Monday, March 29, 2010

Twinkies: The Retort

(A reader response to the March 14 post, "Intoxicating Twinkies. A new perspective on college girls, noted as "muffins" in the earlier entry, and on baked goods in general. Enjoy!)

Who Doesn’t Love Muffins?

I stand in defense of muffins everywhere. Face it. Men love muffins. They are cute, sweet, warm, and tasty! They are very hard to resist. I would like to clear up a few misconceptions about muffins.

A muffin is not a bimbo. A bimbo has nothing in her head. A muffin has a brain which she may or may not choose to use. The brain is a highly useful tool of the muffin. Muffins are known to use their brains to get things such as drinks, gifts, or higher grades. This is not to be confused with prostitution, because sex is not traded.

A muffin is not a slut. Sluts use sex to get male attention. Muffins do not need to use sex to get male attention. Just by being a muffin, male attention is often available. Muffins are frequently asked to be ‘trophy dates’ and attend events where the male wishes to make himself appear more virile.

A muffin cannot hold her liquor. Okay, this one could really go either way. Most muffins can freely imbibe and keep up with the men. However, as previously mentioned, a muffin may or may not choose to use her brain. And on occasion, a muffin may make the mistake of not using her brain and will end up on the wrong end of some Jagermeister shots and end up in the ED. Let’s face it, the men in the ED love to see a muffin come in so they can feel superior and remark how silly the muffin looks once she is powerless over them in her state of inebriation.

But alas, some people, no matter how much they love a muffin, may tire of muffins. The truth is muffins are great while they last, but everything has an expiration date. Muffins must eventually move away from muffin world and become a different dish, something more substantial or sophisticated. But men will always love muffins.

Friday, March 26, 2010

Sheep, Birds, and Brownies

Rams Make St. Louis Miserable

09:45 AM ET 03.26 Forbes may be right on the money as to why St. Louis is one of America's most "miserable" cities. While most of the cities are supported with complementary socioeconomic data, we'd like to call attention to the "reason" our beloved St. Louis is listed as one of America's 20 Most Miserable Cities. The Rams are 6-42 in the last three years.

(“Truth & Rumors”, 3/27/10,

The last time I flew into St. Louis, it was for the 2007 Annual Meeting of the Association of State and Territorial Health Officers (ASTHO). Whenever I head into Eastern Missouri, I always have a vague sense of venturing into enemy territory. I recognize that this is a totally irrational belief. The City of St. Louis has never done anything to inconvenience me. It has not sent me random parking tickets, nor has it sent goons to my home. My cousin Tim and his family lived in St. Louis for several years without any obvious damage. (Tim is the cousin who decided…quite rightly…that the best wedding gifts I could receive were Justice League Monopoly and the DVD of “Challenge of the Superfriends, Volume 1.” He’s also the one, when the rabbi at my grandmother’s funeral mixed up the number of her grandchildren and great-grandkids, not only audibly snickered but joined me in assigning all of our cousins into their new categories to figure who got to sit at the adult tableat the next family gathering. The six demoted ones are probably still bitter.)

I think this vague feeling of unrest must have something to do with being a long-time Kansas City boy. I’d heard it said that St. Louis is as far west as you can go and still be in the east, while Kansas City is a far east as you can go and still be in the west, so it could be a deep-seated cultural xenophobia. Or maybe it has something to do with the Gateway Arch, which at one time in my life I characterized as the World’s Largest Croquet Wicket, but which I now, in an older and wiser fashion, see as a giant handle, as if the city erected it in the fond hope that someday a really really really big giant will just pick up the city and move it to someplace else, like Djibouti, where it will fare much better in comparison.

Or maybe it’s a sports thing. I still resent the whining coming from the west bank of the Mississippi when George Brett led the Royals in their righteous quest for the 1985 World Series crown over the cross-state, cross-cultural Cardinals. (I don’t care what anyone saw…Dane Iorg was safe at first…and don’t even try to explain away the 11 run meltdown in Game Seven.) Perhaps it’s not so much the sporting contests as the team names. The monikers of the Kansas City teams…the Royals, Chiefs, and even the late lamented Kansas City Kings…all suggest nobility. And while the former NHL Kansas City Scouts didn’t fit that mold, it at least the name made sense, harkening to one the hallmark spots in Kansas City, a statue in Penn Valley Park overlooking the confluence of the Missouri and Kansas Rivers. And while I’ll grant that Cardinals are probably seen flitting through the springtime Missouri skies, I can’t recall the last time I saw a bighorn sheep trying to knock down the Arch. The St. Louis Blues are essentially named after a clinical depression. And we’re not even going to talk about what the old St. Louis Browns might have been named for.

