The Soda Sampler

There was one other adventure in Las Vegas I forgot to mention. Toward the south end of The Strip there’s a Coca-Cola store. As you can guess, you can buy all kinds of Coca-Cola merchandise and even have your picture taken with the Coca-Cola polar bear. (No personal cameras, please.) So late one night as we were walking back from dinner we dropped in.

The star attraction was the soda fountain on the second floor, where you could order a “Taste of the World” platter featuring 4 ounces each of sixteen different sodas on trays stacked one on top of each other. At a cheap $7.00, it was like the carbonated version of a Las Vegas buffet. It would be wrong to walk by that. (I was hoping we would get bread cubes and a spit cup to cleanse our palates between samples, but apparently bread and spit are not Coca-Cola products.)

So here’s a list of what we tasted and what I thought, in no particular order:

Inka Kola (Peru)

I’ve actually had Inka Kola before. It’s a very sweet, syrupy, bright yellow-green drink, and tastes as if someone had taken the undiluted extract of lemon-lime Gatorade and added some fizz. I actually like Gatorade, so I’m okay with the drink. I’m also intrigued with the historical aspects of its use by the ancient Inca culture. Bottles have been found in the ruins of Macchu Piccu. Archaeological studies continue. I understand the Inka Kola plant is being considered for designation as a United Nations World Heritage site.

I learned about Inka Kola on a hiking trip to South America in 1987. Even though I had read the warnings about eating food from street vendors, I was wise enough to not listen. So one night in Cuzco I bought some kind of meat-filled pastry and a bottle of Inka Cola from a very sincere-looking pushcart gourmet. The next day I was confined to my hotel room with a severe gastrointestinal illness and wound up spending quite a bit of time watching the Peruvian National Volleyball Team on television. (I also found out that Peru is pronounced Pey-ROO and not PA-roo as we gringos tend to do.) See the experiences I would have missed if I had followed sound travel advice?

That was also the trip where I learned to chew coca leaves, but that’s another tale. And I think the statute of limitations for the coca leaf tea I managed to sneak back through customs has expired. The tea itself is long gone, so don’t send the Department of Agriculture Beagle Brigade to the house. Thank you.

Sunfill Mint (India)

This drink had a very nice light green color that suggests the freshness of early spring, when there is just a touch of white still on the ground to lighten the air. It tastes like Scope mouthwash. This is probably not a bad thing if you eat a lot of Indian food, and I say this as someone who loves Indian food and who could happily eat it exclusively if confined to a single cuisine for the rest of my life. (I would undoubtedly feel some pangs for real Kansas City barbeque. But there’s got to be some way to turn a tandoori oven into a smoking pit). But I am also aware that after I eat Indian food, everyone knows it no matter how vigorously I brush my teeth. So I figure a good slug of soda with antibacterial qualities along with carbonation to dissolve any dental buildup can’t hurt. (That is what carbonation does…clean the teeth, like Dow Scrubbing Bubbles, right?)

Nestea Peach (France)

Nestea Peach didn’t look like tea and didn’t look like peach. It was clear in tone, tasting like tepid seltzer water with a twist of cardboard. Not awful, but very bland. It’s probably made that way so it doesn’t spoil the palate for real French dishes such as sautéed organ in sauce. I’m not making the organ thing up. When I was flying out of Paris on my first and only trip to the French capital, I stopped at an airport restaurant and ordered what I thought was a beef stew. I got what I asked for…just not the part of beef I anticipated. I think the taste buds…not mine, but those on the slice of tongue…is what gave it away. Judging by the size, cows must taste a lot.

Stoney Ginger Beer ( Africa)

I actually like ginger beer, and buy an Aussie version of it for myself at World Market. It’s not real beer, of course, but it tastes like spicy beer with the addition of ginger. Ginger is good for nausea, and I suspect that if we started to put ginger in our beers rather than slices of lime, we’d be a lot less prone to barf after drinking. I would like a government grant to explore this idea.

Smart Watermelon (China)

In the interest of full disclosure, I need to say that watermelon is my favorite fresh fruit of all time, followed closely by a perfectly ripe and juicy Jaffa orange. I’ll eat or drink just about anything with watermelon in it, like Midori liquor, or I’ll pair watermelon with just about any other foodstuff on the globe. (I’m probably the only guy in the history of the buffet at Paris Las Vegas who loaded up his plate with frutta della mare, macaroni and cheese, and watermelon.) So I loved this stuff. And to find that watermelon in also one of the more intellectual fruits? A bonus, to be sure. I feel bad for folks who have to drink Moronic Mango or Stupid Kumquat.

Kinley Lemon (England)

A clear soda that tasted like Spite with a bite. Not bad, but probably better as a mixer than a stand-alone. I think you could combine this with an English liquor called Pimm’s to make a drink called a Shandy, which is especially tasty when punting on the River Cam. (Just in case you were wondering where such a drink might be especially tasty. This blog strives to be a public service.)

Lift Apple ( Mexico)

It was a nice light apple soda. Pretty tasty. The Bride has some kind of allergy to processed apple products that makes her break into hives. So I can’t drink this and kiss her. (Well, I might as an experiment, but I think that would be a bad relationship moment. I’m good enough at creating those without carbonated help.)

