follow-up information...)

One last World Cup note before we tuck away the soccer ball for another four years. Listening to the “play-by-play” announcers for the past four weeks have convinced me once again that American culture, while eminently democratic in appealing to the masses (including me), lacks a sense of refinement and grace. It’s not just that soccer…okay, football…is referred to as “The Beautiful Game,” and it’s not only that you win but you lose points if you don’t do so with style. It’s the use of phrases such as “He performed nobly for his country” after a particulary good defensive play, and the liberal scattering of words like “rarified” and “tenacity.” By way of contrast, an American commentator described World Cup Final as, “like putting a pig on lipstick.” (And while it may not represent culture, nobody does enthusiasm like Andres Cantor, the Univision commentator who says the word

"¡GOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOLLLLLLLLL!"
followed closely by Al Michaels asking, “Do you believe in miracles?” during the 1980 Winter Olympics, Russ Hodges shouting “The Giants win the pennant! The Giants win the pennant!” way back in 1951, or Jeff Spicoli letting us know that “That was my head! I’m so wasted!”

A number of us have decided that we love the pig, however, so we’re already planning to head out to the 2014 World Cup in Brazil. It just looks like so much fun…and we have our own vuvuzelas… that it would be wrong not to go. So we started talking about other places you could have the World Cup, and that maybe we could resolve world issues through soccer. Maybe Israel could hold the World Cup, teams could be based on religious preference, and they could duke it out over Jerusalem as a way of brigning peace to the Holy Land. Personally, if we do it that way, my bets are on the Catholics. They’ve got a drawing pool of Argentina, Brazil, the Guays (Para and Uru), Italy, Spain, and Portugal going for them. Second place would be the hard-working protestants of Northern Europe…the Germans and the Dutch. (I would put the English in this category, but I don’t think there’s anything that can make those folks play together. Divine might only goes so far.)

This idea is similar to something my father came up with many years ago. He noted that virtually every athlete will, at some point, thank heaven for the most recent victory, despite the fact that God, being the author of life, death, and the universe, probably had other things on his mind than bestowing his grace on an NCAA Division III contest. But since every victorious athlete believes that God is on his side, my Dad thought that the best way to sort this out is to have a football bracket similar to March Madness, with all the teams from religion-based colleges included. (No secular humanist powerhouses, like Alabama, Texas, Florida, or Cal-Berkley need apply). That way you get tussles like Baylor at SMU, Brigham Young against TCU, and Notre Dame against Brandeis. The winner would clearly be the team that God really favors in the end.

(Personally, I’m not so sure that God doesn’t pay attention to football. I like to believe that the Lord is a long-time Saints fan…it fits…and maybe he does intervene in miraculous ways. I mean, Peyton Manning throws a last minute interception in the Super Bowl? Peyton Manning? How can you not see divine hands at work here?)

I this idea a lot, and I know my father’s willing to put good money out there on the Disciples of Touchdown Jesus. And I’m pretty sure he’s right. After all, Peyton did throw that interception…

(Here's the updates. Paul the Octopus, the Clairvoyant Cephalopod who correctly predicted the outcome of every World Cup match involving Germany, had died. Viewing was held at the Olive Garden in Munich.

Larissa Riquelme, the Paraguayan lingerie model who pledged to run naked in the streets of Asuncion if the national team won the World Cup final, has not let a loss in the quarters stand in her way. As her tribute to the bold Guyanos, she was pictured in various patriotic poses in the 7th issue of the newspaper Diario Popular. They're quite stirring, and bound to engender a significant amount of national pride. Yep, that's the euphemism we'll use for that.)

Cost Containment

2010-11-01T23:07:00.004-04:00

The first health care provider a most patients see in the ED is the Triage Nurse. It’s a pretty challenging role. The nurse out front becomes the face of the ED, not only responsible for making sure that patient and their families feel welcome and cared for, but also for sorting out the wheat from the chaff, the patients with true emergencies from those who are simply hangers-on.

The other day I saw a patient who had presented to the triage nurse with chest pain. As the story goes, she had gotten a case of the munchies that morning and, finding nothing in the icebox box save a package of questionable “Brown ‘n Serve” sausages, she popped one into the microwave for a bite. Following the obligatory “ding” from the Radar Range (I’m showing my age here), she grabbed the casing and shoved it into her gullet. However, she had neglected to wait the recommended three minutes for the sausage to cool, and developed a severe burning discomfort in her lower chest as the wrapped pork shards flamed down her esophagus and into her stomach.

In many hospitals, triage nurses are also responsible for initiating medical care protocols based on the patient’s chief complaint. Doing so often speeds care, especially when physicians are busy and cannot get to the patient to order labs, x-rays, and certain medical treatments within a reasonable time. They’re really a very good way to increase both efficiency and enhance patient care. However, these protocols are blind to circumstances and to costs. Which is why, by the time I got to the patient, she had been subject to a full cardiac workup, including an EKG; a chest x-ray; and a complete laboratory profile including blood count, coagulation studies, chemistry panels, and enzyme studies to look for evidence of heart damage. I have no idea how much all that cost the taxpayers, because Lord knows this patient is not paying her own bill.

Being the doctor, who works off no set protocol other than the 10% of medicine that is science, the 30% that is common sense, and the 60% that is voodoo, my workup cost the taxpayers less than a dollar. It was called a cold can of Sprite.

Problem solved.

Holy Cards, Batman!

2010-10-29T11:40:00.001-04:00

This past summer I went to a wedding in El Dorado, Kansas. El Dorado is not only home to the Kansas Oil Museum, but is also the childhood home of President Obama’s mother. As El Dorado is good GOP territory, there is not, and will never be, a sign commemorating the event. But the wedding itself was really very nice. The bride was beautiful, the groom nervous, the parents proud, and the priest did a great job of explaining the process of the mass as well as the rationale why only practicing Catholics were able to have snacks in the middle of the service. (No word of what the Catholics who are done practicing and actually good at it are allowed to do.) And like most houses of worship there’s a lot of literature scattered throughout the pews. I was especially taken by a small card with a photo of Pope Benedict XVI on one side and a prayer for his wise guidance of the Church on the other.

I had seen Holy Cards before with pictures of saints on one side (like Saint Dominic, Saint Theresa, Saint Pierre, Saint Thomas, Saint Pierre Thomas, Saint Brees, and Saint Whodat) and appropriate prayers on the other, but the Pope card was a new one. This got me thinking that maybe there’s a market out there for Pontiff Trading Cards. You’d have a picture on the front of the Pope in full regalia, and on the back you’d have his stats and a small vignette:

Leo XIII (Vincenzo “Prayin’ Vinny” Pecci)

Year Team League SS EW SC WB IT

1901 Papal Catholic 4,800 2 18 7,010 0

Leo XIII was the first Pope to have his voice recorded on a phonograph, reciting “Maria ha Avuto un Piccolo Agnello” into a tinfoil cylinder. Or maybe that was Thomas Edison. They looked a lot alike.

(In case you were looking for the code:
SS = Souls saved
EW = Encyclicals Written
SC = Saints Canonized
WB = Wafers Blessed (in thousands)
IT = Impure Thoughts
The latter is the equivalent of fielding errors.)

I see real potential here, especially with the rare and collectible rookie cards.

I’m not sure that this idea translates well to Judaism. We really don’t have designated rabbis in charge of the whole shebang, and while congregations may belong to an umbrella organization for their own theological bent each temple or synagogue pretty much runs its own show. (Old joke: Name the kinds of Jews. There’s Reform Jews, Conservative Jews, Orthodox Jews, Orange Jews, Grapefruit Jews, Apple Jews, Grape Jews…)

The closest thing we have to folks who are “card-eligible” are the leaders of the ultra-orthodox Chasidic sects, who from an outsider’s perspective seem to spend a lot of time out-davening and out-fruitful-and-multiplying each other. I’m thinking that while the front of the card would again feature a picture in complete uniform (which, with black coat, long bread, and hat would look pretty much like all the other uniforms), the back might look something like this:

Shmuel “The Kreplach” Kapowitz

Year Sect NC CO BL DPH PS PA

1964 Lubavitch 8 613 11.5 7 3 2

Rebbe Shmuel once smelled bacon, but studied the Zohar to obliterate the memory and then soaked in a mikveh for a week to ensure his place in the world-to-come, Ha-shem be praised.

As usual, there’s a code:
NC = Number of Children
CO = Commandments Observed
BL = Beard Length (inches)
DPH = Davens/hour
PS = Pigs Seen
PA = Pigs avoided

I thought about adding a “Circumcisions Performed” category, but ran out of space and snipped it off at the end.

(One last saint story. I went to ninth and tenth grades at Brebeuf Preparatory School, a Jesuit high school in Indianapolis, Indiana. The school was named after St. Jean de Brebeuf, a Jesuit missionary to the native peoples of Canada who died a martyr. I know this because on the wall of the cafeteria was painted a mural of the saint tied to a stake, flames around his feet, red-hot hatchets strung around his neck, while half a dozen hooting Iroquois danced around him in glee. Forget the total lack of political correctness in the picture…learned white man tortured by savages, that kind of thing. Can you imagine trying to eat lunch looking at that? Understandably, there was no hot lunch line. Hail Brebeuf Forever!)

Excuses

2010-10-28T21:38:00.001-04:00

The astute readers of this blog (and by definition that’s everyone, because if you read this blog you automatically fall within the category of “astute”) will have noticed that this writer has been, to put it mildly, dysfunctional over the past few months. Those who know him personally have seen in it his failure to engage in society in any meaningful way save occasional cryptic notices on Facebook (the modern day gossiping fence); those who know him only from afar have probably noticed little change except for a lack of those annoying “New Post up on The Blog!!!” notices accompanied by a proliferation of what Everett Rees, my high school English teacher who had a habit of massaging his male student’s shoulders and whom we used to call eccentric and now call someone who can’t get married in California, would have called “cheerleader exclamation points.”

(I would beg to differ from the venerable Mr. Rees’s contention, though I continue to hold him the highest regard for sponsoring the Categories Team, a quizzical celebration of useless trivia in which I proudly claim two District Championships. The Categories Team was one of the Three Pillars of Dweebness at our high school. The others were the AV Squad, to which I did not belong, and the ZITS team, to which I did. ZITS stood for Zoo In The School, and basically consisted of feeding and cleaning cages for a host of mice, lizards, and snakes that occupied a back room in the biology departure. We would also give monkey chow to a simian named Houdini, which is why I knew before The Animal Planet that bored capuchins have a keen interest in self-pleasure.

But back to punctuation. They’re not cheerleader exclamation points because 1) I have never changed the text color to pink or purple and B) I haven’t figured out a way to make my fonts put a smiley face within the circle below the bottom-pointed oval forming the bulk of the exclamatory sign. And yes, the itemizing was on purpose, ‘cuz it’s a cheerleader thing. Ready? Okay!)

So why the absence of the blog? (This question assumes that you’re wondering why, and have not already concluded that the absence of the blog is my own way of doing a remarkable service to mankind). In short, it’s because the last three months of my life have been an unmitigated disaster. It has been a series of personal and professional catastrophes that has not been a slow progression, but has occurred on specific dates such that one can actually draw a line graph charting the time on one axis and the damage on the other. The details are and will remain mine, but the events are of the magnitude that I am angry…no, that’s too light a word, but it’ll have to do…at the world for what it’s done to me. I think I’ve played by the rules, done the right things for the right reasons, and lost everything. I had a plan; now I have none. I used to be somebody; now I am nothing. I see those of lesser ability succeeding while I drift backwards; I find my fate is no longer my own but is controlled by the insecurities and vicissitudes of others who see me as a source of…well, I don’t know what. Those things that gave me purpose and validation have been taken from me, and what results is the guy eating day-old bologna sandwiches on the airport floor and checking the meat to make sure it hasn’t changed color. (And for what it’s worth, I’m probably not very good at rhetorical hyperbole, either.)

Different people do different things when they fall apart. Some yell and scream. Some are able to refocus and find new challenges. Some count their blessings and accept their new lot in life. Some spend recklessly, drink, or gamble. What I do is nothing. I sit, I brood, I glower, and I don’t talk to anyone. Paradoxically, I talk less to those closest to me, friends and family than I do to the odd acquaintance at Golden Corral. Which is why I haven't been blogging, because blogging is talking to myself, and I’m about as close to me as anyone.