(In the spirit of fairness, and with a nod to history, I recently finished a fascinating book called “The Gashouse Gang” about the 1934 Cardinals, a team featuring Dizzy Dean and other characters such as Pepper Martin and Joe Medwick, players whose skill on the diamond was coupled with the need to club the opposing fans with a bat and who were removed from games for their own safety. And speaking of Famous Cardinals, I have a very soft spot for a pitcher from The Roaring Twenties. Before my son was born, I randomly flipped pages in a book of baby names, and my finger landed on Grover. Thinking this was fate, I did my best to convince the powers that were that this was a great name. There were lots of famous Grovers in history, and it would be wonderful for our child to follow in their footsteps. There was Grover Cleveland, a notoriously uncorrupt President; Grover Cleveland Alexander, a Hall of Fame pitcher and the hero of Game 7 of the 1926 World Series when the Cardinals defeated the mighty Yankees of Babe Ruth; and of course everyone loves Grover on Sesame Street. Let’s just say this was a battle that I lost. Quickly.)

Maybe it’s the songs. “Meet Me in St. Louis” conjures up better times of long ago, which probably resulted in the more current “St. Louis Blues” (see hockey, above). And it also turns out that in downtown St. Louis you can find the home of the company that makes the antacid Tums, which puts whole new twist in the song “Louie, Louie,” which in turn makes the one comprehensible lyric of “We gotta go. Ya ya ya ya ya,” suddenly make sense. Whereas in Kansas City, we’ve got “crazy little women,” and you stand pretty good shot to “get me one.” Plus, even the Beatles did our tune.

But as I said, there’s no rational basis for these beliefs. Everyone I’ve ever met in St. Louis has been nothing but good and gracious to me. The Italian restaurants are incredible. The National Bowling Museum has a pair of high heel bowling shoes, which makes my bride smile. The City Museum is not a museum, but an incredible fantasy playground for young and old. The folks there even have the good sense to remember that the best steak is properly called a Kansas City Strip rather than the Yankee variety. The zoo is great, the Arch is fascinating, and the Hyatt at Union Station where I was staying is nothing short of spectacular. And unlike my beloved Kansas, St. Louis still has franchises of Jack in the Box, where I’m able to unashamedly indulge my own personal food fetish and gorge myself on deep fried Super Tacos…whose after effects get me thinking once again about the old St. Louis Browns.

Sunday, March 21, 2010

Chocolate: A Brief History

(The Child is reading a set of books by Pseudonymous Bosch. The third book in the series, entitled "This Book is not Good for You" inspired the following essay. That, and when he decided I needed to wake up at 7 AM on a Sunday, I decided he needed to write something for the blog until the morning reached double digits. I'm sooo tired...)

Chocolate. A delicious substance made from special beans made in South America. But do you know the Real truth about it?

Chocolate was first used by the Aztecs (1400-1500). They had the idea of using the pulpy juice from cocoa beans to make a hot drink with cinnamon. We now know that drink as hot chocolate.

The Aztecs believed that chocolate was food of the gods (right up there with pork chops and Coke) and only the emperor and nobles were allowed to drink it. Anyone else who was caught drinking it was put to death.

Later, the Spanish explorer (and also big jerk) Cortez came to South America and was gifted this chocolate drink by Montezuma, who believed Cortez was a god who could cause the end of the Aztecs (actually, he did, but that`s another story).Cortez brought this drink back to England and it became very popular with rich men and nobles. Eventually, an English scientist found out how to compress the cocoa pulp inside a shell made from cocoa. This was the invention of the Candy Bar.

The candy bar, over the past hundred or so years, has undergone some major improvements. The Hershey`s Candies Company was opened in America in-you guessed it-Hershey. The chocolate bar has improved so much over the years.

Now, I have some chocolate to eat.


The Child`s All-Time Favorite Chocolate Recipie:

1 Bar of chocolate (preferably dark)
1 Hand
1 Mouth ( can`t you see where this is going?)

Remove Wrapper from candy bar. Place chocolate bar in hand. Raise bar to mouth. Eat. Repeat.

Friday, March 19, 2010

Twinkies Redux: Reader Mail

(My EMS colleague Mike Fulton, from waaaay back in my Gainesville days, chipped in with his own follow-up story of college mischief with fermeted beverages. So without further ado...)

Great stories Howard! I don't know if this is appropriate, but I have a favorite "muffin" story of my own.It is a story about a girl I picked up in the bathroom at Nichols Alley, late one Saturday night. She was attended by three young men that were more interested in gaining possession of her purse, than her current state (or non-state) of consciousness. Upon intense questioning, they finally admitted that it was possible…that maybe… she just might…. have taken a Quaalude.

We put her on the stretcher and took her out the unit with the boys in tow. Once she was loaded, I jumped in and closed the doors. She suddenly awoke, sat up and threw an arm around me and said, “Take me to the bathroom and then we’ll make out.” I thought she has just gone back in time 30 minutes and responded with my usual line, “My name is Michael, I’m a paramedic and I’m here to help you. You are going to the hospital.” She looked around and said, “OK, give me a bed pan, and then we’ll make out.” I told her we would be at the hospital in three minutes, and she did not want to sit on a bedpan in front of a strange man.

Then the young men knocked on the door and requested that I give them her purse. It seems they had all ridden with her and were really after her car keys. I responded. “You boys were up to no good tonight. You had a plan didn’t you?!” Silence. I told them to contemplate their karma on their long walk home...

