Seperation Anxiety

I’ve never been a particularly demonstrative person. In fact, during my first go-round on the Wheel of Matrimony, when I was married to the only daughter of a large Italian family addicted to the Art of the Hug, another in-law and I would spend most family gatherings by ourselves in what become known as the Non-Sicilian Non-Hugging Corner. But once I became a father, all that changed, and I simply couldn’t hold my son anywhere near enough.

The infant they couldn’t pry out of my arms in the delivery room is now twelve, and I’m not taking the aging of my son very well. It’s not that I mind the fact that he gets a bit more verbal and lots more worldy, although I do regret his loss of innocence (and, to be honest, gullibility…it’s a lot harder to get “tall tales” by him than it used to be). He’s becoming a more interesting person by the day, and while we always talked to each other now we have real conversations about things that matter. What I feel most acutely is the loss of physical closeness.

The first blow came when he was seven. Our usual night time routine was called “Daddy and Boy Movie Night.” We would fix a snack, pick a video, and watch together until it was time for story and bed. We’d sit at one end of the couch, both of us sharing the scratchy llama blanket, and he’d lean up against me as we delighted in the hijinks of Laurel and Hardy, that week’s rented film, or the cartoon du jour from our collection.

One night I made us two bowls of ice cream and headed towards the sofa. He was already seated at the far end, blanket wrapped around him. I put dessert on the table and sat on our traditional side of the couch.

“Brendan, don’t you want to come over here and sit with me?

“No thanks, Daddy. I’ll be okay here on my own.”

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

After movie time was story. Over the years, we had moved from picture books to stories to chapter books. I would tuck him into bed, Mr. Monkey under one arm and Clark the Shark lying across the foot of the bed standing guard, and climb onto his bed to sit next to him as I read. If he didn’t fall asleep while we were reading, he would ask me to sit with him until he drifted off, and he’d be sure to tell me to check on him during the night before I went to bed. (Which I did, and still do, religiously).

About a year and a half ago, we had just finished one book and it was time to choose another. I got out a couple of Great Illustrated Classics and laid them out on the bed.

“Brendan, what do you want to read for story tonight?”

He sighed. “Well, I really want to read my Calvin and Hobbes book on my own.” I must have looked stricken, because he quickly added, “But you can still tuck me in if you want.”

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

My son is now in sixth grade. Two weeks ago, I picked him up from school. We went through our usual pick-up routine, which goes as follows”

“Hi, Dad.”

“Hmmmm…you look familiar.”

“Daaaaad!” (Insert scorn, then raise two octaves for full effect.)

We got his backpack and headed out towards the car. As always, I leaned over to give him a hug and a kiss. He stopped me in mid-lean.

“Dad, not in front of the school. But you can still hug me in the car.”

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

The following day, we were walking towards the mall when I felt his hand slip into mine. Surprised, I looked at my son. No longer my little boy, but now a boy rapidly heading towards manhood. A little taller, a little leaner, the voice just a touch deeper, moving away faster than I want but just as fast as he needs.

“Brendan, you know I love walking with you. But are you sure you want to keep holding hands when we walk together?”

“Don’t worry, Dad. I’ll never get too old for this.”

If only.

Christmas Eve, ED, 2009

Ever since I entered the medical profession, Christmas Eve has always been a workday for me. While it’s true that as an MOT (Member of the Tribe) I have no spiritual affiliation with the day, I enjoy a day of cheer, fellowship and good tidings as much as anyone. But the simple fact is that the nature of what my colleagues and I do for a living means someone has to be in the ED at all times. That’s why I like to think of Christmas Eve as The Official Shift of the American Jew (if only I could get a beer sponsor for that). It’s why I’m at work, or sleeping off night shifts, while most of my fellow co-religionists are performing the holiday rite of eating Chinese food and going to a movie.

This concept of the Official Shift does not just exist in my mind. I actually tested this theory last year. It was two AM, and I called two other ED’s in town and two out of state to see which doctor was on. It was always the Chosen People, chosen especially for duty that night. I was so inspired by this phenomena that I wrote a poem about it:

‘Twas the night before Christmas
And Elvis was bluish.
All the doctors on duty
That night had been Jewish.

I recited this poem last night to my friends Hung Doan (Buddist) and Ahmed Amawi (Muslim), who had also drawn the holiday duty. So the poem has now been modified to be more inclusive:

It’s the night before Christmas
And in case you have missed ‘em
Here’s all of your friends
Who say they’re not Christian.

Every year I keep expecting Christmas Eve to somehow be radically different from any other shift of the year. I expect it to be slower than usual, and I always anticipate a certain gentleness of spirit among patients and staff, and for all of us to have a better perspective on what’s really important in life…friends, family, the blessings in life we have from living in this country.

In reality, it’s not all that different from any other day. People come in for the same things, you see the same range of problems and personalities, they get on your same nerves and you get onto theirs (the latter phrase translated as “You’re here at 3 AM all the way from Orlando, bypassing three other hospitals on the way, for THAT?). In the wee small hours of the morning, you get just a bit philosophical and start to wonder if there really is a Christmas, or if Christmas was just a day in the calendar picked out by someone to celebrate an event, the same way that New Year’s Day is not really the start of anything but just a day we picked to commemorate the next revolution around the sun. Maybe we could have made Christmas April 14th and New Year’s August 22nd and had the same effect.

But then you notice the subtle things that make Christmas Eve in the ED just a bit different than usual. Food is one. Piles of it. Industrial strength sheet cakes. Cookies. Hot dishes. Tins of popcorn. Platters of sandwiches and veggies from the grocery store, sausage and cheese from Hickory Farms. It comes from lots of places. Hot foods we bring for ourselves, potluck style. Some is provided by local churches as an appreciation. Much of it comes from doctor’s offices to say “thank you for your patronage…and for covering our butts.” There is so much food that we violate our normal Rule of Hoarding and invite patient’s families to raid our stash because we simply can’t get through it all.

It’s kids in fleecy holiday pajamas with colds and earaches who want nothing more than to go home and wait for Santa. It’s watching the NORAD Santa Tracker (www.noradsanta.org) and telling them that Santa will be at their house very soon, as he’s flying up the coast of South America right now. It’s letting them know that the best thing they can do is go home, lay out cookies for Santa and carrots for the reindeer (they LOVE carrots), and get to sleep because everybody knows Santa doesn’t come when kids are awake. It’s watching them nod gravely with understanding.

It’s the family of the bedridden elderly woman who didn’t give her insulin for four days so her blood sugar would be critically elevated and she would need to be admitted to the hospital. It’s knowing that they did this so they could get her taken care of while they went on vacation.

It’s the guy who brought in his cetacean mother with low back pain, who dressed for the holidays in a red knit hat, red Dale Junior #8 Budweiser shirt, green sweat pants, and red hospital socks that have little white treads on the bottom to prevent slips and falls.

It’s the lady who decided to de-louse herself before she went to church because she thought she had flies in her head that nobody had ever been able to see. She got the shampoo in her eye and now has pain which her Methdone just isn’t helping.

It’s two women who come in by ambulance within an hour of each other, both short of breath, both in heart failure because they’ve been stuffing themselves with turkey and ham and handfuls of salt, and you just smile at them and wish them a Merry Christmas, because this is the one day the dietary rules don’t apply.

It’s not being able to stop at Dunkin Donuts on your way to or from work for a Vanilla Chai tea because it’s closed. (You see a lot of forlorn police officers on Christmas as well).

It getting doubly upset at the person who comes to the hospital at 4 AM because they don’t need to be there, they’re abusing the system, they’re trying to take advantage of the holiday spirit by requesting I give them the gift of pain pills, and they’re interrupting my viewing of the White Christmas marathon on AMC. (Okay, I know I was born forty years too late, but I must have Vera-Ellen.)

It’s the patient EMS brings in a 6:45 AM, fifteen minutes before it’s time to go home, who is pulling an extremely loud Reverse Santa (“OH! OH! OH!”)

It’s the nurse telling the doctor who’s been watching the Santa Tracker all night that Santa might not be real, and watching his face fall. It’s watching the Charge Nurse tell her to never say that again.

It’s going home and jumping into bed.

It’s moving on to the next day which, in the end, is the best holiday gift of all.

Merry Christmas, everyone. Best wishes to you and yours for the New Year.

Survey Scandals

Many people think that hospitals are large black boxes that function like The Great and Powerful Oz. Patients come in and patients go out, and nobody quite understands or oversees what goes on behind the pneumatic doors.

The fact is that hospitals are one of the most regulated types of institutions out there, and where mandated oversight is limited voluntary surveyors step in. One of the most well-known survey agencies is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, now called simply the “Joint Commission.”) JCAHO accreditation of hospitals is a comprehensive process. Every three years, a hospital receives a team of surveyors who evaluate all aspects of hospital operations. The survey is “voluntary,” but in reality is mandatory because many third party-payers, Medicare included, will not reimburse a hospital for care if the facility is not JCAHO certified. The accreditation process by necessity focuses more on paperwork and less on patient care. This is simply a function of the fact that while patients are subjective and variable, paperwork is not. However, one can easily hold the impression that the Joint Commission process bears little relevance to clinical care.

For folks on the front lines, the Joint Commission visit is a necessary evil. Surveyors can ask anyone anything within reason, so we all learn where the policy books are located, the names of appropriate supervisors, and the answers to typical questions we might be asked according to a pre-set script. For example, we are all taught that in the event of a fire we would follow the mnemonic RACE (Rescue, Alarm, Confine, Evacuate/Extinguish) as opposed to our usual response, which is to sit and complain about the loudness of the fire alarm, ignore any possible signs of danger until the Styrofoam coffee cups melt, and then run screaming out the doors because we believe that heroes are people who by and large do stupid things and get away with it, and we are not heroes. We also have to memorize all our hospital alarm codes, which literally span the rainbow from Code Pink (Infant Abduction) to Code Brown (Weather Emergency…although that’s not what it means in the ED).