I got to thinking about this a few weeks back during Yom Kippur, the Day of Atonement. There’s a wonderful prayer in the holiday liturgy called the Al Cheit. (Don’t worry about how you say it…Hebrew doesn’t transliterate well in to English, and if you’re not semetic in some fashion you can’t pronounce it anyway.) It can be very roughly translated as “all sins,” and depending on who’s counting it reels off a list of 23 or so separate kinds of sin that we’ve managed to stray into over the course of the previous year. Usually I can find at least three that I’ve stayed away from. Not this year, I’m afraid. What I’ve been thinking and feeling over the past three months has gotten me a perfect score. Batting a thousand made me realize it's time to move on, and restarting the blog is one way to forge ahead.

(Okay, one funny story about this prayer. I grew up in a tradition of liberal Judaism. But when I first moved to Florida the only synagogue in Gainesville was a conservative one. Conservative services involve a lot more ritual and Hebrew than I was used to. So when they did this prayer on Yom Kippur, not only was it done in Hebrew of which I had a poor understanding, but it was accompanied by rocking back and forth on one’s heels and a beating of the breast that for all the world seemed like something out of a National Geographic Special on the Plains Indians and had me looking up to the sky for rain. Now, of course, I recognize that the ritual comes from the movie 300, and what I was hearing must have been Hebrew for “We are Sparta!”

By the way, while I recognize that all faiths have some ritual of repentance, I really like the way we Jews do it, and that’s not just saying so as an MOT (Member of the Tribe). It always made sense to me to do all your confessing on a single day and with all the other Jews at the same time. That way, the chances of God singling out your sin for punishment amidst the cacophony of guilt are relatively less.)

So for those of who feel like I’ve done wrong by not blogging, I truly apologize and hope that resuming our online discussion will serve as a small effort at atonement. And for those of you who thought this blog was a load of bull to start with…well, I suppose I’ll just keep on sinning. I’ve got to have something to repent for next year.

Larger Problems

2010-07-09T09:52:00.001-04:00

Have you seen this new piece of female lingerie from Victoria’s Secret? It’s called the “Bombshell Bra,” brassiere, and it raises the lucky purchaser two breast sizes when worn. It’s really quite remarkable, even if counterintuitive to the old adage of not making mountains out of molehills. But it makes me think of one of my favorite ED tales.

I had just started working in Daytona when a very attractive young woman came into the ED with abdominal pain. This was back in 1996, when I had first come back to the USA from working overseas, and this was my first job as an ED doc in the private world outside of academia. What that meant is that I was still trying to figure out how to best use my time to get in and out of the patient room as fast as possible, which is a skill that you acquire only in the world of community medicine. When you’re learning medicine, like in medical school and residency, that’s not an issue. You’re expected to be pathologically complete and glacially slow. And when you’re teaching medicine as I did at the University of Florida, that’s not a problem as there’s always someone lower on the totem pole who’s already asked all the right questions for you.

Even with the merciless push of technology, each medical encounter is still based on the patient’s history and physical exam. Each of these segments has it’s own constituent pieces. The history begins with History of the Present Illness (HPI), where you ask about whatever it was that brought the patient to the doctor. (This is actually often the trickiest part in the ED setting; patients have multiple problems, and you have to be able to politely tell them that, “Here in the ER we only deal with one problem at a time, so if there’s one thing that made you decide to come here today would that be?” You have to do so or you’ll never get on with the rest of the work.) You then ask about the Past Medical History (PMH), Medications, Allergies, Social History (SH), Family History (FH), and finish up with a series of general health-related questions called the Review of Systems (ROS). The ROS is really designed to uncover other related symptoms or problems you haven’t thought about before that might be related to what’s going on. However, if used incorrectly and not focused on the problem at hand, it provides you with far too much information to be really useful. (Have any problems with headaches? I had one last week after playing the Wii for three hours straight. Any chest pains? I climbed to the top of the Washington Monument two months ago and got short of breath. Difficulty with urination? Well, no, but they tell me that urine smells funny after you eat asparagus. I don’t like asparagus, but why is that? You get the drift).

The final piece of the history, at least according to those medical sociologists who never actually see patients and exist under no time constraint other than the time until tenure, is to ask an open-ended question such as “Is there anything else you’d like to talk about today?” to allow the patient to express their own concerns and expectations for care. This is a great question in a primary care office. It’s a rotten question in the ED, because getting the answer and trying to figure out where to go from there is often the kiss of death to any kind of efficiency in the ED.

But I hadn’t figured this out yet the fall day in 1996, and so when I asked if there was anything else bothering this particular patient, she replied, “Ever since I got my breasts done, I can’t sleep.”

This was new one on me. I knew that large implants can give women back pain; I knew about the alleged dangers of silicon implants; I had taken care of wound infections and even dealt with what happens when you get a blow to the chest and the implants pops. (It’s kind of funny, to be honest). And of course I had been party to discussions, usually…well, always…over beer about personal preferences for real or fake breasts, and had thought that women with well-crafted implants probably don’t need to worry about knowing if their airline seat can be used as a flotation device. But implant-induced insomnia was breaking new ground.

So I had to get more of the story. Turns out she was a dancer at one of our better men’s clubs here in town. (That’s not a joke…it was actually pretty nice in there.) In order to maximize her income, she had to maximize her assets. This was working out well for her, and she figured that in three years time she’d be able to quit. But in the meantime it was hard for her to sleep. She usually slept on her stomach, with her head turned to the side. But with the new, improved, and greatly enlarged breasts, when she tried to sleep on her stomach her head was too far off the pillow, and when she drifted off her head fell down, blocking her airway, and she would wake up with a start over and over and over again.

The problem was easily solved by asking her to use three pillows for support at night…we trialed this in the ED for her, comprehensive folks that we are…and while I have been telling this story for years, I didn’t really understand it until last month. The Bride, who is fairly well put-together to start with, got one of these new Victoria’s Secret bras to see what it would do. (To be fair, I certainly encouraged her in the shopping.) Let’s just say the effect was an impressive demonstration of textile engineering. But we’re out late one night, and we’re both a little beat so we’re having a late night cup of tea at a seaside coffee shop. She’s so tired she starts to put her head down on the table. But she can’t, because…yeah, I finally got it.

Plumbing Surprise

2010-07-08T08:10:00.001-04:00

Here’s the weird note for the day. The bathtub wouldn’t drain after my shower yesterday morning, so I got a handy guy to come look at it. Turns out that when he removed the stopper and the supporting grill, there was big ball of hair blocking up the drainage pipe.

Talk about mixed feelings. On one hand, I’m supremely embarrassed that a total stranger is extracting huge plugs of hair form my shower. One the other, to be 47 and be able to spontaneously shed that much hair from my head and still need a thinning out and a cut every month just to keep things manageble...we’ll, that’s just something to be proud of.

Soccer News

2010-07-07T20:36:00.000-04:00

World Cup Update: Paul the Octopus is now six for six. Having predicted German victories over England and Argentina, the clarivoyant cephalopod correctly selected Spain as the winner of today’s semifinal match. Congratulations to Paul for finally making the right choice.

That being said, I’m kind of dissapointed that we’re not having The War of the Guays (Para and Ura) in the World Cup Final. But as they say, you go Uruguay and I’ll go mine. (I’ve been waiting for years to use that line). But fortunately, as we learn from Ryan Wilson at BackPorch.com:

Despite Paraguay Loss, Larissa Riquelme Will Still Run Naked Through Streets

Paraguay made it all the way to the quarterfinals of the 2010 World Cup before losing to tournament favorite Spain, 1-0. Not a surprising outcome...but upsetting nonetheless, particularly for those individuals who were looking forward to lingerie model Larissa Riquelme's naked romp through the streets if Paraguay had won the whole thing.

All is not lost, it turns out.

According to Metro.co.uk: "Riquelme has confirmed she'll go ahead with her promise - even though her countrymen fell a couple of wins short of the target she'd set them."
"It will be a present to all of the players, and for all the people in Paraguay to enjoy,' she said. "They tried as hard as possible and gave it their all on the field." That's called taking pride in your country.

In related news, Diego Maradona will be forced to run through the streets naked as punishment for Argentina's no-show effort against Germany in the quarterfinals.

(And from my own visits to Buenos Aires, I know that the Avenida 9 de Julio is one big street.)

Higher Power

2010-07-06T10:42:00.000-04:00

There’s this bit from the Bob and Tom Radio show about getting on in years. I forget his name, but one the featured comedians notes that one of the signs of age is that when you’re checking out hot girls at the Food Court in the Mall, they run to security because there’s a creepy old guy looking at them. This is why I’m now publically declaring that when I pace the floor at Barnes and Noble, Borders, Starbucks, or an airport staring at your feet , I am not a frustrated late forties guy with an unsatisfied fetish or hoping to spy a reflection off polished leather. I am instead a frustrated middle-aged guy searching desperately for an outlet in which to plug in my laptop and feed my Facebook addiction, because the child has burned out the battery playing Civilization IV in the car, having named his four cities Hamburger, French Fires, McNugget, and Happy Meal, and hoping to build combat units called Big Mac and Mayor McCheese. (I understand he’s saving Filet-o-Fish for the first city he builds near the coast.)

Thank you in advance for your understanding.

Set 'Em, and Forget 'Em

2010-07-05T09:49:00.000-04:00

The fear of missing something weighs heavily on every doctor's mind. But the stakes are highest in the ER, and that fear often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomachaches.

Many ER doctors say the No. 1 reason is fear of malpractice lawsuits. "It has everything to do with it," said Dr. Angela Gardner, president of the American College of Emergency Physicians.

The fast ER pace plays a role, too: It's much quicker to order a test than to ask a patient lots of questions to make sure that test is really needed.

"It takes time to explain pros and cons. Doctors like to check a box that orders a CT scan and go on to the next patient," said Dr. Jeffrey Kline, an emergency physician at Carolinas Medical Center in Charlotte, N.C.

Patients' demands drive overtesting, too. Many think every ache and pain deserves a high-tech test.

"Our society puts more weight on technology than on physical exams," Gardner said. "In other words, why would you believe a doctor who only examines you when you can get an X-ray that can tell something for sure?"

Refusing those demands creates unhappy patients. And concern that unhappy patients will sue remains the elephant in the emergency room.

Associated Press, June 21, 2010

Lots has happened in medicine in the 21 years since I finished my training in emergency medicine, but the changes in our field are probably less than in other medical specialties. Because of the limitations of the ED setting, we most often don’t have access to all of the advanced tests, tools, and techniques that can be used in diagnosis and care during normal daytime hours. But that’s okay, because with the exception of emergency cardiac catheterization for heart attack and drug therapy for early stroke, things like MRI’s, serum levels of just about anything, and advanced surgical techniques rarely make much difference in the care we provide. Lives are saved by doing old-fashioned stuff like giving oxygen, keeping airways open, and use of fluids and maybe a dozen select medications which are essentially the same as they were two decades ago. One of the fun things about ED work is that there’s still some room to be a medical detective, as long as the investigation is limited to looking for an emergency and not definitively diagnosing everything else.

But that doesn’t mean technology isn’t invading our practice. It’s more than just tests and x-rays we do for medicolegal purposes, although that’s one of the most commonly held notions. (And realistically, while extensive lab tests and CT scans may find more things might expect, they often don’t affect the actual disposition of the patient; you usually already knew what needed to be done. A surgeon I respect…and for me that’s saying a lot…once told me that CT scans in trauma patients find a lot of injuries, but nothing you’re going to do anything about.) The article cited above is one of the few that talk about other reasons for excess testing, including effects on workload and patient demands.

Here’s an example of what I mean. A couple of weeks ago I saw a very pleasant 28 year old woman with pain in the right lower part of her abdomen. The basic approach to the problem…a history and physical exam…haven’t changed. You ask a set of questions, listen to the answers, and then poke, prod, and have a look around.

During my residency, the initial workup after exam would have consisted of a urinalysis and a urine pregnancy test. The one major emergency you always watch out for in a woman with one-sided lower abdominal pain is an ectopic (tubal) pregnancy. If the pregnancy test was positive, the patient had a possible ectopic until proven otherwise. Ultrasound was relatively new, and even when available you weren’t going to get one in the middle of the night. So you’d next get a blood pregnancy test, because most of the time levels of the pregnancy hormone b-HCG don’t rise above 2500-5000 with an ectopic pregnancy. If your clinical suspicion was still high, and if the b-HCG level was very low considering the date of the patient’s last period, you would call up the obstetrics resident who would come down to the ED and explain to the patient the need to do a culdocentesis. A culdocentesis is a needle puncture through the back wall of the vagina just under the cervix to see if there’s any free blood floating around the pelvis suggestive of a ruptured and bleeding tubal pregnancy. If it’s positive, the patient needed to go to the operating room for repair. That being said, most women would understandably decline the procedure (I’m not a woman, but it just sounds painful), and there would be some extensive patient education and counseling about the uncertain nature of her pain and the need to return immediately if worse in any way.