We pulled out of the parking lot, and this 100 lbs girl cut loose with a volume of urine appropriate for a 250 lbs construction worker that had been drinking all day, and flooded my ambulance. She then heaved a big sigh of relief, and said, “NOW, we can make out.

Wednesday, March 17, 2010

A Hat Trick of Tales

Three brief notes from the ED this past Saturday:

Mrs. Hulstead was a delightful 80 year old woman who came to see us after having an episode of unresponsiveness at a local restaurant. It turned out that a local physician I know well was also there for lunch, and helped ease the patient to the floor and attended to her until the paramedics arrived.

This reminded me of my own tale of restaurant assistance. About two years ago, The Bride and I were eating at a Cracker Barrel in Topeka. It was just after noon on a Sunday, and the after-church crowd was rolling in. I was fully engaged in the cholesterol bath (if quiet, you can actually hear your arteries snapping shut with cream gravy) when she saw an elderly man at another table starting to slump over his meal. She elbowed me and said I should pay attention and go help him out. I looked up, decided everything was okay, and went back to the unmitigated glory that is a plate of cheesey eggs.

This, however, was not the preferred response, and again the elbow collided with my rib cage. (Note that this was still relatively early in the marriage. Now I’ve been trained to respond at the first elbow.) This time the man was half out of his chair on the way to the floor. It turned out that, as usual, she was right. I should go do something.

I went over to the table, introduced myself, and helped the patient to lie down on the floor. I supported his head, monitored his pulse, and provided reassurance until the paramedics arrived.
I thought nothing of this, as I hadn’t really done anything. But the manager seemed grateful for my acute non-intervention, and comped our meal for the day. We also got a gold certificate good for another meal at a future date.

So two weeks later, it’s another Sunday, we’re back at Cracker Barrel, and the same thing happens. Old person starts to sag. I go over and say the magic words, “Hi! I’m a doctor.” We lay the patient down on the floor, I wait until the paramedics arrive, and I get another gold certificate.

I wish I could say that my luck continued to hold, but the next visit to Cracker Barrel provided unlucky…nobody got sick, nobody collapsed, not even a chance to continue the streak. But ever since then, when I go to a Sunday brunch, I’m always looking for those walkers, canes, and portable oxygen tanks. I just know there’s another golden ticket out there just waiting for me.

One of the elements of any good patient interview is the social history. In its brief ED version, it consists of asking the patient about the use of alcohol, cigarettes, and drugs of abuse. In older patients, one adds questions about their current living arrangements and the use of home medical or social services. Usually this is pretty straightforward, but every now and then the patient will surprise you.

Take Mrs. Jackson, a lovely African-American centenarian who was brought in by her family for generalized weakness. When I asked the usual questions about smoking and drinking, she proclaimed proudly said in the rich tones of Georgia, “Young man, I never have smoked tobacco or touched a drop of alcohol in my whole life.”

(While I’m not a particularly literal believer in the Bible, I have this theory that if the Lord gives you “threescore and ten (Psalms 90:10),” after that you’re on your own. As long as you’ve done well with your divine allotment, you’re free to enjoy whatever vices you choose after that. Of course, you probably won’t have the strength, or the will to do so, but it’s nice to know that after seventy the shackles of decorum are officially off. And for what it’s worth, I have a similar theory about very old…and very wealthy…men and women dating people decades younger than themselves. If you’ve outlived your spouse, and already done right by your children, you’ve got every right to blow what’s left of your nest egg any way you want to. We smile and nod if older folks fritter away wads of cash in Las Vegas, but we get upset if it’s spent on a grade-A bimbo? Please.)

There are some days I have problems with my internal filter. This was one of those times.

“Well, it’s about time you got started, don’t you think?” I said. “Times a’wastin’ here.”

Her family looked at me aghast, as if I’d just suggested that she sabotage over 100 years of work and scuttle her expected tenure at the right hand of God. But the patient looked thoughtful for moment, then turned to me with a warm but insightful gaze.

“You know, young man, I think you might be right.”

Mr. Spaulding was a hale and hearty older gentleman who had some abdominal pain. After a fairly complete workup, we could find nothing in particular wrong of the emergent variety; and as he was already feeling better, we decided not to fix what wasn’t broken and let him go. As he was getting dressed, he mentioned that the following day was going to be his anniversary.

“Congratulations,” I said. “How long have you been married?”

His eyes rolled up slightly, as if he was at the mental blackboard doing subtraction in front of the class. “It’ll be 63 years this time around.”

“That’s wonderful!” I exclaimed. As skeptical as I am about most things, I truly am impressed with people who have kept loving relationships going for decades on end. (It should also be noted that my father, who has been married to my mother for upwards of 50 years, introduces her on occasion as his “first wife” to see what kind of reaction he can get. They are each other’s best friends…and best foils.)

“Yep. We got married ten days after I got off a destroyer in the Pacific.” His brow furrowed in thought for a moment. “You know, I thought I was in love. But it turned out that after 16 months on a ship, I was just in heat.”