(If someone thinks I’m airing dirty laundry, please know that this is far and away not the case. Every hospital I’ve worked at does exactly the same thing. If this news to the JCAHO folks, they’ve not been paying attention.)

The biggest annoyance to us, though, is the restriction on foodstuffs in patient care areas. Accreditation criteria specify that no food and drink can be left open in patient care areas. (Patients can eat and drink in patient care areas, but nobody else can. Go figure.) This prohibition does make sense, as you probably don’t want a big dollop of sour cream from your chimichanga to accessorize your stethoscope, and Lord only knows what kinds of chimichanga germs (Staphlococcus tortillas) might get transmitted to a patient, especially if they were allergic to melted cheese. But in reality you can’t run an ED without having some kind of open container, whether it’s sodas for the nurses, sandwiches for the doctors (nurses get a set lunch time, while docs can leave the ED for lunch only if the patient load allows), cookies and pizza for staff, and coffee for everyone. To prohibit any kind of food or drink from being in the ED is deprive us of our greatest source of job satisfaction, namely sugar and caffeine.

(You REALLY thought I was going to say “patient care,” didn’t you? You haven’t been paying attention to this blog. Hahahahaha.)

Fortunately, our hospital understands this. That’s why when surveyors come around, they blast out over the PA system “WE WOULD LIKE TO WELCOME THE JOINT COMMISSION TO THE HOSPITAL AND HOPE THEY HAVE A GOOD DAY.” This greeting is, in reality, about 10% sucking up to the surveyors and 90% hospital code for “HIDE EVERYTHING.” Everything gets shoved into drawers, thrown into purses, stashed behind bottles of Gatorade in the patient food freezer, stuffed behind blankets in the linen cart (Tip: Drinks in cups and glasses taller than Coke cans will not reliably fit into the upper drawers of under-the-desk metal file cabinets.) We wait until we witness the passage of the suit-bearing Administrative Cluster (“They band together in small troops of five to ten,” says Marlin Perkins. “Now Jim will attempt to befriend a dominant male and separate him from the herd with a Golden Parachute.”) Once the “all clear” is sounded, feasting may again commence, with care to not pull things out of bags and drawers too fast or they spill.

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

Speaking of suits, one of our Case Managers brought a toy into the ED last week. Its little windup penguin that hops and waddles in a most amusing fashion. And every few seconds it ejects a small round chocolate pellet from its backside.

We instantly dubbed this toy the Administration Penguin, because as best as we can tell it’s sole purpose is to strut about importantly and drop…ahem, pellets…on the floor.

How to Lose $4.00

A 21 year old woman came into the ER complaining of intermittent crampy abdominal pain for the past two months. She decided to come to the ED today because she felt like her stomach was getting bigger and she just couldn’t take it anymore.

“Tell you what,” I said to the nurse who had just given me the chart. “I’ll bet you a buck that when it’s all said and done she’s pregnant.” She agreed to the wager and I went into the room to see the patient.

It turned out that she had delivered a child three months ago, but still hadn’t had a resumption of her menstrual periods. Nor did she know when her last one was before she got pregnant. She had been vomiting daily, and had been having unprotected sex. But hse maintained that there was "no way" she could be pregnant. As one of the Cardinal Rules of the ED is that anyone who says they can’t be pregnant is until proven otherwise, I told the nurse I’d double or nothing the bet to a $2.00 total .

The nurse then went in to talk with the patient she learned that the patient had been having unprotected sex, but only with a woman partner. She said she had never had sex with a man, and when the nurse indicated that she must have had some sort of momentary relations in order to account for the three month old child in her arms, she said, “the stork brought him, just like Jesus.”

I try to be respectful of others religious beliefs, but as far as I could tell, this did not appear to be a potentially Messianic scenario. I understand that Jesus came from humble beginnings, but one would think that if three kings had dropped into the middle of Daytona Beach on a warm September night, someone might have noticed.

(To be honest, though, I suspect we all think we’re the products of an Immaculate Conception. The thought of our parents actually engaging in carnal actions is really far too much to bear.)

Armed with this bit of knowledge, my level of certainty grew by leaps and bounds. I proposed another double or nothing bet, which was quickly accepted. And when the labs came back, the pregnancy test was negative, and what was really going on was an intermittent bowel obstruction related to intestinal scarring from a childhood abdominal surgery.

So I now owe the nurse $4.00, which will actually be six or seven once my debt is redeemed for some sort of fruity alcohol-based drink with an umbrella sticking through a slice of tangy citrus. I’m sure there’s some sort of lesson here about trusting the patient, not underestimating their veracity, the need to do a complete workup to exclude emergency conditions, or even about the untapped potential inherent within every child, Messianic or not. But I will tell you that I’d make that wager again any day. And next time I bet I’ll be right.

Emergency Haiku

Worked a shift in the Fast Track area of the ED last week, and started to write up a few anecdotes. However, it quickly became apparent that what showed up on the page was, to be frank, duller than the Annual Meeting of the American Association of Less Personable Accountants. So what could I do to make it better and save typing at the same time, while reinforcing my commitment to cultural diversity? Why, it’s haiku! So I hope you enjoy the following assortment of ED verses...

You have bad back pain
But you have OD’d before.
No Lortab for you!

There are two big boils
In quite sensitive places.
Please, try to hold still.

You face was broken
Last month; last night you hit it on
The open door. Look out!

There is no detox
At our hospital. Go now.
Do not imbibe again.

Sore throat and fever.
Tonsils bright red; take this pill
And feel much better.

Drinking and puking.
Potassium far too low.
You’ll be admitted.

Your own doctor sent you
For an MRI. You might
Have just told me that.

Neighbor’s dog jumped up.
Greeting gone wrong; you fell down.
Scrapes on knee and hand.

Swollen right foot is
Likely arthritis. It helps
If you can speak English.

Fell in the garage.
Knee swells up and hurts badly.
But it’s only a big bruise.

No sex this month; but
You had STD before.
Now it’s PID.

Runny nose and cough.
No help with Nyquil last night.
I can help you out.

Swollen up leg can be
An infection; maybe soap
and water would help.

Antibiotics
Are good for what ails you.
But you have no veins!

Scars on his chest and
Shoulders from war. Happy
To care for his ills.

Felt weak, ate an orange.
Now well. Could your sugar have
Been far too low then?

The Blood of God is
In your veins. But which of us
Wears leather restraints?

I heartily invite your contributions!

Great ED Video!

This video was making the rounds in the ED the last few days..and actually links in with yesterday's blog! Wish I knew how to make these...very funny. Enjoy!

http://www.youtube.com/watch?v=_m64cy1MMPg

Tongue Twisiting

Every profession has its own secret code known only to acolytes, and medicine is no exception. Medical terminology seems complex, but it’s actually pretty easy one you know the scheme. The key is to recognize that most medical words come from a specific set of Greek or Latin roots, and that virtually everything is a combination thereof. So to describe just about anything, once you know the code all you have to do is mix and match the hundred or so roots to come up with what you want. So if you want to describe a blue extremity, you combine the root for extremity, “acro,” with the root for blue, which is “cyan”, to come up with acrocyanosis. If you want to talk about an enlarged extremity, you use “acro” again, but now combine it with the root “megaly,” meaning enlarged, to come up with acromegaly. The root “path” pertains to disease; a pathologist is someone who studies disease, and idiopathic means you’ve got a disease but it beats me why. It’s this flexibility that gives rise to medical puns such as dyspareunia (“dys” meaning bad, “pareunia” meaning biblical knowledge of another) is better than no pareunia at all. We can also use it to describe invented non-clinical conditions, such as hypocyanocrutiatism (“hypo” meaning low, “cyan” meaning blue, and “crutio” meaning cross…translated as “low Blue Cross”), and ainsuria (“an” meaning without, “insuria” meaning…well, insurance. I so totally made that one up).

You can also use this flexibility to play with medical students. One of the joys of the teaching of medicine, in which I was engaged for six years after residency until I rejoined the real world, is the opportunity to amuse yourself with the ignorance (of those who think they actually know something) and gullibility (for those who know nothing) of the children.

It’s especially fun with the former group. There was a particularly obnoxious student at the University of Florida, the kind who walks around with an AMA pin in his lab coat and a license plate that said “MD 2 B” and who thought he could date the ED attending’s ex-girlfriend. He was truly getting on everyone’s nerves, so the senior resident and I conspired together and formed a plan.

One day when the student was on duty, we called him over to the X-ray room to look at a chest X-ray that both the resident and I had verified was completely normal. We asked his opinion, and he said it looked fine to him as well. Then the resident pointed at the upper left part of the film. “Hey, up in the corner. Isn’t that a sign of hypocyancrutiatism?”

I peered closely at the lighted screen. “Yeah, I think so. Nice pickup.” I turned to the student. “Ever heard of that?”

You could see his mind start to work. Sometimes it’s just too easy, like shooting fish in a barrel or vegans in California.

“Yes, I did. I read an article about it. Some of the symptoms are…”

The resident lasted about 23 seconds before bursting out in hysterics, and I didn’t last but a few moments more. We told him we had made it all up, that there was no such disease, and that he should probably review his essential references (medical school-speak for “you’re a moron”) before commenting in our presence ever again. He was quiet for the rest of the month.

(This is one of the students who passed the ED rotation only because we were sure he was never actually going to do emergency medicine and those who failed had to do another month.)