Today it’s different. Same patient, same presentation. But now once the pregnancy test is positive, we get an MRI to look for an ectopic (and avoid radiation exposure to a potential fetus). If it’s negative, we get a CT scan to see what else might be going on. Most of the time, we find nothing, and the patient is discharged with a diagnosis of “pelvic pain of unknown cause.” It’s a more definitive process to actually be able to visualize the area of pain. But is it better medical care?

There is no question that a CT scan or MRI is less invasive and less painful than a culdocentesis. Direct imaging does take the guesswork out of medicine, which is probably a good thing as well. Perhaps it provides a more definitive diagnosis (or at least a more definitive way to say there’s nothing wrong), and maybe there’s some reassurance value in that. There’s no question that medicolegally, you’ll be taken to task for not getting a test no matter how much time you devote to patient education and discussion. (And this is in a sample case where the test might actually be indicated, but physicians run the same risk if patient demands are not met regardless of clinical need. And believe me, it’s easier to give in to testing than explain why not.)

But sometimes I wonder if the sheer ease of getting tests and scans is a way of excusing ourselves as clinician, making us sloppy, and makes us really unable to communicate and talk with patients in the ways we used to do. Maybe we use the medicolegal excuse as a crutch for not wanting to make the physician-patient connection, but I doubt it. I don’t know anyone who went into this business purposefully to not talk to people. I think what testing does allow us to do, especially in high-volume ED’s where speed of patient turnover is often prized over compassionate and personal patient care, is to allow us to keep the system moving. I can spend twenty minutes talking to you, or I can order a CT scan and your case becomes a Showtime Rotisserie Oven. I set you and forget you until the timer on the CT scanner dings and then we sample the results in front of a studio audience. And all for three easy payments. But wait! There’s more…

Pet Sounds

2010-07-04T05:52:00.002-04:00

Ms. Wilson was a 54 year old woman who, by her overall appearance, looked as if she had been walking on the wild side of life for quite some time. (The politically correct term for this is “looks older than her stated age.” The Joplin, Missouri term, taught to me by my old friend Dr. Michael Joseph, is “rode hard and put away wet.”). When someone looks that way, you never know quite why. Maybe it was a life of hard luck, of working two jobs and barely scraping by. Maybe it was selfless service to those in need, of bearing the pain of others on her shoulders. Maybe it was living like Bike Week was a full-time job. But regardless of the cause, with folks like this you know there’s always a story out there somewhere.

She had come in complaining of left rib pain. The pain had been present for two days since she fell out of bed and landed on a toolbox. The reason she fell out of bed is that she rolled onto her pet who was on the bed, the pet yelped, and she was startled.

Up until now, I’m with the story. I’ve had a pet sleep on the bed (most notably the late lamented Jimmy Leemer the Dog, aka The Amazing Furry Walking Garbage Disposal.) Indeed, this is a fundamental part of The Second Axiom of The Dog Rules of a Relationship, which are:

1. You must love my dog.
2. The dog is going to sleep anywhere it wants, because the dog was there first.
3. If we get into a fight and you ask who I love more, you or the dog, you don’t want the answer.

But here is where the story changes, because the pet in this case is a rat. A domesticated white rat, she was quick to point out; a dear member of the family that has been scurrying about the house and climbing into bedclothes for the past two years.

And you do you get a rat for a pet? Well, they were going to feed it to the snake, but it just gave her this look…

Pain, Drugs, Rock 'n Roll

2010-07-03T23:08:00.000-04:00

The woman in Room 34 has been here 27 times this year alone for the same abdominal pain, and it’s only June. I asked one of our nurses what was wrong with her as I strolled towards the room. The nurse struck a pose, hand on her hip, hand grasping the stethoscope and holding it close to her lips.

“She’s a drug seeker!”

Her smile turning into a rocker sneer, another nurse stood to mirror her and grabbed her own stethomike.

“Narc eater!”

Together they swivel on the balls of their feet, pop their hips, and swagger around the desk.

“I’m the nurse so you don’t mess around with me!”

Suddenly we’re all rock stars, as the ED choir…two sopranos and me...begins to wail.

“Hit me with your best shot! C’mon, hit me with your best shot. Give me some Diluadid! Fire awaaaaaaaaaay!”

(Pat Benatar is not the only musician we adapt in the ED. For psychiatric patients, we usually bring in Gordon Lightfoot:

“If you could read my mind, Lord,
What a tale my thoughts could tell
Just like a schizophrenic
On some Haldol and not too well.”

He’s also good with bowel issues:

“Sundown, you’d better take care.
“Cuz when I’m constipated I ain’t goin’ down there.”)

ABC ETOH

2010-07-02T06:59:00.003-04:00

Mr. Frisen was found lying on the sidewalk outside the ABC Liquor Store. I’ve always thought that they should put a bench outside of ABC, because it seems to be a favored place for some of our ED clientele to relax and recline. Perhaps they could even build a small, self-service hostel as a way of building customer loyalty. It makes sense to keep your best customers close at hand. You could call it Motel 6 Proof.

(By the way, have you ever noticed that you never see an ABC Liquor Factory Outlet Store at the Outlet Mall? Is there no such thing as seconds or overruns? “By gosh, we put just a bit too much alcohol in that bottle. Maybe we can sell it at half price?”)

However, the passers-by tend to frown upon live bodies obstructing the sidewalk. So the police brought Mr. Frisen in to see us to make sure he was okay. They left him in our care, but with a note to please contact them before he was to be released. This is the polite law enforcement way of saying “We’re not leaving an officer here with you, but when you’re done he’s going to jail.”

Unfortunately, Mr.Frisen was not a patient man. He had people to see, places to go, and things to do, and apparently all of them were quite urgent matters for 2:27 AM on a school night. So when he demanded to leave, it was with great regret that we informed him that this was not really going to be possible, as the police wanted a word with him after we were done. He must have been displeased with the news, because he decided to tear out the plexiglass walls of the exam room.

When someone goes ballistic in the ED, there is generalized bedlam. The charge is led by well-muscled young guys seething with vital hormonal secretions, who are able to secure the patient from harm by subduing them with gentle, patient-friendly techniques learned from watching cage fighting. But these are social occasions as well, where every free staffer gathers to offer commentary, complement particularly creative holds, gossip, and generally observe the fun. In fact, when we know of an upcoming event (such as when we hear security paged to certain room), we all tend to gravitate towards our next shared experience.

This happens on a reasonably frequent basis, and is not really news in and of itself. But what makes Mr. Frisen’s case worth noting is the sheer volume of good lines that came out of it, and the large number of staff who got in on the act.

There’s the nurse apply leather restraints, saying “Most of the time I get paid for this.”

There’s the tech who has one knee on the small of Mr. Frisen’s back and his arms engaged in holding down his right wrist, noting “If I stay here, I can’t send you any more patents from triage.” Mr. Frisen utters a profanity as he tries to wriggle out from under him. The tech tightens his grip and smiles. “Sure you wouldn’t like me to stay here for a while?”

There’s our registration clerk, who pops into the struggle to notify us that he has spoken with Mr. Frisen's sister and has been told 1) If he needs life support, don’t do it; and 2) If he dies, we should call her in the morning.

Once in restraints, Mr. Frisen calms down. (They most often do.) His alcohol level comes back at 398, almost five times the legal limit in our fair state. This prompts someone to note that he should have his own liqour license. In turn, our female-unit-clerk-in-a-committed-relationship-with-another-woman notes, “Hey! I want one of these!”

(It’s a sound-alike joke. Keep working on it. Thank you.)

The jail won’t take him until his alcohol level drops below 200, which is about eight hours away. He’s asleep, and I think we’ve run out of one-liners for the evening. Besides, it’s close to 7 AM, and Waffle House is calling my name.

Sleep well, Mr. Frisen. But come back tomorrow night. We’re here all week. And be sure to tip your techs. They’re out there working hard for you.

*******************************

A few other quick takes on a very slow night…the kind where you’re paid to socialize (and the kind I can never get enough of):

“Mrs. Payne is 88 years old. She’s been a pain for a long, long time.”

Phone call taken at 6:30 AM by our Unit Clerk. “You said you need a wheelchair to be waiting for you when you get here? I’m sorry, but we can’t have someone sitting outside just waiting for you. We’ll be happy to help you if you need it when you get here.” A pause. “And you’re driving yourself?”

“I’m looking forward to July 4th. It’s Redneck Natural Selection Day.”

Catching On

2010-06-30T12:14:00.002-04:00

Every now and then you realize you’re way too deep in what you do for a living…

Have you ever played Catch Phrase? It’s a great game. The electronic version is a fat disc that shows unusual word or phrases on a screen, and teams of two or more players try to guess the word or phrase. When one team gets it right, the disc is passed to the next team. There’s a timer in the device that beeps with ever-increasing urgency, and the team holding the device when the buzzer goes off loses the round. You can guess that this leads to the disc being flung about like a hot potato as time grows short. It’s kind of like Password on steroids.

Anyway, I’m over at a friend’s house the other night, and a bunch of us ED folks are playing Catch Phrase. It’s my turn to guess the answer, and my partner Kristin is looking at the screen. She turns to me and says “People do this all the time in the ER,” and she starts to gag and make a gesture with her hand like things are coming out of her mouth.

I knew exactly what she was doing. It is something people do all the time. It’s one of my least favorite bodily functions that expels one of my least favorite bodily fluids. (Blood, urine, lung stuff I can handle. GI secretions? I’m outta there.) But I know too many words for it, including:

Vomiting
Vomicking
Nauselated and Vomicking
Barfing
Upchucking
Regurgitating
Worshipping the Porcelain God
Producing the Technicolor Rainbow
Aspirating
Aspiration Pneumonia
Aspiration Pneumonia in a Nursing Home Patient
What you do when Administration Comes by

After about a minute and a half of this, with the beeping growing more intense and frantic, she grabs me by the collar. “WHAT AM I DOING?” she shouts?

“You’re throwing up, right?”

“RIGHT! IT’S THROW UP. THROW UP! LIKE NORMAL PEOPLE SAY! THEY THROW UP!”

And the disc was passed.

True Creepy Story

2010-06-30T10:37:00.000-04:00

This is absolutely true. I’m driving down the street taking my son for an overnight visit with his grandparents. As I pass by one of the homes on their street, I noticed there are huge black birds circling over the house. I slowed down to find that they were also perched along the eaves, standing on the concrete facing of the garden wall, and even pacing up and down the driveway, driving their hooked beaks into the pavement with a mixture of determination and boredom. It was like something out of a Hitchcock film, but all the more scary because you knew…beyond a shadow of a doubt…that there was neighbor inside who hadn’t been seen in quite a while.

Don’t look for a punchline here, because there isn’t one.

A Soccer Suit

2010-06-29T11:58:00.002-04:00

…I am the armchair fan who desperately wants to love this game, and, like untold thousands (millions?), had no choice but to curse it out, turned off by incompetent refereeing, a situation exacerbated by a governing body so intransigent and arrogant it makes British Petroleum look like a warm and cuddly quilting circle. "I am very, very satisfied," Jose-Maria Garcia-Aranda, the head of FIFA's referees, said of the quality of officiating in the World Cup matches…

…Even the most tradition-bound purists must agree that a goal should be a goal. So when referee Mauricio Espinosa mistakenly disallowed Frank Lampard's goal on Sunday, a score that would've enabled England to tie Germany 2-2, it was a very big deal. And when FIFA general secretary Jerome Valcke all but ruled out the use of video replay that would correct such situations, it exposed a sport crying out not just for visionary leadership but for leadership with some grasp of reality. Not counting a goal for fear of dehumanizing a sport with replay is not in the tradition of anything besides the tradition of ignorance.

Jack McCallum, sportsillustrated.cnn.com, June 28, 2010

The Fédération Internationale de Football Association (FIFA) officiating problem is really pretty easy to solve. Take a lesson from American medicine and make both the referees and the governing body legally liable for bad decisions. After all, it’s not like the actions of the referee go without consequence. A decision to allow, or disallow, a goal has a major impact upon the ratings of individual players and their ability to make a living at their chosen sport. Similarly, football clubs depend on proper officiating to ensure that both game results and overall standings are true and correct. With low-scoring games, a single inappropriate goal can cause a large change in the standings, which in turn affects a club’s ability to attract players, fans, and advertising. In addition, many football leagues feature end-of-season “relegation,” in which the lower performing teams and sent down to a lesser level league, and the best of the minors is promoted to the big time…and big money. The revenue impact of relegation on a team, let alone the psychological hot on a community, is staggering. If doctors can be sued for errors in decisions that affect the livelihood of others, even in those cases when these decisions can’t be made on any objective evidence at all, why shouldn’t FIFA?