We shared a laugh, and I asked if he was still in heat. He smiled broadly. “Yep, I still am,” he noted proudly. “But,” he sadly confided, “since I hit 80, it’s down to once a week.”

Sunday, March 14, 2010

Intoxicating Twinkies

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Thursday, March 11, 2010

Truth...or Consequences

There are four people in this world you never lie to. One is your pastor, because they have a direct line to God. The second is your accountant, because that lands you in jail. The third is your lawyer, because you’re already paying them to lie for you. And the last is your doctor, because if you do we might do something that kills you.

The fact is that it's actually pretty hard to lie in the ED. Experienced staff have an acute filter in place for products of bovine digestion. So if your alcohol level is four times the legal limit and you can’t remember what happened to you or why you are wearing nothing but a “Girls Gone Wild” tee-shirt, it’s not because someone put something your drink. (Well, technically you’re right. It’s called “alcohol.”) If your drug screen comes up positive for marijuana (as it did in a young lady my last shift), don’t tell me it’s because you were exposed to secondhand smoke. When it’s positive for methamphetamine, don’t have your boyfriend say you couldn’t be doing any because between motherhood and pole dancing, there’s just no time in the day to do so. And if cocaine shows up, the chances are pretty good that it’s not, as you say, because you held some for a friend while he was getting ready to smoke it and it seeped into your system through your skin.

Here are some other lies that don't fly in the ED:

“I don’t know why my doctor won’t see me anymore.” (Yes, you do. I do, too.)

“There were these two girls, and when I woke up my wallet was gone and this thing was stuck up in me.” (Don't ask what or where. I said, don't ask. Stop that now.)

“I’m allergic to codeine, but I can take Percocet.” (If you’re allergic to codeine, you can’t take Percocet because it’s in the same chemical family.)

“You’re going to treat me badly because one of your docs had an affair with my wife. (For the record, knowing the doc in question, the quality of what he’s dated, and the quality of the accuser, there’s simply not enough beer in this world.)

“All those records where they said I was looking for drugs? That’s my brother. He takes my driver’s license and impersonates me. All except for the time I had a heart attack. I’m still having pain from that. Can I have some morphine?”

“I’m allergic to oxygen.” (Presumably, this person also does anerobic exercise as well. Interestingly, patients who are allergic to oxygen often end up being labeled as oxygen thieves. An oxygen thief is someone who uses up perfectly good oxygen that could be used by another human being.)

Of course, there are also those things that sound like lies but really aren’t. One of these is the phrase, “I’m pregnant? How did that happen?” You’d be amazed how often I wind up explaining. Just recently we had a 19 year old girl who we diagnosed with her second pregnancy. I tried to answer her question diplomatically. “Well,” I said in my most grandfatherly voice, “it happened in the usual way, with unprotected sexual intercourse.” Seeing the look of confusion on the girl’s face, one of our nurses took over for me. “Honey,” she said, “you (homonym for clucked) without a rubber.”

Believe it or not, it really doesn’t bother me if you come into the ED higher than Marion Barry at the Mayflower Hotel. If I know what you’ve been taking, both our lives are much easier. Just ‘fess up and we’ll be fine. But if you'd rather tempt the tightrope of truth, be aware that lying does not go without consequences.

If you insist on an adverserial relationship with veracity, here’s what happens. First, I may not be able to give you the care you need or treat you properly. You’ve probably heard of the potentially lethal interaction between Viagra and nitrate medications used to treat heart attacks. This is literally just the tip of the iceberg. (That being said, I’ve found that most men over 70 who use Viagra are proud to admit it, extolling its’ virtues with beaming smiles while their wives shrink into the wall like the embarrassed schoolgirls they once were. Caring for skyrocketing blood pressure or a rapid heartbeat due to crack use is a different ball game than the same symptoms caused by other problems. An irregular heartbeat or seizure caused by overdose of certain antidepressant medications is treated in a different manner from those caused by other disorders. Not telling me about getting beat up may cause me to miss subtle signs of head injury. I may order too many tests, not do enough workup, or miss the boat entirely. It’s true that part of my job is to try to include the vast majority of life-threats in my plan, but it’s got to be a cooperative effort.

Second, I will call your bluff. I have a telephone, a computer, and a hospital laboratory at my disposal, and I know how to use them. I can and will find out things about you. And I will tell you what I’ve learned in front of friends, family members, law enforcement officers, or whoever happens to be in the room. Unless you’ve told your personal posse (and I use the term in its best sense) to leave the room, I’m assuming that you have given them permission to hear whatever I’m going to say to you. I will also document everything I’ve learned in your medical record for the use of the next physician who sees you.

Third, I will ask you if you’re interested in going to detox to help you with any drug or alcohol problem you might have. I will document this in your medical record, so the next time you come in for the same problem you will have no excuse for your behavior.

Finally, I will be much less likely to accede to any of your requests. This pertains especially to requests for additional medications, but also to requests for phones, food, taxi fare, bus passes, or virtually anything else that adds to your comfort in the ED. My job is to take care of your medical problems, not to facilitate your abusive behavior (I believe that lying to ED staff is not only disrespectful, but constitutes abuse of the individual doctor or nurse and of the health care system as a whole). So while it’s not an absolute rule and can be modified based on other clinical problems, in most cases lying gets you an enthusiastic recommendation for over-the-counter Tylenol and a trip out the door.