Another trick you can do with medical students and terminology is to take recognized medical eponym and turn them on their heads. For example, there is something called a “Chandelier Sign.” It’s actually a pun on a clinical finding…when you do a pelvic examination on a patient with a pelvic infection and you move the cervix, the pain is so bad they want to leap towards the ceiling and grab the chandelier. That’s not, of course, what you tell the student. What they hear is:

“You know, it’s an interesting story behind this eponym. Most people think it’s something made up. But in early 19th century France, there was a pioneer gynecologist named Jean-Marie Chandelier (it’s critical to say “shaaan-deee-leee-ay” to make it sound real). He was the one who first discovered the pathologic correlate between tenderness of the cervix on exam and pelvic inflammatory disease. He was actually a first cousin to one of the leading families in the French glass-blowing industry, the family that first produced the lighting fixture we call in English the Chandelier (pronounced shan-dee-leer to emphasize your erudition).”

That being said, sometime the eponyms are funny enough without needing to make up more material. When you examine a patient’s eyes, among the things you look for is responsiveness (if the pupil contracts when exposed to bright light) and accommodation, which is normal when light shown to one causes the opposite pupil to contract as well. So the Argyll-Robertson Pupil, a sign of tertiary syphilis, is known as the Prostitute’s Pupil because it’s accommodating, but not very reactive.

One last language trick is to ask the students if they really mean what they say. One of my favorites in this category is the use of the term “appreciated.” For some reason, we are taught in medical school to “appreciate” heart murmurs and other clinical findings, as in “There was a 4/6 murmur appreciated over the lower left sternal border.” But I always ask if they just heard something, or really appreciate it? Did they gasp in astonishment? Did they call their parents to let them know? Did they send a singing telegram to the relationship de jour? And speaking of singing, we’ve also learned to describe lung sounds as “musical” in terms of pitch. (Pitch and tone are important clinical indicators. This was first noted by the French composer Louis-Nicolas Clerambault, a close friend of Rene Laennec, inventor of the stethoscope. On rounds with his friend one day at the Hotel Dieu, he is reported to have heard breath sounds and was inspired to write his very popular “Symphony for Harpsichord and Sputum in D.”) But we could go so much farther. What key are they in? G flat or A major? Does it have a beat? Can you dance to it? Best in the east, give it at least, a 75?

(For more information on the linguistic joys of the teaching life, I would also refer you to a classic 1989 JAMA article entitled, “The Art of Pimping,” by Frederick Brancati. A copy of this work can be found at http://www.neonatology.org/pearls/pimping.html.)

However, every now and then the playful use of use of medical terminology can take an alarming turn towards political correctness. The latest example is the term “psychogenic non-epileptic status epilepticus,” or PNESE, which I saw for the first time in the November 2009 issue of Critical Decisions in Emergency Medicine. Breaking this down to root words, it means a continual seizure state that is not related to seizures but has its origin in the psyche and not in the wiring of the brain. (The fact that it’s a non-seizure seizure means it’s not a seizure, right?) It turns out that, when you read the actual clinical description of the PNESE, it’s what we used to call a “pseudoseizure,” or “faking.”

As best I can tell, the change in terminology came about because the term pseudoseizure implies that the person is doing it on purpose, while the PNESE suggests that the event may not be intentional, but a result of unconscious forces driving a “somatization” disorder, where psychiatric illnesses are manifested as physical symptoms. (See “fibromyalgia.”) But the fact is that the PNESE is still not a seizure. I know this not just from analysis of the word roots, but also because I asked a neurosurgeon if he knew what a PNESE was. He said no, and so I read him the description. “That’s a (homophone for clucking) psueodseizure,” he said. “What kind of idiot needing tenure thought that one up?”

Umm, probably the same ones who spent six years in academics getting promoted and tenured before joining the real world…

Shared Interests

While it’s probably true that opposites attract (see “first marriage”), it’s also important that people in relationships share some basic interests, views, and values. That’s why I’m pleased to tell you the following story of two people who are truly meant for each other. Let the chant of the cherubs begin:

Dennis Krimmons arrived in the ED on a Pleasant Valley Sunday, girlfriend in tow, complaining of swelling in his left leg. This was especially important as it was his only leg, having lost the lower half of the right one as a result of complications from a motor vehicle accident (MVA). He said the swelling had started four days ago after he was helping out in the yard and got scratched on his leg by some branches from a rose bush. Shortly afterwards, a friend had managed to run a chair over his foot, and later that day, in a trifecta of minor trauma, he managed to tip over a curb and hurt his foot yet a third time. On exam, he had some small scratches over the inside of his ankle, and lots of swelling in the foot and ankle as well. He complained bitterly of pain when I ran my hands over his foot. The foot, while swollen, was not red or hot like there was an infection; it did not go along with any calf pain or swelling like you might find with a blood clot; and there was no specific site of bruising or bony pain as is typical of a fracture. In addition, Dennis had a hard time staying awake while I was talking to him. He was noted to be taking multiple pain medications, including Oxycontin and Valium, for neck and back problems, and had the kind of thick, slurred speech that goes along with enjoying your prescription medications to excess, thank you very much. Fortunately, he assured me that he was just really very tired, having not been able to sleep the night before due to his intense leg pain.

(Incidentally, in another bow to political correctness and legal avarice, the MVA is now more properly called the MVC, or motor vehicle crash. This is because there are no such things as accidents, as every event has both a cause and a fault.)

I suggested to him that the plan of action would include an x-ray of the left foot and ankle to make sure that nothing was broken and causing the swelling, and if that looked good we would get an ultrasound study of the leg to make sure there was no blood clot causing a problem. I explained to him that his findings were pretty non-specific, but since he was having intense pain and it was the only leg he had left it made sense to spread the net widely. Unfortunately, Dennis thought that was a bad idea. He was pretty sure it wasn’t broken, and was worried about the cost of the x-ray. (For the record, his payer status was “Charity Care,” meaning that he wasn’t going to pay for the radiograph, but that I and other residents of our hospital taxing district would.) He then proceeded to demonstrate to me that his foot and ankle wasn’t broken by removing his prosthesis on the right and hopping about the room on his one remaining foot, calling out, “If it was broken, I couldn’t do this now, right?”

He did agree to the ultrasound (a more costly test, which should have raised a red flag but didn’t). This was negative, and I reassured him that nothing serious seemed to be going on, and since he was already on good pain medications at home and there was no sign of infection I couldn’t tell him exactly what was going on, but it didn’t seem to be an emergency and he could follow-up with his own physician.

I was preparing his discharge paperwork when the nurse told me that his girlfriend had disclosed to her that the real reason Dennis had lost his leg was because he was crushing tablets of Oxycontin (a narcotic pain reliever) and injecting himself under his skin. She also suspected he was going to inject himself here in the ED since we gave him no additional pain medication. She also told us that if he knew she had told us, he was likely to beat her when they got home.

The nurses did the absolute right thing. One nurse got her away from him and into a separate room in the ED so they could talk to her about domestic violence services and the need to stay somewhere safe. Meanwhile, another nurse tracked down the patient to find he had locked himself in the bathroom for twenty minutes and would not answer the door. Security got the door open, to find the patient standing at the washbasin. I peered in.

“You doin’ okay?”

“Man, I’m taking a (euphemism for movement). What’s your problem?”

“When someone spends that much time in the bathroom, we worry that they might of fallen or something. It happens, you know.”

“I’m fine. I need a laxative.” (This is probably true, as constipation is a common side effect of narcotic use.)

It was then that I noticed two small drops of fresh, wet blood staining the outside of his jeans over his thigh. I pointed them out to Dennis.

“What’s going on there?”

“Where?”

“The spots of blood on your pants.”

He looked down. “They’ve been there.”

“Tell you what. Appease me. Let’s check it out and make sure you’re okay.”

He drew himself up. “I refuse your care, (euphemism for an Oedipal event),” he proclaimed. He strapped on his other leg and clip-clopped rapidly from the ED.

Meanwhile, the Charge Nurse was taking special pains with the girlfriend to try to arrange a safe environment for her. But when she learned that Dennis had flown the coop, she couldn’t leave fast enough to be with her man.



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

This is how the story stood for the next hour and a half. We finished our paperwork (one of the paradoxes of modern medicine is that it takes longer to do the paperwork on a patient who is unpleasant, unruly, threatening, or drug-seeking than it does on someone with a cardiac arrest…one is more likely to complain to administration.) Life in the ED moved on…a kid with strep throat here, an older person with VD (“Veak and Dizzy”) there. The radio sputtered to life with reports of an overdose patient being brought in. She had been found asleep in a taxicab near the beach just south of the hospital.

The patient looked familiar when she was brought in…more disheveled, speech slurred, makeup smudged. No obvious signs of trauma. But it was undeniably Dennis’ girlfriend, and she brightened up when she saw us. (Nothing like being among friends.) The reunion lasted but a few moments before she went back to sleep, which is how she stayed while we drew blood, passed a catheter into her bladder, and put a tube down her nose into her stomach so we could give her a whopping dose of charcoal…crushed up Kingsford briquettes, albeit without the impregnated lighter fluid…to try to absorb whatever was in her system.

And what was in there? Yep, you’re way ahead of me. Oxycontin and Valium.

Ain’t love grand?

Adult Notes

Two off-color but very funny incidents in the ED today:

Over the last few months I’ve been experimenting with growing a beard. Not a beard, really, but something called “designer stubble.” I’m striving to maintain that semi-hunky five day growth so that I look like I’ve been too busy saving lives to attend to personal grooming and so someone besides the nursing home patient with dementia will mistake me for Dr. McDreamy. (True story.) I’m being very careful to try to keep it short, not only for the McDreamy factor, but because I know that if I let it get much longer I won’t be able to ignore the sensation that there’s probably a piece of a Spaghetti-O left in there someplace. There are now four ED docs in the facial hair derby growing winter beards, which is especially strange when you consider that we are in Florida and today there was a record high for Daytona of 85 degrees.