The threat of liability, of course, will drive a headlong rush to embrace as much technology as possible to put error out of the realm of possibility. That is the current unreasonable standard in medicine…that there is perfection in an inherently unstable art…and one of the main reasons why doctors do so much testing and imaging and so little talking and educating. But if referees knew that they could be held personally liable for a missed goal or allowing an illegal play, I don’t know any that would participate at the sport’s highest level. They might if they were indemnified by FIFA itself, but would the organization want to take on the question of liability? I don’t think so. Like medicine, they will rush to a technologic solution and install goal cameras, mandatory instant replay of all scoring plays, and maybe even a coach’s challenge to eliminate their own risk. Because World Cup soccer is not about fair play or making sure that the better team wins at the end of the day, but all about FIFA.

FIFA president Sepp Blatter has apologized to England and Mexico for the refereeing errors that helped eliminate them from the World Cup…

The English said 'thank you.' The Mexicans, they just go with the head,'' Blatter said, indicating that they nodded. "I understand that they are not happy. It was not a five-star game for refereeing.''

England was denied a clear goal that would have leveled its match against Germany at 2-2, while Argentina took the lead against Mexico with a goal that was clearly offside.

Associated Press, June 28, 2010

If you still had any doubt about the arrogance of FIFA, this should resolve that quandary. I would think that the Swiss Mr. Bladder (intentional error, because the lines he spouts sound a lot like the organ’s contents) would be grateful that he got a “Thank you” from the English. It would have been a lot easier, and probably more appropriate, for the Red and White to say something like “Still got those hidden Nazi bucks bankrolling your election?” (Blatter’s 2002 election to the Presidency in FIFA was surrounded by charges of bribery and corruption.) And as for the Mexicans, I think a head nod was the most gracious gesture possible to someone who clearly feels he lives on a plane far above these mere dark-skinned colonials. I can think of a few other motions that might have gotten the message across more clearly. I’d probably even be willing to help.

In the early 1970s, Blatter was elected president of the World Society of Friends of Suspenders, an organization which tried to stop women replacing suspender belts with pantyhose.

“Sepp Blatter,” Wikipedia, June 28. 2010

Ah, well, that explains it all. If you can’t talk a woman out of her pantyhose, you’ve got to find something else to screw.

Newtonian Sex

2010-06-28T13:51:00.003-04:00

There were plenty of starry nights, but a NASA commander says there was absolutely no sex in space during a mission that brought three female astronauts to the International Space Station.

Space Shuttle Discovery commander Alan Poindexter spoke definitively today on the outer space romance ban during a trip to Tokyo, where he and his team discussed their two-week resupply mission in April.

"We are a group of professionals," Poindexter told a reporter when asked about consequences for space sex. "We treat each other with respect and we have a great working relationship. Personal relationships are not ... an issue. We don't have them and we won't."

Michelle Ruiz, AOL News, June 28, 2010

At one point in my life, I played Professor at Embry-Riddle Aeronautical University here in Daytona Beach. I taught a couple of courses, most notably a three-hour extravaganza called “Human Factors in Space.” The course was designed to explore the physiologic and behavioral aspects of space flight for budding engineers and, like most university courses, I was able to take twenty minutes of material and turn it into twenty weeks of work, plus papers and a two-hour final exam.

(As you can guess, the ERAU curriculum is aviation-focused, with most students getting degrees in aeronautical science…pilots…aerospace engineering, aviation management, meteorology, that sort of thing. It’s a very good school, and if The Child chooses any of those career fields I’d be happy to have him go there, despite the added burden of doing his laundry for yet another four years. But knowing the students well does create some problems when they graduate. About eight years ago I was on a commuter flight from Daytona to Atlanta when I heard a voice in the cockpit say, “Hey, doc!” It turned out that the First Officer was one of my students, one who had gotten a C minus only out of my good graces because I figured he was such as slouch that he’d never wind up in a position of responsibility and he was so good spirited about the whole thing that I felt bad giving him a D. To his credit, the flight was about as tranquil as it could have been. It was also the most unnerving fifty-two minutes I’ve ever had in an aircraft.)

Being that the class is full of hormone-addled collegians, it was obvious that they were going to ask about sex in space. That’s why I made sure the lecture was noted on the syllabus, so I could avoid having to keep answering the question until the appointed time. But Isaac Newton could have predicted all you have to know about having sex in space.

Think about sex. Now wipe the smile off your face (assuming you are smiling…I do extend my best hopes for you) and think about the mechanics of sex. Not only do two people have to come together in an intimate way, but they have to be able to stay together and they have to be able to move against one another. On earth, that’s not a problem. If one partner is on top of the other, in whatever configuration might be, gravity keeps them in place; and even if the partners are on the same level, if you will, gravity keep them pinned to whatever surface they happen to be on, whether it’s a bed, a floor, or the backseat of a 2003 Saab 9-3.

In space, gravity is not a factor. (Technically, it actually is a factor, but not to the extent where it’s noticeable on most routine activities. If gravity weren’t in play at all, spacecraft wouldn’t orbit a planet, but would just shoot straight out into space. The more appropriate term is microgravity, not “zero-G.”) So if two people come together, they will not do so on a surface because there is no gravity to keep them there. Instead, they will tend to “float” within whatever enclosed space they inhabit at the time. Floating sex sounds like a lot of fun, and I suspect that it would be. However, if you’re floating abut, and one partner thrusts forward, Newton’s Third Law (the “equal and opposite reaction” one) suggests that there will be a corresponding movement in which the other partner will be pushed backwards, not only seperating themselves from their desired but also slamming against whatever wall, container, or overhang happens to be nearest in the direction of flight. They way to avoid this, and biomechanically the only way to have efficient sex in space (this was a human factors engineering course, after all) is to indulge in a bit of goal-oriented bondage play, restraining one partner to a solid surface with straps or tapes while the other secures his or her position through the use of brackets, handholds, or some other way to hold the body in place.

So what’s the real answer to the question, “Has anyone ever had sex in space?” We know the official answer, as well noted by Commander Poindexter. The real answer, of course, is “Not that we know of.” Let’s be frank…there have to have been times when there was some definite attraction between members of mixed-gender flight crews. (I’m excluding pathological attraction involving cross-country drives and the use of astronaut diapers to stalk your beloved.) So if I’m really attracted to the girl working the robot arm (and you can take that any way you wish), do I want to give it a shot, especially with the radio to Houston off and the good graces of my crew members? You bet I do. And if I was not one of the involved parties, would I be willing to go down to the middeck, close the hatch, and put on some earplugs so my colleagues could have a half hour to themselves? Absolutely. (Although the ear plugs might prevent me from hearing some really good lines, like “I felt the earth move,” because it is, and “I feel like I’m floating on air,” which you are. Which are better lines than “I hope this duct tape peels off,” and, “Gee, when we’re locked up here together for two weeks without a shower, you do pretty much smell like a gym locker.”

I think we should explore these issues with the same intensity we devote to learning the hidden story of Jake and Vienna (whom I do not know personally, but have seen on three magazine covers this morning at the local bookstore and found myself intrigued that a girl should be named after a sausage). Personally, I want to know these things not because I am a voyeur, but a scientist. When our sun goes supernova in a few billion years, the continued existence of the human race may depend on our interstellar procreative prowess. And how else to you learn stuff besides experiment and observation? I hereby volunteer to go up and try it. I’ll take notes. You can even make a video. But that astronautess had better be smiling.

Basic Instinct

2010-06-27T08:01:00.000-04:00

A 2-year-old octopus oracle — born in England, but raised in Germany — has predicted a German win over England in Sunday's World Cup game.

The mollusk named Paul chose a mussel out of a water glass marked with the German flag over a mussel in a glass with the English St. George's Cross, said Tanja Munzig, a spokeswoman for the Sea Life Aquarium in the western city of Oberhausen, on Friday.

Paul has proven to be a reliable oracle in the past — he predicted Germany's win over Australia and Ghana and its loss to Serbia. During the 2008 European Championship, he predicted 80 percent of all German games right, Munzig said.

Associated Press, June 26, 2010

Being of a medical mind, this animal prognosticator made me think of Oscar the Cat. As you may know, Oscar has been written about in the New England Journal of Medicine:

Since he was adopted by staff members as a kitten, Oscar the Cat has had an uncanny ability to predict when residents are about to die. Thus far, he has presided over the deaths of more than 25 residents on the third floor of Steere House Nursing and Rehabilitation Center in Providence, Rhode Island. His mere presence at the bedside is viewed by physicians and nursing home staff as an almost absolute indicator of impending death, allowing staff members to adequately notify families.

David Dosa, MD MPH, NEJM, July 26, 2007

Oscar is even the subject of a book which not only tells his story, but also offers lessons in caring, compassion, and end-of life care. That being said, I think the best end-of-life lesson I can learn from a cat is not to smell like tuna, and I will shortly be adding to my medical power-of-attorney form a codicil specifying that should I be placed in a nursing home, an attendant will be paid to place an open can of Little Friskies at the other end of the hallway three times each day (once per shift).

Oh, wait, back to the AP article:

Other animal oracles in German zoos cannot claim such a strong track record.

Nineteen-year-old hippo Petty falsely predicted a German win over Serbia last week. She had to choose between two piles of hay with red apples on top at the Chemnitz zoo in eastern Germany and nibbled from the wrong pile.

Tamarin Anton, a monkey at the same zoo, chose the wrong raisin a few days ago, incorrectly claiming that Ghana would beat Germany, kicking it out of the World Cup.

Not to mention the schnauzers that predicted the outcomes of the last two World Wars. As memory serves, Germany didn’t fare too well in those matches, either.

Rule Britannia!

A Lego Note

2010-06-26T07:58:00.004-04:00

Yesterday in the car The Child was telling me he had read that if you have 16 Lego bricks, each of them a little square with four studs on the top, there are enough combinations to keep you busy for a lifetime. So I’m not surprised by the infinite variety of things he comes up with given his three full drawers of pieces and parts collected over the past decade. In fact, this weekend he built a Lego museum, complete with exhibits on zoology, the wild west, life on Mars, an armory, a pirate ship, and a gift shop.

Yesterday he was puttering around with his toys…actually, he was stalling because I had asked him to clean up his room before going on a mission to seek pizza…and he brought out a small pink and yellow helicopter to show me. “What do you think, Dad?” he asked. “I call it the Chopper of Doom.”

I looked at the model, which was indeed a very convincing helicopter. He had, however, constructed it from pink and yellow bricks that I think came to us as some kind of Happy Meal toy. The sloped brick that represented the front window of the cockpit had an imprinted picture of a female being with blond pigtails, yellow flesh, and a bill.

“Son, you can’t call it a Chopper of Death. It’s pink and has a girl duck for a pilot.”

“What can I call it, then?” he asked, whipping it up and down in a flight path designed to poke out an eye.

I thought for a moment. This is a formative stage in his life, and I don’t want to say anything negative about the female end of our species. I want him to inculcate a sense of respect towards women, as well as a secure sense of his own gender identity. So I settled on something that I thought was pretty clever.

“You can call it the Chopper of Feminine Quack.”

He liked this a lot, and soon we came up with a theme song for the inevitable television show that will result when news of his creation spreads to the coast:

It’s the Chopper of Feminine Quack!
It’s the Chopper of Feminine Quack!
It’s pink and it’s yellow and it’s flown by a duck.
It’s the Chopper of Feminine Quack!

Because this is Lego, however, the chopper soon became boring. Which is why, within minutes, there was also the Killer Robot of Feminine Quack, the Airplane of Feminine Quack, the Speedboat of Feminine Quack, the Other Slightly Different Helicopter of Feminine Quack, The Seaplane of Feminine Quack, and the Guided Missile of Feminine Quack.

Thank the Lord there were only 9 pieces in his model, or this could go on forever.

Bored by the Board

2010-06-25T08:40:00.000-04:00

Libertarian ideology rejects most of the modern regulatory systems that protect consumers, because everyone should be responsible for determining whether the hamburger contains E. coli on his own. But does that do-it-yourself dogma apply to the regulation of medicine, too? If you're Dr. Rand Paul, practicing ophthalmologist, the answer is emphatically yes.