(Here’s another related pet peeve. You come into the ED asking for help in getting off of drugs or alcohol. Maybe you’ve even been talking with the local detox centers, AA, or NA in your effort. This is commendable, and I will do most anything I can to help facilitate your cause. I recognize that breaking the cycle of addiction can be a physical and psychological nightmare. But that being said, don’t come to the ED and ask for just a few more doses of your drug of choice until you can get further care. This makes no sense. If you want to get off a drugs or alcohol, then get off it. For the life of me I can’t figure out the logic of fighting addiction by giving you more of the same. There are perfectly good, non-addicting drugs out there to help manage alcohol and drug withdrawl, and I will be happy to liberally dispense these to you. And for what it’s worth, it’s no good telling me that they might use other medications with addictive potential at the detox center, and asking why I won’t do the same. The difference is that the detox setting is a controlled environment, where your doses can be regulated and you can be monitored for side effects. You want me to give you a few doses of a medication that’s not only addictive but potentially harmful, and then just send you back out on the street? I don’t think so.)

One final tip from me on this topic. If you feel like you have to lie, at least be consistent about it. Don’t tell me you’re in agony and then let me hear you laughing on your cellphone. Don’t tell me your pain in unrelenting if I have to wake you up to check you out. Don’t stalk around the ED demanding attention and then tell me you can’t get up and walk. Don’t tell me you have a seizure and then call me over to your bedside so I can watch you shake one arm up and down, point to it with the other hand, and shout, “See? See this?” Don't tell me you can't keep anything down and then let me see you happily munching on a cookie or a bag of chips. The internet can help you to insure that your feigned signs and symptoms match your ersatz complaint. Ain't technology grand?

Wednesday, March 10, 2010

Rushing to Judgement

Yesterday, I read a story that said Rush Limbaugh was going to move to Costa Rica if the current Health Care Reform bill is passed through Congress and signed into law. As someone who generally prefers a dialogue to a demagogue, my first reaction was to pray for quick action.

But on second thought, I might have to moderate this feeling. Not because I want Rush to stick around (although compared to Glenn Back he seems to be a moderate, which is in and of itself something of an astonishing fact). But because I’m not sure it’s fair to the good people of Costa Rica.

Let’s take a moment to think about Costa Rica. It’s a lovely little place in the midst of Central America, bordered by the waves of the Atlantic on the east and the azure waters of the Pacific on the west, with lush rainforests and sandy beaches. The government is democratic and stable. The unemployment rate is below that of the United States. Current President Oscar Arias won a Nobel Peace Prize for halting civil wars in the region; the President-Elect is a woman. It ranks first in Latin America in international measures of democracy and press freedom; it ranks first in Latin America in the Life Satisfaction Index of the Inter-America Development Bank. It leads the world in first place in the “Happy Planet Index,” a measure of environmental sustainability of the New Economics Foundation. (By way of contrast, the USA is 150th.) It has set a national goal to be carbon neutral by 2021. And for what it’s worth, they also have universal health care.

It’s an enlightened liberal state that works. So it just seems wrong to ask them to take Rush into their midst.

Of course, if we don’t want to inflict Rush on Costa Rica, that means no health care bill this year. And that means lots of people still without health care coverage, which is a bad thing all around.

Gee, international relations are complicated. No wonder we leave it to people who get paid to do it well…you know, like Halliburton.

(Note: I wrote this note late last night after working a late evening shift in the ED. Today, there was a correction to the on-line article that said Mr. Limbaugh was only going to go to Costa Rica to get medical care if health care reform passes, but he would still reside in the USA. So he will forgo the best medical care in the world because he disagrees with how it’s paid for. That might be okay, because the only time the good people of Costa Rica would have to deal with Rush is when he was under anesthesia.)

Tuesday, March 9, 2010


I got off the elevator from the rooftop helipad and saw the red stain on the floor. Not much question of what it was…blood has a certain look to it, a dull sheen, a viscosity that you can see; a deep red where the blood is still liquid, a crimson where it’s starting to dry, small spots of block where it’s begun to congeal. Blood is slippery; it makes people fall. It was smeared across the tile just after the lip of the elevator car, so that when the doors opened you had but a moment to see the stain, recognize it for what it was, and avoid it. For while television dramas immerse their casts knee-deep in blood, no one really wants it on their shoes.

Twenty-three inches after the smear there was a teardrop of blood, slightly enlongated, the narrow end pointing towards the elevator. Twenty-three inches later another drop, pointed as the first. Then another, then another, another still as they fell out of sight around the corner with a hard right turn. They were going my way, so I went theirs. Half stride, blood. Half stride, blood. Half stride, blood. It was a smooth pace, regular, unwavering, cascading straight down the hallway about sixty feet, then veering to the left. I was going that way, too.