I’m new at the quest for stubble, so I’ve been asking folks at work what they think of the current effort. The reviews have been mixed, about 50-50 for the clean shaven look or the current scruffy façade. But today one of the unit clerks suggested that I adopt a look which removes the stubble over the cheeks, leaving the hair around the mouth and chin in what is apparently called a “love patch.”

This was a new term to me, but not to anyone else in the ED. What was new for everyone was how easily we were able to transition the term “love patch” into the singular best composition in human history. I am, of course, referring to “Love Shack” by the B-52’s. So it was in tribute that soon we were rolling back and forth in our swivel chairs with the plastic wheels, chanting:

“Love Patch!
Baby Love Patch!
Cuz the Love Patch is a little ol’ place where we can
Get To-geth-er!”

We’re still working out how to handle, “Tin Roof! Rusted!” but we’re sure something will come to us.

Speaking of music and adult themes, regular readers of The Blog will recall that I’ve noted the tendency of our voice-recognition software system to interpret my pronunciation of the word cardiovascular (pertaining to the heart and blood vessels) as cremaster (pertaining to a muscle layer of the scrotum). I was dictating the results of listening to the heart when the alternate term showed up on-screen. This was noted by one of my esteemed colleagues, who inquired, “What does that sound like, anyway?”

After intense discussion, we decided that each person’s exam probably sings its own tune. In my case, with the spouse currently located 800 miles away and several weeks between conjugal visits, it sounds like a small male chorus singing “Please Release Me….Let Me Go!”

Another Voice from the ER

(Steve Bohannon, a friend and fellow ED doc, sent me this piece the other day. It's a Letter to the Editor from another emergency physician colleague in the Northeast, with his take on emergency care. I really enjoyed it and think he's right on the money...hope you do too. Thanks, Steve!)

Sunday, October 11, 2009

Pittsburgh Post-Gazette

Emergency departments are distilleries that boil complex blends of trauma, stress and emotion down to the essence of immediacy: What needs to be done, right now, to fix the problem. Working the past 20 years in such environments has shown me with great clarity what is wrong (and right) with our nation's medical system.

It's obvious to me that despite all the furor and rancor, what is being debated in Washington currently is not health-care reform. It's only health-care insurance reform. It addresses the undeniably important issues of who is going to pay and how, but completely misses the point of why.

Health care costs too much in our country because we deliver too much health care. We deliver too much because we demand too much. And we demand it for all the wrong reasons. We're turning into a nation of anxious wimps.

I still love my job; very few things are as emotionally rewarding as relieving true pain and suffering, sharing compassionate care and actually saving lives. Illness and injury will always require the best efforts our medical system can provide. But emergency departments nationwide are being overwhelmed by the non-emergent, and doctors in general are asked to treat what doesn't need treatment.

In a single night I had patients come in to our emergency department, most brought by ambulance, for the following complaints: I smoked marijuana and got dizzy; I got stung by a bee and it hurts; I got drunk and have a hangover; I sat out in the sun and got sunburn; I ate Mexican food and threw up; I picked my nose and it bled, but now it stopped; I just had sex and want to know if I'm pregnant.

Since all my colleagues and I have worked our shifts while suffering from worse symptoms than these (well, not the marijuana, I hope), we have understandably lost some of our natural empathy for such patients. When working with a cold, flu or headache, I often feel I am like one of those cute little animal signs in amusement parks that say "you must be taller than me to ride this ride" only mine should read "you must be sicker than me to come to our emergency department." You'd be surprised how many patients wouldn't qualify.

At a time when we have an unprecedented obsession with health (Dr. Oz, "The Doctors," Oprah and a host of daytime talk shows make the smallest issues seem like apocalyptic pandemics) we have substandard national wellness. This is largely because the media focuses on the exotic and the sensational and ignores the mundane.

Our society has warped our perception of true risk. We are taught to fear vaccinations, mold, shark attacks, airplanes and breast implants when we really should worry about smoking, drug abuse, obesity, cars and basic hygiene. If you go by pharmaceutical advertisement budgets, our most critical health needs are to have sex and fall asleep.

Somehow we have developed an expectation that our health should always be perfect, and if it isn't, there should be a pill to fix it. With every ache and sniffle we run to the doctor or purchase useless quackery such as the dietary supplement Airborne or homeopathic cures (to the tune of tens of billions of dollars a year). We demand unnecessary diagnostic testing, narcotics for bruises and sprains, antibiotics for our viruses (which do absolutely no good). And due to time constraints on physicians, fear of lawsuits and the pressure to keep patients satisfied, we usually get them.

Yet the great secret of medicine is that almost everything we see will get better (or worse) no matter how we treat it. Usually better.

The human body is exquisitely talented at healing. If bodies didn't heal by themselves, we'd be up the creek. Even in an intensive care unit, with our most advanced techniques applied, all we're really doing is optimizing the conditions under which natural healing can occur. We give oxygen and fluids in the right proportions, raise or lower the blood pressure as needed and allow the natural healing mechanisms time to do their work. It's as if you could put your car in the service garage, make sure you give it plenty of gas, oil and brake fluid and that transmission should fix itself in no time.

The bottom line is that most conditions are self-limited. This doesn't mesh well with our immediate-gratification, instant-action society. But usually that bronchitis or back ache or poison ivy or stomach flu just needs time to get better. Take two aspirin and call me in the morning wasn't your doctor being lazy in the middle of the night; it was sound medical practice. As a wise pediatrician colleague of mine once told me, "Our best medicines are Tincture of Time and Elixir of Neglect." Taking drugs for things that go away on their own is rarely helpful and often harmful.

We've become a nation of hypochondriacs. Every sneeze is swine flu, every headache a tumor. And at great expense, we deliver fantastically prompt, thorough and largely unnecessary care.

There is tremendous financial pressure on physicians to keep patients happy. But unlike business, in medicine the customer isn't always right. Sometimes a doctor needs to show tough love and deny patients the quick fix.

A good physician needs to have the guts to stand up to people and tell them that their baby gets ear infections because they smoke cigarettes. That it's time to admit they are alcoholics. That they need to suck it up and deal with discomfort because narcotics will just make everything worse. That what's really wrong with them is that they are just too damned fat. Unfortunately, this type of advice rarely leads to high patient satisfaction scores.

Modern medicine is a blessing which improves all our lives. But until we start educating the general populace about what really affects health and what a doctor is capable (and more importantly, incapable) of fixing, we will continue to waste a large portion of our health-care dollar on treatments which just don't make any difference.

Michael Werdmann, MD
Chair, Dept. of Emergency Medicine
Bridgeport Hospital
Bridgeport, CT 06610

The Eye of the Tiger

"We probably thought he was a better guy than he is. I would probably need to apologize to her and hope she uses a driver next time instead of the three-iron.”

-Jesper Parnevik, who introduced Elin Nordegren and Tiger Woods.

I’m not a big golf fan…I really do prefer watching paint dry, because at least you can inhale the fumes…so I’ll admit that I was not following the Tiger Woods story with any great enthusiasm until the tabloids got hold of it. Perhaps my lack of interest is because I’m not a golfer. I’ve played golf twice in my life, which equals the number of times I’ve actually gotten the ball off the ground. One of the shots was beautiful, right down the fairway, the kind of thing you see on the PGA tour. The second one hit a tree. My brother is fond of reminding me that if I had only learned to play golf, I could have done something with my career. This may be true, but I’ll never know. I do know that the former Governor of Kansas and current Health and Human Services Secretary Kathleen Sebelius used to run a few miles every morning down by the Kansas River. As much as I have always liked and respected the Governor (and still do), if waking up at 5 AM to run when it’s a billion degrees below zero on the Kelvin scale means I might get a bigger cubicle, than I’m happy to stay at my level, thank you very much. (Okay, that’s a lie. For the Governor, I’d do it. But only because she’s given me at least thirty free pens at proclamation signings, a gift –giving bonus which prompted Secretary of State Ron Thornburgh to note that if you collect ten, you also get a toaster.)

It was never really a mystery what happened to Tiger. Folks who work in trauma put a lot of stake in describing the mechanism of injury. In essence, based on the visible evidence when paramedics arrive on scene, we can predict how and where injuries are most likely to occur. It’s our own little version of CSI. So when a Cadillac Escalade hits a fireplug just outside the driveway in a residential neighborhood, you already know that it can’t have been going too fast, and that damage to such a heavy vehicle is going to be minimal. You also know that when someone comes upon an accident, they usually run into the house to call 911 and not to grab a golf club in a heroic attempt at rescue. (There is actually an animation from a Chinese news broadcast that outlines the scenario at http://www.youtube.com/watch?v=jV85rD0gfqo.)

So I will make this one additional comment, and then I will leave Tiger alone, because I honestly do believe that he and his family deserve some privacy to work these issues out of the public view, and to determine exactly how much cash Elin will get to not walk out of the house. That being said:

You’re married to a former Captain of the Swedish Bikini Team. By all reports, she is sweet, kind, respectful, and devoted to you. She has borne you two lovely children. She has a twin sister (Ha!). Forgetting the ethical aspect for just a moment, you have no logical reason whatsoever to cheat.

(It may be an apocryphal story, but I’ve always liked what the actor Samuel L. Jackson was reported to think about carnal temptation. “I just ask myself if twenty minutes with this woman is worth half of all my stuff,” he said. “The answer is always no.”)

But if you’re going to cheat, shouldn’t you at least be trying to move on up in the process? (I call the The Jefferson Principle.) You’re the best in the world at what you do. You have a kazillion dollars. You can have any girl you want. But…and let’s be honest here…Rachel Uchitel looks like a caulk gun went nuts in her lips, and Jaimee Grubbs just looks, well, wrong (what in medical term we call an FLK, or “funny looking kid”, where you know something’s not right but you just can’t put your finger on it.) But if these visions are what you really want, you have other options. You can close your eyes, turn off the lights, or learn to start kissing a bulldog. They’ll do just about anything for peanut butter.