According to an amusing story in today's Louisville Courier-Journal, the Kentucky Republican Senate candidate bills himself as a "board-certified" physician even though he is not actually certified by the American Board of Ophthalmology -- the only recognized body that certifies doctors in his specialty.

Paul's only certification was provided instead by something called the National Board of Ophthalmology, which is very convenient because he operates that organization himself.

Joe Conason, Salon.com, June 14, 2010

Most doctors in this country are board certified in something. In a nutshell, board certification means you have met certain training requirements and passed some kind of exam that qualifies you as a specialist in the field. In my case, becoming certified by the American Board of Emergency Medicine (ABEM) means I completed a three-year specialty training program and passed both a multiple-guess written exam and an oral exam consisting of a wide variety of patient scenarios. (Needless to say, the issue of being board certified and being certifiably boring are two separate discussions.)

ABEM was one of the first boards to require recertification. It was easy for them to do, as it was a relatively new specialty with no one who had been certified very long when the decision was made. As a result, nobody felt too inconvenienced. It was different for organizations like the American Board of Internal Medicine (ABIM), where there were already thousands of physicians out there who were certified once under a “one-and-done-for-life” agreement. If they suddenly required 20,000 physicians who had been functioning just fine for the last 40 years to spend their time and money on a new exam, they would have had a wholesale rebellion on their hands. So according to one of my ED colleagues who started life as an internist (he’s much better now), the ABIM sent everyone who was already certified a postcard that had two boxes on it. If you checked one box, you could take the exam again every decade or so, paying a hefty fee for the privilege. If you checked the other, you never had to see the inside of a test booklet for the rest of your natural life. Guess which one most people chose.

The next step is to add a component of continuous learning to the certification process. Most states already have Continuing Medical Education requirements, where you need to be able to document participation in so many hours of CME each year. But these requirements are written for physicians in general and do not relate to the individual specialty. Organizations such as ABEM are looking to fill this gap. For example, I am now required to read a selected panel of articles each year (for no CME credit, by the way), and then pay a fee ($95.00) to take an on-line test. If I do this successfully eight out of the ten years of my certification, I get to pay another fee to take a longer 205 question on-line comprehensive exam, which may or may not have anything to do with the articles I’ve read, for the low, low price of $1,715. If I miss one of the yearly exams, I can take an even longer written 305 question exam for the bargain price of $920. If I miss two or more, then I get to take the longer written exam and an oral recertification at a total cost of $2060. (But wait! There’s more! If you act now, we’ll throw in an amazing spiral slicer!) Interesting to note that it’s cheaper not to do the continuing process…there’s not exactly an incentive to participate.

The recertification process can be a pain, but I really don’t have a problem with it, at least in theory. (That being said, I’ll be perfectly happy to trash the system in the few months before I take the higher-priced exams with my money going to who-knows-where to do-who-knows-what except to make my life more miserable than it has to be, and Lord help me if I don’t use a number two pencil or blacken the oval completely.) But the next step in the evolution of board certification in emergency medicine is clear argument against intelligent design. It’s called Assessment of Practice Performance, or APP, and on the surface it’s not too bad. It’s supposed to assess competence in patient care, communications, professionalism, and practice-based learning through participation in quality improvement programs. Clearly, these are good things to know.

The part that bothers me is that these APP requirements apply only to “clinically active” diplomats of the board. What this means in practice is that if you’ve you’ve managed to get yourself out of the ED and into a comfy executive chair on the administrative floor, there’s no need to ever prove your clinical competence again. I have a real issue with this, as I have always been of the belief that no matter how high you rise in an organization, at some level you should still be able to do the job you were originally trained to do. So if you started out as a copier repairman and are now Chairman of IBM, you should still be able to fix a copier. I wouldn’t expect you to become a corporate accountant or a software engineer, even though your position in the food chain may be over those departments. But you ought to be able to fix the copier, and should go out of your way to do so every now and then. It “keeps it real,” as it were, and it’s incredibly difficult to lead with credibility when you are no longer able to work under the same conditions as those you‘re trying to direct. (That’s one of the main reasons I continued to do ED shifts while working full-time positions in public health.) If you’re unable to continually demonstrate competency in your original position, why should anyone assume you are competent in a higher post? And it certainly seems disrespectful, if not arrogant, on the part of non-practicing physicians to hold those doctors who actually see patients to a higher level of qualification despite the fact that they all present the same credential to the outside world.

And that’s the problem with the new scheme. Allowing those physicians who no longer see patients to hold themselves out as clinically competent ED docs (as the board certification would suggest they are) is contradictory at best and, in my mind, frankly disingenuous. But even if ABEM does the right thing and makes all diplomats meet the same standards, there’s always hope for those NPC (No Patient Care) docs. We can just ask Rand Paul to come up with another board or two…

Absence Update

2010-06-24T15:32:00.000-04:00

Writing With Scissors has been under the weather due to a viral syndrome. Fortunately, with rest, a lack of fluids, and a good scrubbing, it is on the road back to health. Now I just need to argue with the Sprint people that their system has a "redirect" virus implanted into their network, because I only seem to get pointed to search engines that offer me the opportunities to purchase photos of "girls near you" in various relationship states when I'm on the network and not when I use the wireless service in a coffee shop or so. Not to mention, of course, that the enitre sytem is now slower than Congresisonal action on immigration reform. They will, of course, tell me that I'm wrong, and refuse to do anything to help. A royal battle will ensue. You know how if you have a bad week to start with, you actually look forward to yelling at someone? That's us.

A Note for Father's Day

2010-06-20T16:19:00.000-04:00

Every family has traditions, and chasing the ice cream truck is one of ours. My father taught me to do so when I was a kid, and now The Child and I have perfected the art of stalking the frozen treat. So it was no surprise that we spring into action today when we were on the beach at Daytona. The Child heard the truck first, and I spied it coming up the beach lanes towards our Base Camp. I jumped out in front of the van to bring it to a stop, while he went for the backpack to get the money we’d need. And forty-three seconds later, his pace slowed by an arthritic right knee but his enthusiasm undimmed by age, my father came lumbering up the beach.

You know how you have those moments where you wonder how you could ever be related to those people who claim to be your parents? This was not one of those times. There is no question that these three generations of men were united with one goal in mind: To pay the highest price possible for an ice cream on the beach. And because we are men…Rodenberg Men…we did just that.

Happy Father’s Day to one and all.

Let's Twist Again

2010-06-19T01:12:00.000-04:00

The other night at work a nurse brought me a prepackaged table that had been found lying unguarded on a counter near the new drug storage cabinet. “What’s this?” she asked, holding out a blister pack containing an oval, pale yellow tablet.

A bit of skillful detective work (we flipped the package over and read the label) found the tablet to be benztropine, otherwise known as Cogentin. The nurse can’t be blamed for not knowing what it was. It takes a wily and experienced (translated as “old”) clinician like me to fully tell its’ tale.

The story of Cogentin actually starts with the older antipsychotic medications like chlorpromazine (Thorazine) and thioridazine (Mellaril). The science suggests that schizophrenia and other psychotic states are caused, at least in pa art, by excess activity of a chemical called dopamine within the brain. Thorazine, Mellaril, and other older, “typical” antipsychotics work by blocking the action of dopamine within the frontal cortex and limbic system, portions of the brain involved in thought and feeling. But dopamine is a two-edged sword. Excess dopamine activity may lead to schizophrenia, but one of the hallmarks of Parkinson’s Disease, which is primarily a motion disorder, is a lack of dopamine within the deeper structures of the brain that control movement. As a result, even appropriate doses of antipsychotics can result in problems, which fall under a broad heading of “neuroleptic-induced movement disorders.” Cogentin is one of the medications used to control these side effects.

I learned about these problems for the first time on my med school psych rotation. At Western Missouri Mental Health Center (“Listening to the Voices in Your Head Since 1899”), the locked 4th floor was the hotbed of schizophrenic activity in Western Missouri. At the time, the preferred treatment for schizophrenia...or at least the only one I heard about…was to give as much Mellaril as you could find, followed by Cogentin for the inevitable side effects. This was the sole treatment plan authorized by our attending physician, who had an encyclopedic knowledge of Mellaril and a fully anencyclopedic knowledge of any other psychotherapeutic drug on the market. This is during an era when the number of effective drugs you had to know about was probably seven, and while it was known that brain chemistry probably had something to do with mental illness, most likely what really made you nuts was that your id had gotten into a fender bender with your superego and was contacting the Oedipal Law Firm to sue your mother or something like that. But once I had figured out the predominant treatment plan, it suddenly made sense why Father Marshall, who I thought was merely the Catholic Chaplain at the hospital, had a tongue that constantly darted in and out from between his lips like a garter snake and seemed to be talking to no one in particular at any given time.

(It was also one of the peculiarities of the time…and it still may be, I don’t know…that all the attending physicians and residents in psychiatry were foreign medical graduates. It always puzzled me why, in a specialty where communication and cultural sensitivity is probably more important than any other, the majority of doctors couldn’t speak the King’s English, let alone mine. But on occasion we were able to use this to our advantage. We’d tell patients who were destined to spend some time at Western Missouri…WoMo…that, “there are doctors there from all over the world that are here to take care of you.” That would hold ‘em long enough to get across the street.)

Most of time in the ED, these side effects are simply interesting things to note. On occasion, however, they present as a real live acute condition. People who have never been exposed to high-potency antipsychotics before may suffer from what’s known as a dystonic reaction. Dystonia results in contractions, twisting, and contortion of the facial muscles and the extremities, the same look you might find in Tea Partiers who inadvertently strolled into a showing of the Hustler Classic “Who’s Nailin’ Palin.”

The Golden Age of Emergent Dystonia in the 1990’s was a result of a marketing error. Haloperiodol (Haldol) is a potent antipsychotic that works by in a manner similar to Thorazine. Diazepam (Valium) is an anxiolytic and muscle relaxant that causes drowsiness. Both of them were small blue tablets. So when you were having trouble getting to sleep, your friend with the “thinking problems” gave you one of their small blue tablets that were “just like Valium.”

The folks who made Valium were understandably concerned that their tablets were getting mixed up with Haldol. So they decided that they would distinguish their product by cutting as small “V” into the tablet. At the same time, the makers of Haldol wanted to be sure that their tablets were not being mixed up with Valium, so they cut a small “H” into their tablets. Given that both tablets were the same color and about a third of an inch wide, this precaution had no effect at all.

Dystonia is actually really fun to treat. It’s one of those rare “instant cures’ in the ED that make you look like a total ace. The patient comes in all twisted and looking like The Elephant Man without the lumpiness. They are scared to death because they can’t control what their body does. But an intravenous injection of diphenhydramine (Benadryl) literally fixes then within about two minutes. One fun thing to do is to give the medication, wait fifteen seconds and then ask the patient to slowly recite the alphabet. You can actually see their bodies relax and hear their speech clear up as they go, and by the time they hit M they’re all better. When this occurs, they cannot be effusive enough in their praise of you. (These are the patients who go to Steak n’ Shake in the middle of the night and are so happy not to be deceased that they bring you a Double Steakburger and an Orange Freeze without you even asking.)

There are better medications out there now, antipsychotics that work through several different mechanisms at once and pose much less risk of harm to the patient. Still, it’s sometimes sad to see our quick fixes go by. There are so few opportunities for heroism in the ED, or at least heroism that the patient is aware of. It’s a truism of the ED that when you actually save a life, chances are the patient is too far out of it to have any memory of you. The doctor who gets the credit is the first one they see when they wake up. Especially if his tongue flicks in and out like a snake.

Job 51

2010-06-18T11:50:00.001-04:00

Griping about work seems to be a universal human trait, and even those who have followed the oft-given advice to “follow your dream, and the job will appear” I’m sure have days when they feel like their drowsy fantasy has become a living nightmare. I’m guilty of these kinds of thought as well. Consciously, I know that working in the ED is a good job. Fine pay, no call, mild respect, occasional stress, and an excellent sense of “work family” found nowhere else except maybe law enforcement and the military. Yet there are more days than I care to admit where I don’t want to go in and face the next patient who’s been sick forever (presumably since the Korean War…and if it was service-connected, they'd be at the VA) and give the patented two minute spiel entitled “I can’t fix you in the ED today.”