The trail ended below the head of a patient who had shot himself. In the moment, the reasons why or how were really of no matter. There was an entrance wound on the right and an exit wound on the left, and bullets that cross the midline kill, full stop. The staff was trying to get a tube in his throat to help him breathe…not because there was any potential save, but we might keep his organs working long enough to get a donation out of his family. And as they struggled with his airway, I saw the blood pulsating out of his brain…pump, pump, pump…every half second...every leisurely half stride…into another red stain that lapped over the floor.

Sunday, March 7, 2010

Customer Service

A lady has pet duck. One morning she wakes up and finds the duck floating feet up in the backyard pond. She takes the duck out of the water and rushes the duck to the veterinarian.

The vet looks over the duck, shakes his head, and says sadly to the woman, “I’m sorry, but your duck is dead.”

“That can’t be!” cries the woman. “You need to do some tests!”

“Ma’am,” says the vet, “I know this is upsetting. But I’ve been working with animals for twenty five years, I and I can say with metaphysical certitude that your duck is dead.’

The lady crosses her arms, a look of defiance in her eyes. “Doctor, I don’t believe you. I don’t think you’ve checked thoroughly enough.”

The vet sighs. “Okay.” He goes out of the room and comes back with a cat. He puts the cat on the examining table. The cat walks around the duck, sniffs at it, and looks at the vet. The vet looks back at the cat.

The doctor takes the cat out of the room and returns with a Labrador retriever. The dog walks around the table, it’s nose in the air; it rears up on its hind legs and peers over the edge at the rapidly cooling bird. The dog looks at the vet. The vet looks back at the dog, his tail drooping with sorrow.

“Ma’am,” he says again, “your duck is dead. And I’ve done a CAT scan and a Lab test to be sure.”

(You saw that one coming, right? And a tip of the cap to John McLaughlin as well. That man can turn a phrase like nobody's business.)

There are lots of reasons health care costs are rising in this country. Defensive medicine. Increasing health insurance premiums. Technology costs. An emphasis on procedure instead of prevention. Fraud and abuse. Administrative overhead. Profit margins. And while very few of these factors are under the direct control of the physician, doctors are constantly being asked to be the “front line” defenders of the system in order to hold down overall costs.

But then there’s this thing called “Customer Service.”

Amy Zaguni is late 40’s-ish woman with chest pain. She’s had it before about six months ago. She had several cardiac risk factors noted at the time…a family history of heart disease, and she smoked a half pack of cigarettes each day…so she was admitted to the Chest Pain Center of our hospital for further evaluation. Serial blood tests revealed no evidence of a heart attack, and a stress test performed at that time was normal. She was diagnosed with chest pain due to anxiety, and had actually been seen by her cardiologist within the past several weeks and given a refill of her medicine for anxiety.

Today, her chest pain is back. She tells me the pain is sharp, knife-like, radiating from the front of the chest through to her back. The pain is not associated with any nausea, vomiting, sweating, or shortness of breath as would be classic for a heart attack. It’s been constant for a few days, and it gets worse when she coughs or takes a deep breath. Her lungs are clear, and her heart sounds fine. Her heart rate and rhythm on the monitor is normal. I can push at the joints between the breastbone and the ribs and bring back her pain, and her pain is also reproduced and made worse when I ask her to move her arms while I provide resistance to the movement. (The latter actions will tense the pectoralis muscles of the chest; pain to these maneuvers suggests that the insertions of the muscles on the chest wall are involved in some fashion.) The nurse had followed our chest pain protocol prior to my arrival in the room, and had obtained an electrocardiogram (EKG) which was perfectly normal.

I explained to her that everything about her history and exam suggested that this was probably chest wall pain, and most likely did not represent pain coming from the heart. I said we would get a chest x-ray to make sure we’re not missing something else going on, but if that looked good we could send her home with some medication for her discomfort and simple instructions for home care.

“So you’re saying it’s all in my head.”

“No, ma’am. What I’m saying is that I think your pain is coming from the wall of the chest and not from your heart or lungs. The EKG looks good, and we’ll get that chest x-ray too, but with a normal stress test six months ago I think it’s pretty safe to say it’s not your heart. A stress test may change over time, but we’re talking years, not months. So I really think we can get you on your way home in fairly short order.”

“But you need to get some blood tests.” (Sometimes I make the mistake of forgetting, in these days of patient empowerment, that many of them are full graduates of the Wikipedia School of Medicine.)

“No, ma’am. Based on the way you describe the pain and your examination it’s pretty clear what’s going on. I don’t think blood tests are going to be helpful here, and I hate to stick people with needles if I don’t have to.

“I want some blood tests done.”

One of the best lectures I’ve ever been to was called “Ten Things I’ve Done to Change My Practice.” It was delivered by Dr. Gregory Henry, who at the time was an emergency physician somewhere in Michigan. In his talk, he espoused the “Philosophy of Yes.” In the ED, there’s already enough stress on you. When patients make a demand of you, it’s just easier to give in than fight the good fight. You’ll spend less time disputing with the patient, they will like you for giving them what they ask for, and there will be a lot less nasty phone calls from administration. Besides, as most ED physicians get paid a straight salary the only way it affects your income is by losing your job because of patient complaints.