I think you can apply this same criticism to other famous miscreants. Rudy Giuliani dumped a perfectly attractive and accomplished Donna Hanover for the somewhat less glamorous Judith Nathan (“Not so much to look at, but she’s such a wonderful personality and good with children” says her mother.) Peter Cook (Christy Brinkley’s last husband), cheating on the Empress of Fishnet with the babysitter? Come on. Governor Elliot Spitzer? Downgrade. Senator John Ensign? Governor Mark Sanford? Senator David Vitter? Ditto, ditto, and ditto. Governor James McGreevy? Well, perhaps my own tastes in partners…namely, women…prevents me from seeing the charms of the latter, but even so he’s not Governor anymore.

(For the record, I believe this theory holds true for women as well. But I also think that women are actually smarter about following The Jefferson Principal then men. There’s a reason why silicon cupcakes bed and marry saggy older men, and why Jessica Hahn chose to sleep with Jim Bakker over the PTL mail carrier. And that’s’ why I’ve never quite understood these romances that pop up from time to time between female guards and male inmates. I understand that guys can portray themselves as something they’re not, maliciously luring good and trusting women into destructive relationships. But in these cases, the guy is in PRISON! I mean, what more of a sign do you want that something might go wrong?)

So if you’re going to have an affair, be sure to follow the model of George and Weezy as you do it. Because you’re going to need some kind of consolation when you lose half your stuff.

You Choose the Story!

On rare occasions, people I work with will actually admit to reading my blog. (I suppose they don’t suffer enough in my direct presence, and so they need to suffer some more at home. Maybe they’re all Catholic. I'll have to check). Recently, someone asked me why most of the things I write are about the negative side of ED life.

It’s a good question, and if you read what I’ve written over the last few months you might get the impression that everyone who comes to the ED is either a drug-addled alcoholic, an irresponsible systematic abuser of government-sponsored health care, or has a terrible condition about which we can do absolutely nothing. And there’s always an avaricious attorney hovering by the exit trying to drum up business.

The simple fact is that this isn’t even close to the truth. The vast majority of patients who drift through the ED are genuinely nice people, and most of the time you can either make them feel better and let them go home, facilitate their admission into the hospital if needed, or at least reassure them that despite their pain or illness, nothing major is going on today. Every now and then you might even save a life. It does happen, you know. And Security does a very good job of confining attorneys to the far corner of the parking lot.

But I think the reason the “dark side” predominates in my writing is simply because we find that the more unique the situation, and the farther it lies from our own daily lives, the more interesting it can be. It’s a variation of the old adage that Dog Bites Man is not news, but Man Bites Dog is.

I’ll try to prove this to you with a brief example. Here are the stories of two patients who both came in last week within about a half hour of each other. In both cases, I’ll try to stick with a Joe Friday, “Just the facts, ma’am,” approach, and leave out any subjective information as best I can. At the end, you decide which one you’d like to know more about.

Case One: A 27 year old black female came to the ED complaining of vaginal bleeding. She had a LEEP procedure done two weeks ago and was doing fine until she felt a gush of water from between her legs while shopping at Wal-Mart and realized she was bleeding. (The LEEP is done to treat cervical dysplasia, abnormal cells on the surface of the female cervix that might lead to cancer.) The bleeding started about an hour prior to her arrival in the ED.

On exam, there was a large amount of blood in the vagina, and with effort we were able clear out the blood clots and identify the site of bleeding on the lower edge of the cervix. (Most likely what had happened is that in the healing process some tissue had sloughed off a small artery, causing the bleed.) After speaking with the gynecologist on-call, we were advised to try to apply some Monsell’s Solution (a topical anticoagulant) to the cervix to see if that would solve the problem. Unfortunately, the patient continued to bleed, so we called in a physician who was able to anesthetize the cervix and suture closed the blood vessel. No further bleeding was noted, and the patient was able to go home without incident.

Case Two: A 55 year old white female was brought in by ambulance complaining of head and rib pain. She said she had been having a few drinks (“Four Crown Royals”) with her boyfriend. They were riding home on his motorcycle when she said something he didn’t like about a mutual friend of theirs. He elbowed her in the ribs as she was hanging onto the back of the motorcycle. At the next stoplight, she hopped off the bike, and got a passerby to take her home. On her arrival at the home, he slammed her against a glass door, hitting her head and knocking it off the hinges. She then hit him in the face with a frying pan. The police had been called, but left “without doing anything.” She both drank and smoked on a regular basis.

The patient has been in a violent situation for at least three years, and the same boyfriend had hit her twice before, on one occasion breaking her ribs. She still had him in the home because she “can’t afford to evict him.” She was willing to talk to our case management staff about domestic violence resources in the community. She said she had a friend who she could stay with that night for safety.

Her exam showed her to be tender over the left side of the head and the lower right ribs. Her x-rays were all negative. Her alcohol level was one and a half times the legal limit. We gave her IV fluids, thiamine, and multivitamins (part of the standard treatment package for patients with chronic alcohol use, a combination known as a “banana bag” or a “rally pack”), and allowed her to rest quietly in the ED.

We were making arrangements to call her friend to take her home when we were asked to hold her until the police could come to arrest her. Turns out that whacking someone with a frying pan turns you into something called a “primary aggressor.” “He was big,” said the officer, “but she got him good.”

Now you tell me which story, once we add all the subjective layers to it…the sights, sounds, stream-of-consciousness recollections, and pop culture references…is bound to be more interesting? The one where we actually solved a problem and did a very nice lady some real good, or the one with motorcycles, Crown Royal, cops, and a frying pan?

Your honor, the defense rests.

Gleanings

Over the past year I’ve tried very hard to dedicate myself to writing a novel. I make no pretenses of writing the Great American Novel, nor even the Great Florida Novel; and I’d probably be pushing it to even claim a try at the Greatest Novel Within My Zip-Plus-Four Code. I am so dedicated to this task that to date, I’ve got no pages whatsoever under wraps. I do, however, have lots of sticky notes scattered within the pockets of my lab coat and the front pocket of the backpack I take to work. These sticky notes are usually gifts of dug companies, emblazoned with logos for drugs I don’t recall and probably wouldn’t prescribe anyway because most are too expensive for our usual ED clientele. However, they are useful for jotting down writing ideas, which I have apparently done with aplomb over the last few months. And because I want this pile of gummed memorandi out of the house and into the great compost pile we know as the landfill, I have reviewed them for whatever gleanings of knowledge they contain. I have chosen to share these with you because many of them are funny, a few are pithy, and simply retyping these gives me a way to quickly cheat on a blog entry without having to burn any original thought. These selections are also the ones where I could actually read my own handwriting (I am a doctor, you know). So I offer these gleanings for your amusement:

Said by nursing staff to a particular obstinate physician: “They name streets after you. One Way.”

Gynecology nurse: “I’m the Queen of In-Between!”

Noted to angry patient demanding pain medications: “Here’s your requested 5 mg of shut the #$%* up.”

Patient who presented with difficulty swallowing, sore throat, and blood in his semen was considered to have Ron Jeremy Syndrome. (Note: if you don’t get it right away, don’t bother looking it up. Not worth your time.)

Nursing staff: “Just b---h slap me if I ever make the ED my primary point of care for constipation.

Emergency care is the one-night stand of medicine. It’s fun and satisfying, but it doesn’t last long.

Nurse: “I’m a professional mushroom. I stand in the dark and get fed s…t all day long.”

“AA is for quitters…and quitters never win.”

Psychiatric screener: “He’s Off The Wall, and not in the good Michael Jackson sort of way.”

Patient: “You have to give me a prescription for Percocet. I’ve got a (Florida Medicaid) Gold Card.”

Why is it that you cannot eat a Tootsie Roll without drooling? And why is it that we have no compunction eating a tootsie roll, fully recognizing that it looks like an overgrown rabbit dropping?

Nurse reading the newspaper: “I’m checking the obits to make sure it’s nobody we saw last week.”

There was a pop culture magazine on the desk with a picture of a pregnant celebrity on the front. The considerable joy of children aside, clinically pregnancy is a pathologic state. There are changes in hemodynamics, respiratory capacity, and a host of complications and problems unique to the gravid state. So if pathology is beautiful, why don’t we have pictures of tumors and skin lesions and mangled limbs on the cover?

ED Tech: “Let’s not order Chinese. Last time we had it I think I got Chicken Chow Meow. (Or Kung Pow Meow. Or Geneal Tso’s Meow.” ( Or, as the bumper stickers say, “I Love Cats. I Had Two for Breakfast,” and “Cat: The Other White Meat.”)

Parent: “My two-month-old can’t speak.” (Neither could mine when he was that age. Which reminds me, speaking of things that normally can't, of The Child’s favorite talking dog joke:

This 12-year old and his dog go into a restaraunt. The waiter says, "I`ll give you a banana split on the house if that dog can talk!" The kid agrees with this bet.

Waiter: What`s on top of a house?

Dog: "Roof!"

Waiter: How does sandpaper feel?

Dog: "Ruff!"

Waiter: Who was the greatest baseball player of all time?

Dog:"Ruth!"

The Waiter throws the kid and his dog out of the restaraunt with no banana split.

The dog looks at the boy and says, "Do you think I should have said Mantle?"

For the record, said joke was typed into blog by The Child)

Which, in turn reminds me of my favorite talking dog joke, openly stolen from the Bob and Tom Radio Show:

A guy sees an ad in the paper for a $10.00 talking dog. The guy is intrigued by this bargain, so he goes to the home of the dog's owner and asks if he really has a talking dog for sale. "Sure I do," says the owner. "He's out back."