That being said, I’m often amused by small gift books such as “50 Job Worse Than Yours,” which includes such occupations as Chick Sexer and Maggot Wrangler. But I think I’ve run into Job 51. It is:

Arena Marshall at Q-Zar Laser Tag in Tampa, Florida

I learned this about a year ago at a birthday party attended by my enthusiastic “Look-Dad-I-won-enough-Skee-Ball-tickets-for-a-plastic-snake-I’ve-named- Constantine” son. (I think he plays Age of Empires II waaaaaay too often). One of the perks for parents in the new trend towards activity-focused birthday parties is that the old folks usually get to play, too. So at the insistence of The Child, I joined his party group (“D-man’s Team.” Apparently even small suburbanite children get rapper names) for a round of light amplification by stimulated emission of radiation mayhem.

The concept of laser tag is relatively simple. You get a laser gun and a plastic vest. The vest has a flashing square on the front and the back. If another player’s laser hits you on the square, you are “hit” and your gun goes inactive for a few seconds. If you run out of lives (which I did four times in the space of a fifteen minute game, and that includes a good eleven minutes of cowering in a corner…see below), you have to run to a recharge station and get another life by waving your gun in front of a piece of plexiglass. No, I have no idea how it works.

You start by getting a briefing on the rules. The briefing room has five tiers, divided into a green side and a red side, each holding about twenty combatants. Once the players have filed in, the Marshall arrives. Her job is to deliver a briefing about the rules. She has to do so to twenty screaming ten year old boys per side, pre-fueled on ice cream, hot fudge, soda, cake, and the general hubris that comes with an absence of parental supervision, the acquisition of firearms by preadolescent males, and the winning of plastic snakes named for Roman Emperors. She has to explain to this seething mass of testosterone and sugar that there will be no yelling, no running, and no physical c0ntact. She does it saying she will throw the person out. She has to do it at least sixteen times each day.

The job doesn’t end with the briefing, however. During the game, she has even more duties. They include explaining to befuddled parents how the trigger works, why your vest is on backwards, and walking about holding a child’s sleeve with her right hand and that of an angry parent with her left, stopping every adult to ask, “Is this one yours?” (Fortunately, for once the answer was no.) And the look on the poor girl’s face would have blunted the sharpest edge; the desperate gaze of someone who knows this job is not a resume builder, not a step towards middle management, and not even a way to meet cute guys at the mall; the look that says she knows all a job at Q-Zar will do for her is give her a severe case of night blindness and a desire to, no matter how much she may love any future offspring, absent herself completely from any parenting activity from ages 8 to 37.

I was repeatedly tormented by a very large prepubescent girl who took great delight in firing about forty billion laser beams at me just after I recharged my gun. What’s more embarrassing is that, despite the clear evidence of her cardiac and diabetic risks, I still couldn’t manage to hit her “broad side,” or any side. I was also stalked by a thirty-something parent with extremely large teeth that glowed green in the black light of the arena who would pop out from behind obstacles and barriers and cry, “Hahahaha! Gotcha!” as if this was the singular thing that gave him pleasure in this world. (For the record, I use the “singular pleasure” theory a lot to justify the behavior of others. For example, I used to get a lot of parking tickets form campus police when I was teaching at the University of Florida. For no good reason other than sheer obstinacy I would not pay them…I mean, they already used my taxes to build the parking lot…and so once every six month or so a campus “kiddie cop” would come swaggering by and demand payment. Rather than get mad, I just figured that if calling a doctor out on his tickets was as good as they got in life, why deprive them of the moment? So I would hang my head, and apologize profusely, and even generate a sniffle of true remorse. They would give me thirty days to pay up, but which time a new cycle of ticketing would have started all over again.)

It turns out that the only way to avoid getting hit all the time is to curl up on the ground with your back against a wall, cross your arms over your chest, and hope nobody sees you. If course, you can’t shoot at anything, either, but I found some comfort in adopting a Ghandian non-violent approach to death by tag rather than raging, raging, raging against the tagging of the light.

In the end, it turned out that our team had won despite my efforts to the contrary. But that should not deprive you of the right to brag about all the wonderful heroics to which you were never a part. At Q-Zar, however, you can’t even maintain that illusion. Your score is electronically recorded, and at the end of the match they give a printout you’re your statistics on it. Everyone compares cards, and failure to do so invites suspicion. So in fairly short order The Child learned that the Great and Powerful Father was far and away the worst player on the Green Side, with a whopping hit percentage of 14.9%. I think this is slightly worse than Mr. Ed, and we know how hard it is to shoot with hooves. I comfort myself with the knowledge that the guy who graduates last in his med school class is still called doctor, and that people like Jim Sorgi still get a Super Bowl ring.

Thank you, Q-Zar. I’m more grateful for the job that I do…and for the one that I don’t.

Cubby and Me

2010-06-17T13:07:00.000-04:00

A little-known fact about Daytona Beach is that it is the home base of the Class A Florida State League. Our local entry into the minors are the Daytona Cubs, and an evening out at a Cubs game is truly one of the real pleasures of summer here on the Fun Coast.

I love going to watch the Cubs games, and usually get to five or six games each year. Certainly some of it is the baseball, and for the same reason that college basketball can be so compelling where the NBA is not. The players are mostly young kids. A few are high draft picks, and are merely collecting experience (and signing bonuses) before their inevitable promotions. Some of them are trying to prove themselves, striving to climb the ladder to the major leagues. Sometimes they will play spectacularly, and sometimes they will act like boneheads as they try to master their trade and impress scouts from the next level of play. But most of the players know that this is as far as they go, so they play to play with a totally different, and incredibly refreshing, attitude than those who have already “made it” and for whom playing ball is not a dream, but a career.

I also have a soft spot for our ballpark. Jackie Robinson Stadium (known as “The Jack”) is a very minor league place, and it shows. It’s old and charmingly on the shabby side. But that’s the fun of it all. The stands along the first base line dwell under a tin roof, complete with netting across the front and the required obstructed views from the green support beams. Those who live dangerously will opt for seats in the bleachers behind the home dugout, and work without a net. The bleachers back up onto a channel of the Halifax River, and if you listen closely you can hear foul balls sailing over the heads of the fans hit the concrete in front of the concessions and plunk into the water. Fouls tips on the right bang off the tin roof en route to hitting someone’s boat at the marina on the opposite side of the street. If you sit up high enough, you can look out over the palm trees just behind the outfield fence and see the high bridge over the gleaming waters of the Halifax River offer safe passage down to the beach. On a really good day, you can even catch the smell of the ocean and a soft maritime breeze coming in from right field. It’s an idyllic spot to watch a ball game on a warm summer night; and compared with other new, cookie-cutter minor league parks built in the middle of urban renewal or surrounded by suburban parking lots, it’s a very pleasant world away.

(By the way, we’ve been discussing the General Admission seats. They cost $7.00…$6.00 for students and seniors, although if your child has an “A” on his or her report card he gets in free. The twenty-four box seats are $12.00 each, and feature both a designated waitress and a freestanding folding metal chair that you can turn to any angle you please. Maybe if you’re lucky you’ll meet Front Row Joe, who has recently broken the 1,020 mark for consecutive games attended at The Jack.)

The other thing that’s so great about a Daytona Cubs game is that there is no pretense whatsoever that this is a major league operation. I do understand that minor league ball is a growth industry, and that there is often little difference (but for price) in the experience between attending a game at a major league stadium or a new minor league park such as Steinbrenner Field in Tampa or Victory Field in Indianapolis. But I’ve always thought minor league ball belongs in minor league places, and cities like Daytona fit the bill. (I think our logo of the team…a polar bear wearing sunglasses…is also just way too cool, and fits our team in a way you can only do in the minor leagues. Like anyone ever took seriously an NHL team called the Mighty Ducks of Anaheim? Please.)

This lack of pretense carries over into promotions and between-inning activities. (It goes without saying that at the Class A level, the singing of the National Anthem is an adventure every night.) At major league parks, promotions are sponsored by telecoms and major banks. Last Wednesday at The Jack, it was Radiology Associates Dollar Ice Cream Night. Radiology Associates are the x-ray physicians I work with in the ED, and since I have given them so much business over the years I was delighted to take their ice cream at half price. I figure this is worth an acknowledgement, so when the PA Announcer notes that “Dollar Ice Cream Night is brought to you by Radiology Associates, I get up and shout my thanks. “Hooray! CT scans! Hooray! MRI! Hooray! Transvaginal ultrasound!” It was a sparse midweek crowd so, for better or worse, there were few people about to share my enthusiasm.

(Ice cream also goes surprisingly well with Woodchuck Cider, which is sold from a tap stuck into the side of a refrigerated trailer next to the Italian sausage grillers just under the third base stands. Woodchuck and other adult beverages are especially cheap on Thirsty Thursdays, when a 32 oz cup is only $4.75. I’m just sayin’.)

In between innings, there are all kinds of things to entertain the crowd, but again these are done in an intimate, informal, let’s all just hang out together sort of way. There is no Jumbotron, no scantily clad salsa dancers, no KissCam, no random shots of the crowd so people can wave frantically at themselves. Instead, as befits the home of the Daytona 500, we do a lot of racing. There are games such as the burrito speed-eating contest, the “Little 500” involving small bikes and traffic cones, the “who-can-put-on-a-frozen-t-shirt-first” race, and the “Who Let the Dogs Out” run, where kids take off from behind first base, run across right field to touch a “Metro PCS” sign on the wall at deep left center, and then leave the field along the warning track. (There’s always one for two little kids who don’t make it across the grass before the first pitch of the new inning gets flung.) And then there’s the nightly humiliation of our mascot Cubby as he races a small child from first to third. (Cubby’s record over the past six years: 0-137.)

My favorite game is called “Crabs In Your Pants.” There are two teams, and on each team one player has to stand with his back to his partner and toss stuffed crabs over his head into the oversized pants worn by the other. As a medical person, one can’t help but wonder if after catching the crabs, you shouldn’t throw a bottle of Ridd in there as well. (Public health never rests.) And of course there’s the singing of “Take Me Out to the Ball Game” during the Seventh Inning Stretch, led by a random fan from the stands and which, like the national anthem, is both a nightly tradition and an adventure.

The game was actually pretty well played, with the Cubs behind by a single run going into the top of the ninth. Then the Port Charlotte Stonecrabs got three more runs, and it didn’t look good for the Cubbies. I don’t think of myself as a “fair-weather fan,” but I also hate being witness to the agony of defeat. So I started to head out towards the parking lot (which during the daytime serves the courthouse and the public library), looking over my shoulder the whole way because I had this idea in my head that Cubby would spot me walking out and accost me for my disloyalty. I felt like I was less in danger when I saw smoke coming from behind the left field fence. It may just have been the cigarette from the guy who puts up numbers on the scoreboard, but I thought that perhaps Cubby was trying to organize a rally with the Radiology Associates Aztec Ritual Sacrificial Fan of the Night. (“Hey, Cubs fans!” Turn to page 6 in your program! If you see a picture of Huitzilopochtli, say your farewells and report to Guest Services behind home plate!”)

Some people will just do anything to win.

Health Care Reform: After The Fact

2010-06-16T07:04:00.000-04:00

Well, it finally happened. After all the Tea Parties, the Coffee Clubs, the Lemonade Lounges, and the Beer Bunches, Congress went ahead and passed health care reform. It’s now the law of the land. I’ve been avoiding trying to think too much about it. Frankly, one reason is because that in my brief career in public service I’ve enjoyed working with people from all parts of the political spectrum, and taking any hard and fast position is bound to annoy someone I like and respect. It’s probably selfish on my part to put personal relationships over politics, but its reality. I’ve always held in my mind a lesson learned from friends in South America. I couldn’t figure out why they never wanted to talk about the subject at hand when I hit the door, but were perfectly content to wait days, even weeks, before really getting down to work. “Friends first, then business,” was the reply. Since then, it’s always seemed like a better way to run my life.

A second is probably some guilt over not really having a position, or at least one that I’ve publicized. Sure, I’ve nibbled around the edges, but that’s about all. I’ve learned that one of the privileges of having your own blog is the ability to take shots at everyone without actually having to put your own opinion on the line. The third, and probably most important reason I tried to avoid comment is that I’m honestly not sure what I think, and I’m honestly not sure why I’m not.

But after some weeks of reflection, I feel like I ought to say something. It is the largest piece of social legislation since Lyndon Johnson’s Great Society, and (more to the point) it affects me both personally and professionally.

So here’s the bottom line. All citizens of the United States should have access to a basic level of health care. Nobody should be denied access because they are unfortunate enough to have a chronic illness or condition. The new law is a major step forward. This is an idea I absolutely agree with. Period. Full stop. End of sentence.