I’d like to think that a lot of what Dr. Henry said was hyperbole for the sake of making a point, but in many ways I’ve taken his thoughts to heart. So as long as I think that what the patient wants is not too invasive, not likely to cause them any harm, and not likely to violate any of my personal ethical beliefs, I’ll pretty much do whatever they want. Plus, I usually work on the “Baseball Rule.” I’ll explain things twice, and if the request is the same a third time I just figure I’m outta there.

“Sure, no problem.” I’m doing my best to smile. “You seem pretty aware of the medical system. Which blood tests would you like?”

“The ones you would usually do in a case like this.”

“Ma’am, as we talked about before, I would usually do no blood tests in a case like this. So if you ask me to order the tests I’d usually get, the answer is that I would get none, which is not what you want. So what tests would you like?”

This goes on for twenty more minutes, with the above conversation repeated, in its entirety and with much additive excruciating detail, three more times. Meanwhile, as I’ve been trying to negotiate the provision of cost-efficient and efficacious care, the Lords of Triage have just thrown three more patients into my box who need to be seen. This, of course, is my own fault…in the interest of customer satisfaction, I’ve just discharged three other patients rather than make them linger for no particular reason. If I hadn’t done so, the ED would be clogged up and I could actually decrease my stress level and my workload because there would be no further room at the inn. Silly work ethic...we’ll have to fix that.

There are lots of things we could talk about related to this story…what lab tests actually mean, how they should be used, how accurate they are; the benefits and risks of the popularization of medical knowledge and of patient empowerment; if the demands of patients upon their physicians and the health care system as a whole would be impacted by reform that insured all parties are liable in some way for the costs they incur; and what role tort reform would play in the willingness of physicians to aggressively engage in cost containment. As I sit at my computer and write, these are all truly fascinating areas of discussion and debate which can keep me entertained for hours on end. (Note: Beer and nachos help.) And I’ll be perfectly willing to admit that part of why I’m frustrated by this issue is that many of the patients we work so hard to satisfy are, in fact, not responsible for their own costs. Their care quite literally comes out of my own pocket, both in the taxes I pay and the professional fees I’ll never receive.

But for me, as a working ED doctor, this story is all about customer service. And in the medical setting customer service means meeting patient demands, pure and simple. If nothing else, it represents a professional survival strategy. The shame is that it’s not good medical care.

(Author’s Note: The way I write has very little order or structure to it at all. I’ll sit down and type out whatever comes to mind on the screen, going back to rewrite and edit at some later time. So I always find little random segments of thought scattered throughout the document files when I open them up. Following are the things I found appended to the draft of the larger piece above:

On the first day of Christmas
My true love said to me,
There’s no way I can be pregnant.

On the second day of Christmas
My true love said she had
Two beers last Sunday,
And there’s no way I’m having a kid.

On the third day of Christmas
My true love said she got
Three hives from Ultram,
Two beers last Sunday,
And I’m not sure the kid will be yours.

Nurse to patient: “When you tell me you take Lortab and Xanax for chronic pain, and your drug screen turns up negative, it means the sink is peeing for you.”

Saturday, March 6, 2010

Now Boarding...for the Flight of Ideas

One of our roles as emergency physicians is to perform medical screenings for patients with primary psychiatric problems. I’ve always been fascinated by what really goes on inside the heads of people with mental illness. (I know the members of the Socrates Fan Club are now saying, “Know Thyself,” but I don’t hear you. Neither do I.) And I’ve also been intrigued as to why people go into psychiatry. After considerable thought, I think that people go into it because they are either truly interested in how people think, or they’ve got their own problems and are looking for cheap self-help. This latter perspective was reinforced by a good friend of mine from medical school who had always wanted to be a psychiatrist. For the record, he was probably not the most stable guy himself…I recall an incident with a fire hydrant, but who doesn’t steal some municipal property in college? So we were all pretty stunned when he dropped out of his psychiatry residency and went into internal medicine instead. When asked why, he simply noted of the teaching staff, “They’re all f…..g crazier than me.”

More…much more… about Emergency Department psychiatry another time. What brought me to this introduction was a very strange thought process I had on driving back from Tampa this evening. One of the things we look for as a diagnostic clue in psychiatric patients is the pattern, or “flow,” of thought. There are a host of adjectives that are used to describe varied patterns as verbally expressed by patients. Two of the easiest to identify, and ones we’ve probably all experienced, include perseveration of thought and flight of ideas. Perseveration of thought is when one word, phrase, or theme recurs over and over, and the patient seems unable to move beyond it. Examples of this include “Hope,” “Change,” “Hopey Changey,” “Who Dat?’ and “Oprah.” (This is also like when part of a really bad song…like the Frito Bandito jingle, or wrapping up a feminine hygiene product while being blinded by the light…gets stuck in your head and never leaves).