The guy goes into the backyard and sees a dog. "Are you a talking dog?"

"Yep, that's me," says the dog.

The guy is flabbergasted. "You're really a talking dog! This is amazing! But how did you get here?"

The dog answers,"Well, it's kind of a long story. I started out getting trained as a K-9 and rescue dog, but I broke a paw sniffing out the injured on 9/11. Then I did some airport work for the DEA in Miami. Eventually the heat was too much...I've got all this fur, you know...so I moved up north and was a guide dog for the blind. I also had a chance to do some summer stock theater along the way...perhaps you've seen me in Annie?"

The guy runs to the dog's owner. "Of course I'll buy the dog!' he exclaims. "But why are you selling him in the first place?"

"Cuz he's a big fat liar," says the owner.

Nurse discussing toothache patient: “She has summer teeth. Summer there, and summer not.”

Physician Assistant: “Patient is here with back pain after a slip and fall. Guess what store it was in?” (Answer: Wal-Mart. Always Wal-Mart.)

Nurse regarding moaning teenage patient: “She has a case of the IBD’s. You know…I Be Dyin’.”

Patient: "Last time I was here, they lost me twice." (Where? In the broom closet?")

Nurse to physician: "How come your Johnson's levels are up?" (Johnson was a patient. I think.)

Patient: "If the protection fell off, can I get pregnant?" (Yes. Yesyeysyesyesyes. And she was.)

And finally, a note that working in the ED can restore your faith in romance. Just when you think you might be alone in this world, just a look about the ED. When you realize who can get pregnant, and who might have participated in the process…well, it makes you realize that there’s really someone for everybody.

(Please feel free to add your own ED gleanings as comments! Thanks!)

Writing Hurts

Writing the blog is sometimes very painful. It’s not because I don’t like to write, because I do. It’s not because it’s difficult, although I do agree with the fictional author in The Angel’s Game who notes that sometimes to write you just have to sit down, squeeze your brain, and see what comes out.

The writing is painful because I can’t tell you the stories I really want to tell.

The good stories, the real stories, the stories worth telling in medicine are not the ones I write for you. The ones you see are the easy ones. They are the stories with set beginnings and endings, stories with no harm and no foul. They are stories that live in a world of black and white, a world where things are both defined and definite, and where thought is not required but is nice work if you can get it.

That’s not the real world of emergency medicine, at least not where the good stuff lies. The world that’s interesting , challenging, where souls are searched, doubts are harbored, and sleep is lost is a world of grays where the edge of the knife is often unseen and days of sheer boredom are punctuated by moments of utter madness. It’s a world of maybes and possiblys, of probablys and I-don’t-think-so’s, a world where every step into the subjective morass we call humanity is haunted by thoughts of doing too much and what we might miss. It’s a world where things just happen, and whether you do or don’t do something about it seems to make no difference at all. It’s a world where people die for no explicable reason, and where people who should be dead, or need to be, aren’t.

The best medical writing in ages past dealt with these very issues. Especially in the days before effective therapy, physicians would write about the real practice of medicine, about comforting the hopeless, trying to make sense of suffering, standing alone against tidal waves of uncertainty, plunging into the unknown chasm between science and faith. But the reader trying to understand the practice of medicine in our times will find nothing but tales of difficult but successful cases, lots of thoughts on the business of medicine, and a slew of soulless technical reports.

The reason is that it’s just become too dangerous to put reality into words. We live in a society where everything is foreseen through hindsight, and where the mists of time do nothing but sharpen the view. We’ve done such a good job advertising medical advances that nothing less than perfection is accepted; if something happens, it must be someone’s fault. And while we may acknowledge that nature may have her whims, we still cast about for someone to blame for her damage. (I think ED folks have an inherent understanding of nature’s victories. We know that when it’s car versus tree, the tree always wins…even if it’s been turned into a telephone pole.)

So why can’t I write the stories I want to tell? It’s because I’m scared to do so. Terrified, in fact. If I tell you these stories, I have no way to know that someone won’t pick up on the tale and trace it back to a patient. Within medical culture, judgment calls are automatic reasons for criticism. Indeed, there’s a whole academic industry called the Morbidity and Mortality Conference in which physicians who have never actually seen the patient nor work in the same field roundly dissect the care provided by another doctor. There’s also the system of Peer Review, which seems much less concerned with improving care than finding someone to take the fall for failures of the health care system. And that’s not even talking about the medicolegal climate, where anything is fair game for a lawsuit and there’s always an expert to tell you you’re wrong. (I say this as someone who’s done expert witness case review). A clinical tale might be traced back to an actual incident, and what is intended as an expression of the real challenges of care becomes ammunition for an assault on my integrity and my livelihood.

So I probably will never be able to write the kind of stories I really want to, at least until the statue of limitations runs out and I’m truly retired for good with all my assets in trust. Until then, continue to enjoy the pieces of fluff I put out. You’ll never really know what you’re missing.

Gingerbread Breasts

I’ve never been able to agree with those who contend that health care should operate strictly along free market principles, and that allowing it to do so without government involvement or competition is the best way to promote health care reform. I don’t believe this because it’s never worked that way before, and the very nature of health care precludes it from operating as a free market entity.

The fact is that you can't look at health care as a marketplace subject to the same market forces as buying a home appliance. The key difference is that health care is accessed differently than other markets. For example, it’s your insurance plan that often dictates your choice of physician or hospital, not your informed consumerism. Your insurance plan may not be your choice, but the only one offered to you by your employer or the government. If your needs are urgent, your choices are often circumscribed by time, geography, and the need for specialty services. The vast majority of expenditures on your behalf go through a single gatekeeper (your personal physician) rather than an individual having free choice of costs, products, and options to review at their leisure. I don't know that I can support the idea of heath care operating as a pure free market system, not because there's anything wrong with the free market, but because health care cannot by its very essence operate in that way except in a very limited realm of choices and services. An employer choosing which health plan to offer employees can do so using free market principles; the employee's use of that policy cannot.

But health care can work as a free market for those procedures that are purely elective, like cosmetic plastic surgery. There was a time in medical school that I wanted to be a plastic surgeon. It was during my first year, when we were rotated through community hospitals for the purposes of getting acquainted with clinical medicine. (In reality, it was an excuse for the University to charge us a whole lot more money for the privilege of wearing a lab coat once a week and pretending you were something other than a rank freshman dissecting preserved cats in biology class.) By chance, I was taken in by Dr. Michael Hynes, a plastic surgeon in Kansas City. He would let me watch surgery and follow him during rounds, all heady stuff for a teenager.
I still remember the first surgery I ever got to scrub on. It was an amputation of the lower leg for persistent problems with circulation and non-healing wounds, and he had asked my friend Todd Gwin and I to assist. Our “help” had consisted on holding the leg down by the ankle while he worked some kind of surgical magic just above the knee. We were watching him, fascinated by what he was doing but not yet with enough knowledge to actually figure it out, when he quietly said, “Okay, take that leg and hand ot off to the nurse.”

Todd and I looked at each other in the space between our surgical masks and our scrub caps.

“Huh?”

“Yeah, take it off the table and put it on the cart behind you.”

What we hadn’t realized is that he had just detached the lower leg from the rest of the body. Looking at each other with disbelief and a trace of fear, we slowly started to lift the leg up and could not understand why the rest of the limb from the knee up didn’t come with it. We thought that maybe we had just not lifted it high enough, but not matter how many inches we took the leg above the table the rest of the body stubbornly refused to come along for the ride. And then we were holding this disembodied, waxy leg, now cool to the touch with it’s blood supply severed, looking at it with utter disbelief and in total ignorance of what we should do with it.

“Taking it away today would be good.” Dr. Hynes stayed bent over his work.

So as the rolling table was on my side, Todd shifted to weight of the leg to me. While nurse aides and other caretakers have a keen sense of what it feels like to lift the dead weight of an adult human body, most of us really have no idea. We pick up molded plastic bloodied limbs at the Halloween store to decorate our homes and think it’s something like the real thing. The truth is that the human body is heavy and awkward, that the sprawling limbs and floppy head defy all the rules for lifting weights as a consolidated compact mass. This is all a polite way of saying that I had no idea how much a human leg weighed, and I almost dropped it. By the time I had gotten it over to the cart, I recognized that I should have some kind of profound thought, but nothing came to me except a very clinical, “Whoa, that’s a leg.” Which, I suppose, is precisely the point.

Dr. Hynes was a great guy. While he may have done lots of cosmetic work, most of what I saw was reconstructives…facial fractures, skin flaps, rebuilding pieces and parts. I thought it was fascinating (still do), and that this was what I wanted to do for a living. That was, until I learned that in order to become a plastic surgeon I would have to voluntarily submit to five years of butt-whipping and genital-licking to be a top general surgery resident, and then try to weasel my way into two additional years of the same as a plastics fellow, and suddenly three years of shift-based, not-on-call Emergency Medicine residency seemed a much better deal. And while the ER has been a great ride, that’s still one career decision I regret.

But back to the free market, the glories of capitalism, and the shameless pursuit of ersatz perfection. The hospital where I work will be placing an advertisement in the November 30th issue of the Daytona Beach News-Journal. Entitled “Ten Procedures Specially Priced for the Holidays: ‘Tis the Season for a New You,” it pictures a gingerbread man complete with a list of elective plastic surgical procedures and prices, with arrows pointing to the relevant part of the pastry individual. A facelift is $4,000, and new nose is $2,800, and a mere $3,000 gets your ears pinned back to the sides of yur head. (Interestingly, the most common plastic surgical procedure performed on gingerbread people...dental dismemberment and decapitation, or biting off the arms, legs, and head…is actually not listed as an option, probably because it’s free.) The ad mentions that gift certificates for these procedures are great stocking stuffers, because there is nothing more your beloved wants than a gift that says there’s something fundamentally wrong with you and I’m willing to pay real money to make it go away.