I think what bothers me is that I’m not sure the new law will do what it’s supposed to. There’s an employer mandate to force businesses of a certain size to support health care coverage for employees. But if the fines for non-compliance with the mandate are less than coverage costs, why should an employer buy in? Similarly, if an individual finds that the extra bill for not buying coverage is less than the coverage itself, will they still choose to buy? And if someone doesn’t report their lack of insurance to the IRS or doesn’t pay the fine, will the government enforce the law, putting people in prison because they don’t want to buy health insurance? (By the way, medical care is free in prison.)

In a previous blog, I’ve noted that the majority of physicians in this country don’t want to see Medicaid patients in their practice, so it’s hard to see (barring the growth of a new health care sector of high-volume, low-cost Medicaid clinics) how the new influx of Medicaid patients will actually get to see a physician. The administration’s effort to raise primary care Medicaid payment rates to match those of Medicare is a start, assuming that Medicare cuts (a backbone of funding for the new law) don’t dampen the enthusiasm of physicians to accept these patients as well. But unanswered are the questions of access to specialty care under the new legislation, reimbursement for preventive care and counseling, and diminution of medicolegal risk.

And I’m still at a loss to figure out how the law will lower health care costs. If insurance companies are (rightly) compelled to insure those persons with pre-existing conditions, premium rates will assuredly rise across the board. Taxes on medical devices simply drive up the cost of the device. If individuals are purchasing private sector insurance policies with government subsidies, federal expenditures necessarily rise. If employer support for coverage flags, how much more will it require in government subsidies to keep people insured? If new Medicaid recipients are allowed unfettered access to services, costs will spiral out of control. And even assuming that the new law is “cost-neutral” (which is, I think, a suspect prospect), what the estimates do is note that the rate of medical inflation over the next decade will be lower, not that costs will decrease in any way from the present value.

There’s a few philosophical issues as well. I’m not bothered by the issues of increasing federal debt. (I should be, but since it’s clear that neither party in power since 2000 has cared about it, I’m not sure it’s worth my fiscal angst.) The mandates bother me in the sense that I’m not sure I like the idea of being required by the government to buy a private sector product. (I’ll happily leave the constitutionality of that to the lawyers.) I still haven’t gotten over the public bailout of the financial firms that got us into the latest recession, and can’t figure out why once again we’re going to channel more federal dollars to those same insurance companies many blame for being the root of the problem.

But do these objections outweigh the moral correctness of insuring that everyone in this nation has access to health care? Absolutely not. And I wholeheartedly reject the argument that everyone already has access to health care because they can always go to the ED. Having lived my clinical life there, what you get is a screening for emergency conditions and sent on your way. You do not get primary care, preventive care, or anything even vaguely resembling comprehensive care. False statements such as these are used to “cover” for a system that is irrevocably broken. There are any number of fair objections to the way health care reform has evolved. But they do not overtake the basic need for access to care.

I’m also bothered by the failure of nearly everyone…and this is truly bipartisan...to recognize the inherent contradictions in play. Insurance companies are part of the problem, but we’re going to give people public funds to buy their products. Health care access is the goal, but there’s nothing to encourage doctors to see more patients. Cost control is critical, but there are no brakes placed on the runaway train. Improving the health of the nation is the goal, but those measures which can have the most impact on health are ignored. Opponents of the bill were simply that, and offered nothing concrete as an alternative for debate.

But I think the heart of my discomfort lies in the recognition that the new law really isn’t about health. Health is defined by the World Health Organization as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” By way of contrast, health care refers to system of delivery of medical treatments (doctors and hospitals), while health coverage refers one view of how such services are mediated between patients, physicians, and external payors (public and private insurance plans). This distinction is critical to understanding the true impact of the current bill.

Let’s be clear about what has happened. We have started to address the problem of health care coverage. We have not yet begun to address issues of health care quality, health care costs, health care financing, or health care access. The final bill holds provision for panels to study a host of issues, but no definitive statements or policies designed to remedy these problems. For all its volume, the bill is actually quite limited in scope. And any evidence of its effect on health itself is considerably muted.

Supporters of the bill would say that coverage enhances health by insuring access to care. But history has shown us that the biggest factors in improving health, at least in the physical sense that we think of in the United States, is not the existence of an advanced and aggressive health care system. Health is most improved by those measures that fundamentally change the landscape and facilitate healthy behaviors. Updated and enhanced immunizations laws, clear indoor air statutes, the provision of physical education in schools, environmental regulation, mandatory seat belt and motorcycle helmet laws, and cultural change will do far more to promote health than any manipulation of insurance plans.

One of the tasks of the health care community is to help policy makers understand the difference between health, health care, and coverage. Monitoring health outcomes such as life expectancy and infant mortality rates are measures just as key to evaluating our efforts as are persons covered and costs for care.

So in the end, the new law is a significant step forward. (I’m purposefully avoiding the term “Great Leap” because I don’t want to be enmeshed with Maoism or the whole “Obamacare as Socialism” argument which, for the record, it’s not.) I’ve still got some questions. Nonetheless, I support the legislation because it’s the right thing to do. And I look forward to the day our nation recognizes that in the end, health is what really matters. Unfortunately, we’re not there yet.

Hopefully, we can all keep in mind that health care reform is a work in progress. I don’t know about you, but I’m looking forward to the next round.

Behavior Modification

2010-06-15T10:24:00.000-04:00

Kurt Killgore was riding his bicycle across a busy street at three in the morning. He swerved to avoid a truck, fell of the bike, and landed on his right side. The paramedic crew thought he might have a broken collarbone, and rightly put him in a sling. His pain was severe. It was so severe, in fact, that the only way to kill the pain was with sleep. Which he did all the way here during his ambulance ride.

The EMS crew woke him up to move him onto the bed. He opened his eyes and looked straight at me, standing at the foot of the bed. “Hey, man I need something for pain. The damn paramedic wouldn’t give me anything.”

I shrugged. ”Seems to me you were sleeping pretty good.”

“Oh yeah? Well, f…k you. I love you too, man.”

According to the paramedics, he was one of those guys who was full of love for his fellow man. Apparently this duality…carnal lust and romantic affection…was his usual response to anything that was asked of him. Nice to see someone with true joy in his heart. Gives me faith in the human condition. Also good to find that once again my gender identity has been reinforced.

I shook my head and stepped out of the room while the staff got him over to the exam bed, the effort accompanied by much moaning and groaning and use of creative language. The nurses did their part, trying to get some kind of story from him, and trying to start an IV just in case we needed it to do things like, well, treat pain. However, he decided it was much more important to swear at the nurses an occasionally reach out and grab at them instead of allowing us to care for his stated complaint. Finally, it was my turn.

“I’m Dr. Rodenberg. What happened to you?”

“I’m in pain, man. Pain. I need something for pain. And why are these f…..g nurses sticking me for an IV? I need something for my f…..g pain.”

“Can’t give you anything for pain ‘till I figure out what’s going on.”

“What’s your f…..g problem? I’m in pain. I don’t want those b…..s touching me. You better give me something now, man, if you know what’s good for you.”

I took a deep breath, about to begin one of those well-rehearsed speeches I’ve built up over twenty years in the ED. There’s a whole catalog of these speeches. There’s the reassuring, “I don’t know what’s going on but it doesn’t look like anything serious so you can go home,” talk. There’s the hopeful, “Do you think maybe talking to one of our psychiatric staff might help?” conversation. There’s the very sad, “Your loved one is in very critical condition, and while we always hope for the best we plan for the worst” discussion. But the, “You’re being a jerk and I’m not going to put up with this anymore” lecture is one of my favorites.

“Okay, here’s how this works. You know where you are and what’s going on, so you’re in full control of your senses. So you can choose to stop this behavior. If you don’t, and you continue to be abusive to my staff (I get very possessive in these moments; I don’t know why), I’m going to assume that you’re refusing care and I’ll have security escort you out the door. And if you grab at someone again that’s called assault, and the cops will be here to drag you to jail quicker than spit. Are we clear?”

“Man, you don’t…”

“Are we clear on this?

He grunted in a non-threatening way. Care proceeded as it should; x-rays of everything on the taxpayer’s dime, some pain medication to put him out of our misery, and nice dressings over abrasions on his elbow and knee that will soon resemble his socks, adhering to him for the next several years until the breakdown of nuclear forces between the gauze atoms causes them to disintegrate. He was discharged back into the real world with a sling on his right arm for his broken collarbone and admonitions to (chose one or all) get a bike helmet, put ice on your shoulder, use Tylenol for pain, call the local detox center or Alcoholics Anonymous for help with your drinking problem, follow-up with an orthopedic surgeon in 4-5 days for recheck, and go in peace, all of which will remain unheeded.

I don’t know why, but this kind of interaction gives me great satisfaction. While it can’t really contribute to the care of the patient, I can at least make my work family feel protected and supported. Not sure it’s in my job description. Just think of it as a value-added service.

"Forty Kilometers in a Leaky Ol' Boat..."

2010-06-14T08:12:00.000-04:00

A few final notes from Santa Catalina:

The weekend of our visit was not just our anniversary, but also the annual Catalina Island Flying Fish Festival. Apparently the warm summer water breeds lots of kelp, and the flying fish come into the kelp beds to hide from predators and deposit their eggs. The local version of the species is the California Flying Fish, the largest of the class that can top out at 19 inches long.

We took our role as celebrants of this annual extravaganza of piscine aeronautics very seriously. The first night on the island we took the Flying Fish Boat Tour, an hour-long nighttime passage along the southeast coast using searchlights to stir up and sight the fish. In the end, we saw lots of things jump, but nothing chose to fly. But it was still a good tour, and I liked getting out from the town to see some of the hidden infrastructure of the island (power stations, cargo docks) as well as Seal Rock, which is, strangely enough, a rock that seals sit on. The well-practiced guide got off a couple of prime one-liners as well during the safety talk. “See this life jacket? Take a good look at it It’s the only one we’ve got,” and, “You’ll need to stay in your seat because it’s a fire hazard. If you don’t, I’ll get fired.”

Because the fish suffered a failure to launch, I wasn’t able to get up close and personal with a flying fish until two days later at the Flying Fish Festival Parade. It was a little parade as befits a little town, mostly a fire truck with lights on leading a small collection of decorated golf carts and Mini Coopers down the waterfront. The Lions Club Segway Drill Team was there, as were a bunch of preschooler in costume and a poodle dyed pink with cardboard fins stuck on it’s back. Gill the Flying Fish, the festival mascot, made an appearance, and the parade was topped off by the seven members of the Avalon High School Drama Club singing “The Jet Song” from West Side Story.

There was a street fair going on as well, and I really felt it was incumbent upon me to show my support for the fish. So I bought a nylon flag to wave during the parade, and a young girl who was helping her mother in the booth asked if I wanted to see a real flying fish. I did, so she opened up a cooler that had two flying fish in a bed of ice. It turns out you pick them up by their wings, so I did. It also turns out that if you move it’s wings (actually elongated pectoral fins, if you’re keeping score) back and forth, you can make it’s mouth open and close and it looks like it can talk. It was at this point...making a dead fish talk…that The Bride rightfully shook her head at me and moved further off down the block.

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There have been bison on Santa Catalina since a silent film crew brought them over to film a western and never took them off. As a Kansan, bison are nothing new. But I forget that not everyone has seen a bison, let alone a herd of them. So it was amazing to me that when a bison was spotted, the bus tours stop and people spend hours taking pictures of something I’ll quite happily eat.

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There’s a building on the island called the Tuna Club. Founded in 1898, the Tuna Club is the oldest fishing club in the United States. The club’s main goals are "to elevate the sport of fishing to its highest possible standard, and for the protection of the game fish of Southern California.
Located on the edge of Avalon Bay, the Tuna Club is a California Historical Landmark and is on the National Registry of Historical Places. Many notable dignitaries and personalities have been members of the Tuna Club, including Theodore Roosevelt, Winston Churchill, Cecil B. DeMille, Charlie Chaplin, and Bing Crosby (http://www.catalina.com/art_historic.html)."

The Tuna Club originally caught my attention because of some outdoor displays of sea life organized by a research branch of the University of Southern California. This is how I got to hold a sea cucumber, and was reassured that the black sand it pooped out into my hand was actually cleaner coming out than it was going in. (They were scientists, so it must be true. I also hear that USC had a financial relationship with a highly recruited octopus and will not be able to participate in the Goldfish Bowl for the next two years.)