Then there’s flight of idea which can be defined as a sequence of loose associations or extreme tangentiality where the speaker goes quickly from one idea to another seemingly unrelated idea (“Thought Disorders,” Wikipedia). That’s what happened to me tonight, and it was such a classic moment…right out of the textbooks…that I wanted to share it with you.

To set the stage, it’s the end of a long day of driving across the State of Florida. The Saab screams along at 75, The Child is fast asleep in the back seat, and I’ve spent the last three hours listening to a book on tape that shall remain nameless just in case I ever get a book deal and it turns out I have the same agent whose client I’m about to trash. This entire chain of thought occurred in less than two minutes, from mile marker 129 on I-4 Eastbound approaching Daytona Beach to mile marker 131, where I-4 hits I-95 and I have to pay attention to the road again as it make a sweeping north turn.

“This is awful. He’s got no talent. I can write, and I guess that’s a talent. But I’d want a different talent. I want to sing. Not lead. I want to sing backup, like in a Doo-Wop group. Or a Pip. I want to be a Pip. I want to sing about trains at midnight and move back and forth and shout “Woo Woo” at the right times. Or maybe sing in a folk group. A funny one, like The Limeliters. Or The Folksman. I really liked “A Mighty Wind.” Mitch and Mickey were the best. I love that scene at the end where Mickey is singing about urinary hygiene. How’s that song go? Oh, yeah, that’s right:

“When urine thoughts are in....
They will make your patients grin...
Sure Flo..... Sure Flo......
Don't leave them cold and damp.....
Use our buttock drapes and penis clamp....
Sure Flo..... Sure Flo…..”

I wonder if she would sing that on QVC? That would be quite a show, wouldn’t it? “Betty from Huntsville, you’re on the air.” “Oh, Mickey, I just adore your urinary appliances. I have them in all the colors so no one can tell them apart from my clothes.” “Oh Betty, then you’re going to love our newest collection. And our new color is lilac.” Sort of like that lady who called QVC one night and talked about how she had 40 different purses all by that same Kathy Von Zeeland person. The latest purse was supposed to represent travel, with a bunch of fake stickers on it. One said, “PURE LUXE”, which means nothing. The other was a circle that up close said “Fifth Avenue New York” but from far away looked like a target that said “I’m an American. Please Shoot Me.” Kind of like the look I got from that old man years ago who would try and say something, but his wife would leap in front of him and shout, “SHUT UP MOHTY! I’M TAWKIN TO THE DOCTAH!” Honestly, I would have put him down with a bang stick. But if I really wanted to shoot him, maybe they should place me under an involuntary psychiatric hold. But Roberta the psych screener has already told me that she’ll never put me under a hold because she needs me around to clear the psychiatric patients. She says I have knack for it, a real talent. I can write circles around this guy. But I really wish I could sing.”

(The very best example of literary flight of ideas is a small book called “The Mezzanine” by Nicholson Baker. In brief narrative and a host of footnotes, it tracks the thought process of a man going up one flight on an escalator during his lunch hour. Interestingly, his protagonist is named…Howie.)

I think I’m telling you this story because it’s moments like these that I realize how thin the line really is between mental health and mental illness, and that all thinking occurs in shades of gray. Maybe we all tend to drift towards the border from time to time, and perhaps all of us…myself certainly included…should try to be more patient and more understanding of those battling psychiatric problems. Or maybe I’m just writing because it’s the one talent I have, and if I do this I can suppress my desire to sing for yet another night.

If you’ve ever heard me sing, you’d encourage my writing, too.

Wednesday, March 3, 2010

A Pound of Cure

When I was in my residency many years ago, when men were men, women were women, and sheep in Arkansas were (and still are) nervous , I remember that a falsified prescription was posted in the ED. It had apparently been submitted to a local pharmacy on a stolen prescription blank, and had been returned to us for unknown cause. However, it arrived, I still recall it as being taped up on the side wall of the department, a three-part carbon-copy prescription with a special red band on it indicating it was used for controlled medications. On it was written “MOFEEN 1 pound.”

For some reason unbeknownst to me, the dose of one pound of morphine has stuck in the back of my head for years on end. (It occupies the same Niche of Mystery as the full lyrics to “Muskrat Love.”) As a result, when nurse ask what dose of morphine they should give to a patient, I tend to say “about a pound.”

About two weeks ago one of the nurse I’ve known for years turned to me with an absolutely straight face and asked, “And how much is that, doctor?” (Insert sarcasm here.) I suddenly realized that, in fact, I had no idea how much a pound of morphine really was. So it was off to the calculator:

1 kg = 1000 gm
2.2 lbs = 1 kg
1000 gm/kg divided by 2.2 lbs/kg = 454 gm
(454 gm)(1000mg/gm) = 454,000 mg

By way of reference, most patients with cardiac chest pain get 2 to 4 mg. Those with severe trauma or orthopedic injuries often get 10 mg, and some of our high-level pain patients may take up to 200 mg per day. So when I ask for a pound of morphine, what I’m doing is asking the nurse to administer a dose equivalent to a town of 45,000 people who have all broken their hips at exactly the same moment.

Remind me to stop doing that.