(I showed the ad to a friend of mine who actually is a plastic surgeon. He looked at the picture, thoughtfully pulled down his glasses down over his nose, and with all professional seriousness noted, “$2,920 is pretty good for a couple of decent breasts.”)

It took little effort to think through the ramifications of this proposal. Take the breasts. The line from the printed price to the appropriate part of the gingerbread man pointed to a single red hot where the right breast would be. (Since the gingerbread man also had a bow tie, we’re still a little confused about the gingerbread gender.) So the first question to answer is if the price was for a single breast, because that’s what it pointed to, or for a set of two. And then we wondered what kind of breasts you got for $2,920. Saline or silicon? Paper or plastic? Mix and match?
What about size? Was that the full price to go from A to DD, four sizes up? If you only wanted to go up two sizes, say from a C to a DD, is it only have the price? And why was the price an odd number, like $2,920? If you spent the extra $80 and made it an even $3,000, did you get some kind of bonus item like an extra nipple?

(I don’t have any really good plastic surgery breast stories. The only one worth telling is the time I was out with friends, everyone got a little drunk, and one of our more generously endowed nurses decided it would be educational for us to see just how good a job her plastic surgeon had done on her breasts. So she flashed, and I looked, and the pathetic combination of age, alcohol, and clinical acumen in me meant that I actually was noticing the exemplary symmetry and the lack of obvious scarring rather than the intended humongous perkiness of the effort.)

I do think sales like these are a good idea, and not just because they help jump-start the local economy. I know that personally, when I was “on the market,” as it were, I could easily spend at least this much money in meals, movies, and jewelry just trying to get a good long look at a single set of breasts. Imagine spending the same amount of money, and then getting to own them? What a deal! That is, as long as they don’t run off with the undercarriage.

Flying Fish

The hospital where I work has been conducting a series of seminars designed to enhance the patient and family experience at our facility. The effort is motivated by several factors. One is certainly to support the hospital’s mission as a place of care and comfort for the community. However, because health care is now very much a business, there are other, less altruistic reasons for doing so. In a competitive marketplace, the facility where patients and families feel most comfortable has the opportunity to take more of the market share of work. And the federal government is compiling data regarding customer satisfaction with health care facilities through the Consumer Assessment of Healthcare Providers and Systems Hospital Survey (H-CAHPS). The stated goals for the survey are for public reporting to enhance the transparency of care and provide incentives for hospitals to improve their performance. But the unspoken bottom line is that at some point in the future, scores will be used to modify reimbursement patterns. This concern makes it key for facilities and their employees to understand the H-CAPHS system and align themselves in such a way as to insure that scores are as high as possible.

So last month off I went to my scheduled session at 0730 (it sounds more important in military time) after working a particularly nasty night shift. Fortified with two cups of hot tea, I found a place in the back of the room where I figured I could hide when the lights went down and the Sandman stopped by for his imminent a visit. I was careful to choose a spot beneath an air conditioning vent as well, for I’ve learned over time that the sound of air blowing through the ductwork can mask all but the most sonorous respirations.

(This meeting-sleeping parallel is not new to me. During medical school, the daily Noon Conference was held in a large amphitheater with raised tiers surrounding a central dais. Each tier featured a continuous desk with a lowered skirt that extended along the perimeter of the tier facing the speaker. Behind the desks were swivel chairs attached to the table legs. What this meant in practice was that when the theater was full…which it always was because 1) attendance was required and 2) attendance was required…is that you could lay down on the floor on the uppermost tier and take a nap completely blocked from view by anyone except the three people sitting in the chairs just above your head. I took full advantage of this fact every day for the two months of my annual internal medicine rotation. This skill was not unnoticed by my classmates, who awarded me the “Rip Van Winkle” Award three years in a row. To date, I am the only repeat winner in the history of the school.)

The first order of business was to fill out a name sticker with the one word that describes how you felt at that very moment. Being a generally truthful sort, I wrote TIRED in large capital letters. Turns out that was the wrong answer, and I earned a reproach from the trainers who oozed early-morning glee in a pathologically perky manner. (I’m still working out exactly which organ exudes glee.) It turns out that the correct answer was HAPPY or ENTHUSED or BLESSED, and if I had been thinking I could have applied these words equally well. I was indeed HAPPY to be off shift, and ENTHUSED to be going home, and BLESSED by the fact that case management workers exist to find nursing homes for patients in the middle of the night.

The centerpiece of the presentation was motivational video that I’ve seen several times before. It’s been making the corporate rounds, so perhaps you have too. It’s the one about workers at the Pike Place Fish Market in Seattle who make a cold, nasty job into something fun by laughing, joking, shouting, and flinging fish into the air. The point of the video is that you choose your attitude towards you job. In theory, this works well. In practice, however, it’s a bit more difficult to pull off. During one of my stints as a bureauocrat we decided we would enhance our workplace by tossing file cabinets as a teamwork game. Windows were broken, alarms went off, and the local police did not seem like we had made their job any more fun. (I think they just chose the wrong attitude, but given that law enforcement officers can singlehandedly ruin my car insurance rates they can choose any attitude they want and it’s perfectly okay with me, sir or ma’am.)

The group was then invited to talk about ways they can make work fun. I apparently was called on to proffer a suggestion, and I must have said something. The truth is that I was so tired I have no idea if I did or not. I recall watching the fish soar through the rainy skies of the Pacific Northwest, and then I was seeing a packet of crackers in front of me just before a red squeezey trinket careened off my head. It must have been a “carrot-and-stick” sort of thing.

Another party favor I got to take home was a pre-printed card to remind me that “Kindness is Contagious.” Having been indoctrinated throughout medical training that contagious things ought to best be stamped out as quickly as possible, I’m still working through this concept. I also received some notecards that I’m supposed to give to someone when I see them do something of particular value to the health care team. I’ve already pre-written a few, such as “Thanks for graciously cleaning up that bodily fluid spill last night. Lord knows I wasn’t gonna touch that,’ and “I appreciate your kind and considerate help in cold-cocking the patient who came at me with a stick.”

In the end, a good time was had by all, and I was able to go home and rest with my free package of snack crackers and the soft plastic squeezy thing which the Residential Cat promptly took apart. Tomorrow before my shift I’m going down to Hull’s Fish Market and getting three pounds of mullet. If throwing one big fish around is good for morale, imagine the effect of forty smaller ones. It’s a way to spread the joy even farther. Especially if I hide them in various places where they won’t be found for a few days. Just think of what that’ll do for morale!

Are We Keen on the Nicotine Vaccine?

From the Internet last week:

Nicotine Vaccine May Help Smokers Quit

The National Institute on Drug Abuse, a division of the National Institutes of Health, gave Nabi BioPharmaceuticals a $10 million grant to take its anti-nicotine vaccine, NicVAX, to clinical trials. Officials want to confirm its effectiveness, monitor side effects, compare it to commonly used treatments and collect information that will allow the drug treatment to be used safely…

NicVAX is designed to stimulate the immune system to create antibodies that latch onto nicotine molecules in a smoker's bloodstream, preventing nicotine from entering the brain. Trapped outside the brain, the too-large molecules of nicotine can’t trigger the addictive pleasure chemicals invoked by smoking tobacco. …

The results of initial trials on 1,000 patients has been promising and caused few side effects. Nabi BioPharmaceuticals reports that 35 percent of those given the vaccine have been able to remain smoke-free compared with only 10 percent of patients who received a placebo.

(Nicole Straff, AOL Health, November 13, 2009)

I’ve written previously on The Blog about the benefits of vaccinations, and about the need for patients to assume some degree of responsibility for their own health behaviors. So when I read the on-line notice as I sipped my early morning Dunkin’ Donuts Vanilla Chai (Note to Company: Why can’t I get any size larger than medium?), my interest was piqued. The idea of a vaccine for nicotine addiction, and the use of a quick technological fix to prevent the health effects of cigarette use, appealed to every public health bone in my body. (Admittedly, these moments are getting fewer and fewer as I get farther from that phase of my life. Yet every now and then one of these residual ossicles lodges in my throat and I have to resort to the Heimlich Maneuver of Public Concern to get it out.)

Pharmacologic therapy for addictions is not a new idea. There are lots of therapies out there to help manage acute overdoses of medications such as narcotics (Codeine, Lortab, and Percocet) and benzodiazepines (Valium and Ativan). There are also a host of treatments to help manage both narcotic and alcohol withdrawal symptoms, and specific pharmacologic regimens have been developed to provoke acute withdrawal in a supervised setting under sedation or anesthesia to speed up the detoxification process. (This is actually a pretty good business as well; an outfit in Michigan offers a one hour detox under anesthesia for only $6,700. The on-line brochure notes that operators are available 24 hours a day, 7 days a week. And of you order now, we’ll throw in the Showtime Rotisserie Oven and this amazing spiral slicer. Call today!)

Less common, however, are medications that are given on the front end to inhibit the addictive behavior. Many people are familiar with the fact that heroin addicts are often treated with methadone, an artificial analogue of the street drug prescribed by a physician. In theory this takes the addict off the street and facilitates a slow and gradual withdrawal; in reality, it substitutes one addictive drug for another, and while it does take folks off the street it puts them into the ED on nights and weekends when the Methadone Depot is closed. (True story: About three months ago I was working a night shift and the police brought in an empty shipping carton containing twelve one liter bottles of methadone elixir. But it’s not addictive, right?). There are implants that can provide some assistance by blocking the effect of opiates as well, but their long-term success in preventing recidivism is not yet established. And while certain antidepressants (Chantix) have been used to assist with smoking cessation, it’s uncertain whether their effect is really related to the antagonism of nicotine or on managing the mild situational depression that often accompanies attempts at lifestyle change.