Speaking of the Tuna Club, I never got to go inside. So I wonder what actually goes on in there. Is it the kind of place where tuna go after a hard day at the office, a place to kick back, put up your fins, and snack on a mullet? And what do they talk about? “Man, you wouldn’t believe this guy today. Tried to get me with a plastic worm. Plastic! Can you believe it?” Or maybe, “Sorry guys, gotta go. She wants me swim through the kelp and fertilize the eggs again. All 5000 of them. I’m getting too old for this, you know?” And are all tuna welcome, or do the bluefins blackball the yellowfins? Is Charlie a member?

Yep, sometimes I really do think too much.

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There’s an advertisement for a restaurant on the island called The Avalon Grille that summarized every stereotype I ever had about Southern California. It features an older man with dyed blond highlights and an open shirt and jacket dining with a much younger slender and well-siliconized woman in a red strapless dress. One can just imagine that he’s thinking “I hope the Viagara works this time,” while she wonders just how creepy it is to sleep with someone older than your Dad.

This reminded me an incident about a year ago, when The Bride (who is significantly younger than me) and I were shopping at the Mall of Millennia in Orlando. She was getting a few odds and ends, and I was whipping out the credit card from time to time to pay for them. As we walked by a series of full-length mirrors, it occurred to me that if one were to look at us, this young well-assembled woman in four-inch heels followed a step or two behind by a slightly stooped older guy, one might take us for the folks in the advert for the Avalon Grille. I pointed this out to her, and asked “Do you think anyone ever thinks you’re just a trophy wife?”

Smiling, she said, “If I was a trophy wife, you’d have a hell of a lot more money.”

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On Monday morning we had a very nice walk up to the Wrigley Memorial, a granite and marble structure that overlooks acres of botanical gardens about a mile inland from the Town of Avalon. It was mostly an uphill walk, and so we were both pretty tired when we finally reached the stone staircase at the right side of the edifice. Encouraging each other, we climbed to steps to the top and took in the view. It was only after we turned to make our way back down that we found there were no steps over on the left, only a gentle, undulating slope.

“There’s no steps,” noted The Bride.”

“No,” I said.

“You made me walk up steps.”

(You know how sometimes you can see a problem coming, while also knowing there’s not a silly thing you can do about it? Yeah, this was one of those times.)

“I didn’t know.”

“YOU MADE ME WALK UPHILL FOR A MILE AND THEN YOU MADE ME WALK UP STEPS.”

“Yes.”

“I HAVE BLISTERS.”

“I’m sorry.”

“WHAT ARE YOU GOING TO DO ABOUT THIS?”

I’m still working my way out of this one. Might take another trip to fix it. Stay tuned.

Zip-a-Dee-Do-Dah

2010-06-13T09:41:00.002-04:00

(In the interest of saving time, I’d like to offer you some options as you consider the following entry into The Blog. You can choose to read the short version or the long one. Here’s the short version:

“Brack-brack-brack-braaaack! Bock bock bock bock bock. Braaaack!”

For the longer choice, see below.)

There are a lot of reasons The Bride and I think we’d do well on The Amazing Race. We have lots of complementary skills. I’m good at word games, while she’s good at math. I’ll eat just about anything, touch icky stuff, navigate, and dive. She’ll jump off high places, ride scary things, and drive fast.

These attributes become most apparent when we’re on vacation. Last summer we spent a week in the Florida Keys. We rented a jet ski for an hour, and she really wanted to drive. Which she did…fast…laughing the whole time, while I hung on to her waist like a Harley bitch and screamed my freakin’ head off. She would be heading out into the open sea, and I would be constantly looking backwards to find the marker buoy that indicated the way back. When she would turn about to make another run, I would say something like, “Why don’t we get off and have a swim? (The water was warm, and a quick paddle would delay the next screaming episode for just a few more minutes.) So I would jump off the back of the jet ski and splash about, while she would continually be on the lookout for sharks and rays and barracudas and pirhanas and other things that might skeletonize your feet if you so much as dipped a toe into the briny gulf.

Which leads us back to Santa Catalina, and to one of the many activities that were planned for our stay. Specifically, we are at the base camp for the Zip Line Eco Tour. For those who aren’t familiar with a zip line, it is essentially a set of wires strung between platforms along a mountain. You ride in a harness which is clipped to a pulley, while gravity and momentum take you down the hillside, one platform at a time.

(Before we go on, it’s important to the story that you understand there are things I won’t do. Sitting calmly and adjusting the straps over my nose and mouth when the oxygen masks fall from the ceiling of an aircraft is one of them. Another is a roller coaster. I cannot stand the feeling of falling, and even the thought of a fall causes me problems. And except for seven million years of hominid evolution, there is no good reason why I think a fall from a height is a bad idea. Flying doesn’t faze me, and I’ve got a private pilot’s license of my own. I’ve flown in ultralight aircraft, I want to go parasailing, and to fly a hang glider with a fan-like engine strapped to my back. Skydiving’s also on the list. On the other hand, jumping off the ten-foot board at the local pool drives me nuts. Maybe it’s the feeling of being out of control that gets to me about a fall.

Nonetheless, it’s often all I can do to ride kiddie coasters with my son. Here’s an actual dialogue we had at Legoland, just before riding the Coastersaurus, designed for the youngest visitors to the park. He was six, almost seven, at the time.

Child: “Are you scared?”

Me: “No.”

Child: “Then why are you telling me it’s okay to scream on a roller coaster?”

Me: “Because it shows you’re having fun.”

Child: “So if you scream like a girl, you’re not scared, but you’re having fun.”

Me: “Exactly.”

Child (after ride): “Gee, Daddy, you had a lot more fun on that ride than I did.”

Me: “Yes. I don’t think I can ever have that much fun again in my life.”

Fortunately, it appears that he has inherited my abject fear of coasters, so I don’t have to worry about being around the next time he is forced to ride a coaster, which will most certainly be at the request of a girl. Which is also the last time I rode one. That girl is now The Bride.)

All the above being said, if there’s one thing I’ve learned over the years, it’s how to put up a brave face. (At least until the moment of truth, when the sniveling coward inside emerges from his shell like Botticelli’s Venus arising from the waves.) So I sat there with the rest of the group, chatting amiably about my aversion to roller coaster aversions. Apparently I did quite a job, because The Bride leaned over and said, “Okay, how much of this talk is actual fear and how much of it is you being charming?”

“About 80/20, with fear in the lead,” I replied. This was also an attempt to be charming. The truth is that it was more like 95% charming. I wasn’t really scared at the time, because I thought I had it all figured out.

In retrospect, I thought that zip lining would be kind of like skiing. First there’s a bunny hill where you can’t go very fast or fall very far, and you to use a rope pull to get to the top of the sloe. Then there’s a series of slightly higher inclines and more complex lifts to master until you finally get to the top of the mountain on the longest chair.

So I kind of thought the zip line course would follow the same model. You know, there would be a small line, maybe 100 yards long, where you might be ten feet off the ground. Once you were convinced you probably weren’t going to die (at least not yet), there would be another one just a bit higher and slightly longer. At some point, you might go over a crevasse, but this would be very quick, without any real time to think about what lives in the abyss and how fast it will eat you when you hit the ground.

Needless to say, that’s not how zip lines work. It’s a function of physics, really…since there’s no way to go back up, it starts up high where the ground is steeper and the spaces between platforms are deep and wide. So the first line goes several hundred feet with trees fifty feet below, while the second is a little over 1000 feet long and soars 300 feet above a canyon floor.

It’s a five line series, but all I saw were the first two. This is because the minute I came over the top of the mountain and saw the first station, the edge of the platform and the wire over space, I felt the Angel of Death smiling over my shoulder and froze. Deferred. Made a risk-benefit decision. Or, perhaps more accurately, chickened out.

I’m standing there at the top of the platform, looking out into space. I am not crying. Guys do not cry. We tremble, perhaps, and may on rare occasion weep, but we do not cry. The Bride, however, is in tears, but only for the most wonderful of reasons.

“I can’t go.”

“Oh, if you don’t go, I won’t go either. I don’t want us to be apart on our anniverserry.”

“No, you have to go. You’ll love this.”

(The bus driver who took us to the top of the mountain said the whole thing was very romantic. I’m trying not to cry because I’m terrified. She’s crying because she doesn’t want us to be apart. I’m insisting that she leave me in the throes of a panic attack because I want her to have fun. Could be a Hallmark card.

“To My Wife:

I love you so much, there’s no error.
You go on, I’ll flee in terror."

I’ll take royalties, please.)

While this is going on, any number of passer-bys in golf carts (the preferred way to get about the island) are pausing to watch this romantic interlude. Meanwhile, every time I screw up some courage and take a step towards the platform, I become aware of an impending autonomic parasympathetic discharge. I believe lay people call it a need to barf.

Eventually we got it worked out. I would take a video of her between the first two platforms, and then when she was out of sight I would head on down the mountain and meet her back at the base. It was a great walk with some beautiful views, and I had a great time. Plus, there was no sweating, salivating, or barfing, and all of my bodily fluids stayed within the cavities where the Good Lord intended them to be.

I actually got to the base camp before the group was done with the zip line tour. This was actually the most awkward part of the whole thing. The staff know you were the one who chickened out. You know they know. They know that you know that they know. And so you purchase a large number of zip line tour baseball caps and sweatshirts as an act of atonement.

Please do not let my experience dissuade you from doing a zip line. The folks at Catalina Zip Line Eco Tours were nothing but professional, and I have no doubt that the operation is as safe as it comes. The Bride had an absolute blast. But if they would like some unsolicited advice, how about a bunny line?

PC Police Blotter

2010-06-12T18:18:00.005-04:00

Hallmark has pulled one of its graduation cards off the shelves after the National Association for the Advancement of Colored People complained that it used racial stereotypes and contained an abusive slur aimed at black women.

The card's micro speaker has two Hallmark characters, Hoops and Yoyo, bantering about how the graduate is going to dominate the universe. They tell the planets to "watch your back" and issue a stern warning to "ominous" black holes.

(The NAACP) say that the audio sounds more like "black whores," and that card is implying that black women are not as capable or as powerful as their white counterparts.

Hugh Collins, AOL News, June 12, 2010

Groucho: "Now down here are the levees."
Chico: "That's-a the Jewish neighborhood."

The Marx Brothers, Cocoanuts, 1929

I haven't heard the entire message of the Hallmark card, so I can't comment on what it does or doesn't say. However, I do find it interesting to note that the Anti-Defamation Leauge of B'nai Brith did not issue any charges of anti-semitism when the disaster in New Orleans was blamed on the failure of the levees. Nor do I recall a large outcry from the gay community when there were clearly problems with the dikes.

Echolalia

2010-06-11T16:45:00.000-04:00

Here’s a linguistic memory of Santa Catalina that will stay with me forever.

You know how certain phrases become keynotes for a relationship or an event? For example, The Bride and I have developed our own language of metaphors that reflect certain moments in our lives. For example, one of them is “Learn, learn, learn. You can learn at the fair!” This came about during our first trip to the Kansas State Fair in Hutchinson, where we got a firsthand look at cattle restraints. (You don’t think they just stand there for branding, do you?) Another is the phrase, “Gee, maybe someone could made a two-dimensional graphic representation of that,” based on the time I got us lost in downtown St. Louis looking for the Bowling Hall of Fame because I refused to look at a map.

This happens outside of the marital bond as well. I was in Israel on a public health preparedness study tour about three years ago. What we found was that every speaker began their presentation by noting that “Israel is a small country, about the size of New Jersey.” It got to the point that even before a speaker would start, one of us would raise our hands and ask, “Is it true that Israel is a small country, about the size of New Jersey?”

(It was a great time, and I did indeed “learn, learn, learn” that for us, preparedness is a hobby. For Israelis, it’s a way of life.)

In Santa Catalina, one of the mad-made landmarks is the Casino, a strange hybrid of Renaissance and Art Deco that somehow manages to outshine both its parents. (However, just like a mule, I suppose it is unlikely to reproduce.) It sits on a rocky point just to the edge of town, and it’s one of those things that are always in view. This means that every bus driver, boat guide, kayak instructor, and street vendor reminds you that “Casino is an Italian word meaning gathering place.” I think there is probably something in the law of the island that says if you do not repeat this fact once every three hours, you will be deported to the mainland and given a choice of jobs as Lindsey Lohan’s probation officer or Head of Risk Management for BP.

While the phrases by themselves are amusing, the problem is that when you build up a repertoire they end to run together. So by the end of the trip, I would look out over the harbor of Avalon at this wonderful Mediterranean structure, and note that “Casino is an Italian word meaning ‘about the size of New Jersey.’ Learn, learn, learn. We can learn in New Jersey!”

If only there was a two-dimensional graphical representation of how to find it…now, wouldn’t that be something!