Wednesday, November 11, 2009

The Nose Knows

I’ve had people ask me from time to time what doctors actually talk about in the ED. I think the assumption is that, just like on television, we spend most of our time either talking about difficult cases, weighing critical medical decisions, or discussing relationships. The truth is much, much stranger than you ever thought.

Here’s what passes for intellectual conversation one day last week. One of my colleagues was trying to dictate the medical record of a patient with a nosebleed. Just for the record, nosebleeds (“epistaxis,” from the Greek meaning “really disgusting”) are one of the least favorite things to care for in the ED. I don’t know anyone who thinks it’s an interesting clinical challenge, and I think it’s because nosebleed’s don’t just bleed. They bleed in a particularly unpleasant fashion. Blood by itself is really pretty innocuous...a little thicker than water, it has a little sheen to look at it and slickness to the touch, but you get it on your gloves and you move on. (If fact, in some cases of vaginal bleeding you’ll intentionally break up a blood clot with your fingers to look for fetal tissues suggesting a miscarriage.) With a nosebleed, however, you get blood mixed with snot (“mucus,” from the Latin “also disgusting”) which results in a product of varying shades, the consistency of snail traces, and a tendency to stick to everything worse than internists on old people (there’s a reason that specialists in general internal medicine are known as “fleas”). Add to it that when this stuff comes out of the nose, it either flows down the back of the throat and results in gagging and occasional retching of the nasal blood and mucous plus stomach contents, or (if you’re in just the right place) it comes out the front, punctuated with sneezes seemingly designed to cause maximum damage to the physician, who is inevitably standing in front of the patient trying to see where the bleeding’s coming from at that exact moment.

Treatment just adds to the fun. Fortunately, the bleeding often stops on it’s own. Rarely you’ll be able to see the bleeding spot along the nasal septum and cauterize it with silver nitrate. More severe bleeding comes from the back of the nasal cavity, and can’t be seen by the physician without the special tools and toys of the ENT specialist. So to get the bleeding to stop, the ED doc goes on a fishing expedition which essentially consists of jamming things…pieces of foam, plastic balloons…of increasing discomfort into the nose until the bleeding stops. And you’re doing this in the face of continued hemomucoid (“blood and pus” from the Arabic, “that’s bound to ruin your shirt”) expulsions directly towards the operator, who has to lean into the line of fire to see what he or she is doing.

At this point, the patient will be in pain (it hurts to have stuff jammed into your nose), and will feel short of breath because they can now use only one nasal passage instead of the requisite two. They don’t like you very much for what you did, and you’re not too enamored of them for making you do it. Hopefully, though, the bleeding will stop. If it does, you call the ENT and arrange follow-up for the next day, because if someone’s going to pull that stuff out of the nose and make it bleed again it sure isn’t gonna be you. If it doesn’t, you drag the ENT out of bed. (To be fair, I will say that ENT physicians so rarely have to come to the ED that when they do, they actually have a pretty good attitude about it. The chance for them to do something acute makes them feel like they’re a golden retriever and you’ve just thrown them a new red rubber ball.)

So anyway, the other doctor is trying to dictate this chart and is trying to figure out the right adjectives to describe the nosebleed. This got us started on all the different adjectives that can be used to describe bodily fluids and the ways they emerge from the body. This became a large-scale discussion involving the entire health care team in a management-friendly collaborative process. The only rule was that it had to be an adjective that you might actually hear used, not something like “paralleling the national debt” to describe a volume of fluid. (Please note that we’re talking adjectives here. The fluids themselves are nouns. You can combine two nouns to make it an adjective…for example, a mixture of mucus and pus can be described as mucopustular… but we thought that was cheating.)

At the end of the day, we decided that there were really four categories we could use to describe bodily fluids:

Amount: Scant, rare, mild, moderate, large, copious, voluminous, massive, elephantine. (Nobody really uses elephantine. I just wanted to see if you were paying attention.)

Rate: Oozing, dripping, steady, profuse, gushing.

Quality: Clear, discolored, purulent, creamy, thick, viscous, foamy, frothy, foul-smelling, feculent, phlegmatic, gooey. (I would personally never use the latter term, because it would permanently ruin Starburst and Japanese Rice Candies and Jujyfruits for me for life. But I actually know a physician who uses that term…copiously.)

Method: Pulsatile, spurting, projective, explosive.

Taking these general categories, one can mix and match to describe the clinical fluid of their choice. (I actually started to write some examples here, but as I did I began to lose my appetite. I’ll let you string together some examples of your own and you’ll get the general idea. “Feculent,” “copious,” and “explosive” is particularly queasy combination.)

In my continuing quest for medical immortality, I would like this system to be known as the “Rodenberg-Other People Adjectival Classification of Bodily Fluids (ROPA-CBF).” I look forward to it’s immediate inclusion in curricula everywhere. And thank you for your support.


  1. you realize, I am currently writing a chapter for a Nursing Essentials book about Health Assessment....Can I quote you? those are really excellent :-)and you made the instuctor laugh.

  2. I'd be flattered to be cited in your book! Thanks!