There is also a medication out there to prevent alcohol abuse. It’s called disulfiram (Antabuse), and its use was quite the rage when I was in training. What it does is block the metabolism of alcohol so when a person taking the drug uses alcohol, there’s a buildup of acetaldehyde formaldehyde in their system. Acetaldehyde is the main ingredient of a hangover, and the patient who swigs a beer while on the drug has an immediate (5-10 minute) and quite potent hangover complete with sweating, shaking, flushing, nausea, violent retching, and a feeling of being generally unwell (I use that term because I’m not sure “crappy” is a word befitting medicine, and I can’t in good conscience refer to a bowel-product in a family publication.) Recall that the closely related formaldehyde is the stuff they use to pickle dead fish and fetal pigs in jars on the wall in high school biology, and you can figure that you probably don’t want any of that in you. Disulfiram isn’t used much anymore. The official reason is that there are so many products with alcohol in them (mouthwash, liquid medications, etc), that patients were inadvertently pushed into reactions, which was admittedly unfair to them. However, my own theory is that nobody takes it anymore because it stops alcoholics from drinking, and if I’m an alcoholic the last thing I’m going to do is take something that going to make me sick when I drink. In my experience, most alcoholics would like to have their hangover the old-fashioned way, so compliance with Antabuse is usually abysmal. Personally, I wish it would make a comeback, and specifically that they would develop an injectable form for use in the ED. I can’t help but think that if we could induce a violent hangover in some of our more chronic alcoholic patients rather than just letting them sleep it off, they might be more motivated for treatment.

(To be frank, there are other examples of punitive theory in which I fervently believe. For example, gonorrhea can be treated equally well with either a painful injection in the posterior or with a dose of oral medication. If you’re the one passing the disease around, or if you’re just being a jerk, guess which therapy you get?).

But there’s never been a vaccine that regulates behavior leading to long-term health problems. The concept is fascinating. By blocking the passage of nicotine through the blood-brain barrier, we stop the stimulation of nicotine receptors in the brain. If the receptors are blocked, there’s no pleasure from smoking. The idea opens the door to a world of possibilities. Can we do the same for the metabolic products of alcohol, preventing them from affecting the brain and blocking the pleasant feelings of Cap’n Jack? How about narcotics? A biochemical stimulant that produces obesity? Sound waves at the frequency of Glenn Beck’s voice?

Like most things, the idea of a vaccine against behavior is easier said than done. This use of technology also opens up an entire spectrum of ethical issues. Let’s say that we are, in fact, able to regulate behavior with vaccines. Do we want to? Is it right to do so? How do you give informed consent for behavioral change when the end result may be permanent? What does it do to the concepts of autonomy and free will? And as our knowledge of immunology and neurochemistry gets more specific, can we develop vaccines to block other behaviors not related to poor health? I don’t know that I’d go as far as to invoke George Orwell’s 1984, but it’s pretty easy to see where the argument is headed. Clinically, there’s a problem here as well. It’s entirely possible that a drug addict who got an anti-narcotic vaccine has a broken leg six months later. Even I’d be hard pressed to say that the patient should be denied the beneficial effects of pain medication simply because the vaccine is already “on board” and doing its stuff. (I think the people I work with would tell you I’m a relatively hard person to get narcotics from, but I do have my limits. My theory has always been if you break something, lose something, bleed somewhere, have cancer, or let me stick a sharpened piece of stainless steel somewhere into your body, you can have all the pain medication you want.)

There’s also a flip side to the coin. Vaccines designed for clinical purposes can be perceived as facilitating undesirable behavior. We’ve seen this with the advent of the Human Papilloma Virus (HPV) vaccine. Clinically, this is great thing. We know that cervical cancer is a leading killer of young women, and that cervical cancer is caused in large part by infection with HPV. HPV, in turn, is fairly ubiquitous in our society, so it makes sense to offer the HPV vaccine to all girls and young women in order to diminish their risk of cancer. While there are still some issues to work out…namely if there are long-term effects, and if boys who are carriers of HPV should get vaccinated as well…this is a wonderful innovation and the first in what we hope will be a virtual cornucopia of preventive immunotherapies for malignant disease.

How can something this good get tuned on its head? Well, HPV is contracted through sexual contact. And if we make unprotected sex safer, that might encourage more teenagers and unmarried people to have sex. That’s not right. And if that happens, there might be more abortions. That would also be wrong. Clinically, I would argue (and have done so) that while it’s true that there may be less risk of cervical cancer, there are still plenty of other reasons to discourage sex outside of a long-term monogamous relationship. Things like unwanted pregnancy, gonorrhea, syphilis, hepatitis, and AIDS come to mind. But you can see the politics at work here, can’t you?

In the long run, I suspect the story of the nicotine vaccine (at least the form currently in trials) will be a lot like the tale of the gastric banding procedure. The “fatpass” (official medical term) decreases the size of the stomach so less food can be taken in at each meal, therefore decreasing total caloric intake and inducing weight loss. That being said, I’ve seen hosts of patients who had the procedure and, after initially losing poundage in the triple digits, have put most of it right back on. This happens because their underlying issues with food and lifestyle cannot be solved with surgery, and so they learn to compensate for the procedure by eating the same volume of food, but eating smaller amounts more frequently. (One of my ED doc colleagues is a perfect example of this. The day after his gastric bypass, someone called to see how he was doing. He was eating a pan of brownies, but with the bypass he could only eat them only one at a time.)

The article described a success rate of 35% in getting patients to remain nicotine-free. Checking out the company’s web site, the trials have lasted only 6-12 months. And while a short-term return of 35% is surely better than nothing, it’s still only 35%. People who are successful with permanent weight loss after gastric bypass surgery are those who also change their diet, lifestyle, social circles, and self-perceptions. If the vaccine helps only a minority of smokers to quit, there must be a host of other reasons for tobacco use besides the nicotine kick. While the vaccine can be part of the solution…and if it passes clinical trials, I’ll be proud to be a cheerleader…it is a single piece of the puzzle which also includes higher prices on tobacco products, clean indoor air legislation, enforcement of underage tobacco purchases, expansion of smoking cessation programs, and public education. My fear is that in this technology-happy, quick-fix society, those strategies shown to have real impact on the health effects of tobacco use will be lost.

Abbott, Costello, and Microsoft

After the serious stuff, and two very tiring ED shifts, I will freely admit to cheating on today's post. I got this from The Father with an infinite email trace, so nobody knows where it started...but I hope you think it's as funny as I did!

(If you are of an age that this dialogue makes no sense to you, please go to YouTube, http://www.youtube.com/watch?v=wfmvkO5x6Ng, for the original.)

You have to be old enough to remember Abbott and Costello, and too old to REALLY understand computers, to fully appreciate this. For those of us who sometimes get flustered by our computers, please read on...

If Bud Abbott and Lou Costello were alive today, their infamous sketch, 'Who's on First?' might have turned out something like this:

COSTELLO CALLS TO BUY A COMPUTER FROM ABBOTT

ABBOTT: Super Duper computer store. Can I help you?

COSTELLO: Thanks I'm setting up an office in my den and I'm thinking about buying a computer.

ABBOTT: Mac?

COSTELLO: No, the name's Lou.

ABBOTT: Your computer?

COSTELLO: I don't own a computer. I want to buy one.

ABBOTT: Mac?

COSTELLO: I told you, my name's Lou.

ABBOTT: What about Windows?

COSTELLO: Why? Will it get stuffy in here?

ABBOTT: Do you want a computer with Windows?

COSTELLO: I don't know. What will I see when I look at the windows?

ABBOTT: Wallpaper.

COSTELLO: Never mind the windows. I need a computer and software.

ABBOTT: Software for Windows?

COSTELLO: No. On the computer! I need something I can use to write proposals, track expenses and run my business. What do you have?

ABBOTT: Office.

COSTELLO: Yeah, for my office. Can you recommend anything?

ABBOTT: I just did.

COSTELLO: You just did what?

ABBOTT: Recommend something.

COSTELLO: You recommended something?

ABBOTT: Yes.

COSTELLO: For my office?

ABBOTT: Yes.

COSTELLO: OK, what did you recommend for my office?

ABBOTT: Office.

COSTELLO: Yes, for my office!

ABBOTT: I recommend Office with Windows.

COSTELLO: I already have an office with windows! OK, let's just say I'm sitting at my computer and I want to type a proposal. What do I need?

ABBOTT: Word.

COSTELLO: What word?

ABBOTT: Word in Office.

COSTELLO: The only word in office is office.

ABBOTT: The Word in Office for Windows.

COSTELLO: Which word in office for windows?

ABBOTT: The Word you get when you click the blue 'W'.

COSTELLO: I'm going to click your blue 'w' if you don't start with some straight answers. What about financial bookkeeping? You have anything I can track my money with?

ABBOTT: Money.

COSTELLO: That's right. What do you have?

ABBOTT: Money.

COSTELLO: I need money to track my money?

ABBOTT: It comes bundled with your computer.

COSTELLO: What's bundled with my computer?

ABBOTT: Money.

COSTELLO: Money comes with my computer?

ABBOTT: Yes. No extra charge.

COSTELLO: I get a bundle of money with my computer? How much?

ABBOTT: One copy.

COSTELLO: Isn't it illegal to copy money?

ABBOTT: Microsoft gave us a license to copy Money.

COSTELLO: They can give you a license to copy money?

ABBOTT: Why not? THEY OWN IT!

(A few days later)

ABBOTT: Super Duper computer store. Can I help you?

COSTELLO: How do I turn my computer off?

ABBOTT: Click on 'START'.............