Thursday, September 24, 2009

The Vicious Divorce and the Laws

While I'm not happy to have a divorce on my record (but just as happy that it occurred), every now and then it helps to know it could be worse. Take this guy I saw in the ER today. His complaint was that he had hot and cold feelings in his stomach. These started about three weeks ago, when a waitress at Burger King called him "sweetie," which he thought was unusual in itself. Then he noticed that his burger had something sweet in it, and he knew that "they" were trying to "hit" him again. Again, because last month "they"put bleach in a pitcher of beer and had had blisters in his mouth the next day. And then a few months ago "they" dropped a full can of Colt 45 Malt Liquor on his head. Not to mention that last August, "they" had tried to kill him in an auto accident that left him with chronic chest pain. They, of course, are his ex-wife, her mother, and the wait staff at a variety of eating and drinking establishments. But he understands why "they" are out to get him, ever since he reported that his ex-wife had left the children in the company of vagrants living under a bridge (a step even below a VAN DOWN BY THE RIVER, for you Matt Foley fanatics). And he knows that that legal system is against him, too, because a judge ordered him to have an involuntary psychiatric evaluation last February. And today I led the heath care system into the fray, running up a bill on the citizen's dime in order to document that he, in fact, does not have an acute medical emergency. This was frustrating to him as he saw something floating in his urine, and wanted me to personally watch him pass the wasteful amber fluids to check. I declined the opportunity to build further patient rapport. He departed a dissatisfied client, and I reflected that this case likely represents an unreported side effect of marital separation. I think I can get a publication out of this.

(The fact that lab tests were actually done in this patient is not only a reflection of our current medicolegal climate, where clinical judgement means nothing without copious doses of fear and technology, but is also a prime application of Sirridge's Law. The Law is named after Wild Bill Sirridge, a Professor of Internal Medicine where I went to medical school and one of my supervising physicians during my internship. Wild Bill was a country doc from the old school, the kind of guy who would tell a terminally ill patient that it was probably smarter to rent than buy.

The Law was promulgated one morning when I had admitted yet another patient with an altered level of consciousness that I surmised might be related to a serum alcohol level three and a half times the legal limit (and in those unenlightened days, the limit was 0.1, not the pansy .08 level we use now. So what if the lower level is actually a better measure of impairment? In those days, we could hold our liquor. Men were men, women were women, and sheep in Oklahoma were nervous).

Anyway, I had admittedly not done a very complete workup, figuring that if he woke up okay in the morning it would be the alcohol wearing off; if not, we might look a little closer. Wild Bill greeted this idea with disdain. He pointed out...quite rightly...that there was more to evaluating the patient with an altered level of consciousness than just thinking about his alcohol level. What if there was a head injury? How about an environmental problem, like hypothermia? A nutritional disorder with central nervous system effects? Liver failure with a buildup of toxic ammonia? How about other intoxicants? Is there underlying infection that could cause a change in mental status? The conversation was summarized in The Law: "Rody, even crocks get disease."

I have remembered this caveat all these years, and often found his advice to be critical in patient management in the ED. But the immediate aftermath of The Law was that for the next three weeks every patient that came in drunk received an extensive workup, all of which were completely negative. This lead to Rodenberg's Corollary to Sirridge's Law, offered at the conclusion yet another negative patient report: "Bill, sometimes you've just got to call a squirrel a squirrel."

These have been words to live by. I hope someday to find them carved on a building.)

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