Fanta Kolita (Costa Rica)

For years I’ve had a crush on Sophia Fanta, the grape member of the Fantanas. While she is lovely, to be certain, I’m sure that part of the appeal is that I just like the word “Fantana.” I also like the name of the group “Bananarama.” If they formed a septet they could be Fantanabananamrama.

How would you play The Name Game with Fanta?

Fanta fanta bo-anta
Banana-fana fo-anta
Fee-fi-mo-manta
Fanta!

It’s even better with Bananarama.

Bananarama Bananarama bo-ananarama
Banana-fana fo-ananarama
Fee-fi-mo mananarama
Bananarama!

The Wikipedia article on “The Name Game” indicates that if you use names such as Alice, Chuck, or Art, the result will contain “profanity or crude language.” Which it does. But it’s funny. Funny funny bo-unny. Banana-fana fo-unny. Fee-fi-mo-munny. Funny!

Bibo Kiwi Mango (South Africa)

I don’t recall exactly what it tasted like. I do know it tasted the same in English, Afrikaans, and Zulu. The Xhosa version had a little click to it.

Simba Guarana ( Paraguay)

This tasted like a heavier version of sarsaparilla. Sarsaparilla happens to be the best soda of all time. Afternoon Delight is the greatest composition in human history. If you do not agree with me, I will fight you. (Apologies to Ron Burgundy.)

Vegitabeta ( Japan)

I have no idea what this tastes like. By the time we got to this stuff, I was on my eleventh sample of sixteen, and was on some kind of sugar high. So all I could think of was Lucy doing the Vitaminavegamin commercial, and laughed so hard I almost spit the soda out my nose.

Sunfill Blackcurrant (Mauritius)

This is black cherry cola. It’s quite tasty. I wasn’t sure where Mauritius is, so I looked it up. Turns out it’s an island republic located east of Madagascar in the Indian Ocean. The Prime Minister is Dr. Navinchandra Ramgoolam GCKS FRCP MP. It was the only known habit of the dodo bird, extinct since 1681. They drive on the left. Ninety percent of the arable land is grown in sugar cane. Blackcurrant is not listed as one if it’s agricultural products. Part of me wants to say that its’ not right to have a drink you can’t raise in your own country. On the other hand, we don’t grow kola nuts in America.

It is also useful to note that I am convinced that a 4 ounce serving of soda named after a fruit is equivalent to a full serving within the fruit and vegetable food group. I also believe this to be true of Starbursts, Skittles, Gummy Bears, and Jolly Ranchers.

Bibo Pine Nut (South Africa)

If we’re supposed to eat pine nuts, why have I never gotten a can of Planter’s Mixed Nuts and found a pine nut in them?

Smart Apple (China)

Compare and contrast the Chinese concept of cognitive fruit with the Mexican idea of apples as a form of manual labor. You have fifteen minutes. Begin.

Beverly (Italy)

I’m not making this name up. It is a real soda, and a horrible one at that. It tastes like someone mixed tonic water with quinine and dropped in some mustard for good measure. I wonder if it’s used less for refreshment and more as a test of manhood, kind of like shots of cheap tequila. You think you’re a man? Drink a glass of Beverly and don’t flinch.

All I can think of is that someone must have really been dumped, and dumped hard, by someone named Beverly. It has the taste of a failed relationship, one so bad that not only did she take your money and break your heart, but probably even won over the love of the dog you’ve had for seventeen years. One also wonders if there is a whole Mediterranean cottage industry in bad sodas named after ex-girlfriends.

Mezzo Mix ( Germany)

Dull, tasteless. Kind of like German comedy. Name the last good German comedian. Can’t do it? Exactly.

(I’ve heard it said that Germans might laugh if it weren’t against the rules. But I doubt it.)

Reader Contest Winner!

(A few weeks ago, I proposed a writing contest for readers of this blog. I set up a scenario as follows:

At 7 AM on a Saturday morning a physician walks into an Emergency Department. As he turns the corner to head towards his workplace, he sees a tall, sultry, dark-haired female nurse carrying a full plastic urinal in each hand and a younger, taller, and beefier male tech with his hands full of leather restraints walking side by side.

There have been several replies, but none quite like the one I’m about to publish. It’s from a reader who will intentionally remain nameless, because if I did name him I’m certain the authorities would be at his door within minutes to pick him up. In fact, I’m not so sure I wouldn’t call them myself. It’s certainly going to make me much more careful about passing out after drinking at his house.

Here you go. Stephen King, beware!)

At 7 AM on a Saturday morning a physician walks into an Emergency Department. As he turns the corner to head towards his workplace, he sees a tall, sultry, dark-haired female nurse carrying a full plastic urinal in each hand and a younger, taller, and beefier male tech with his hands full of leather restraints walking side by side. In the distance two security officers could be seen running down a corridor in pursuit of what at first glance was a patient in an open backed gown. Seconds later the fire alarm started wailing and water poured from the ceiling spouts.

The physician ran to the front desk while patients and staff flooded past fighting their way out. He shouted to the receptionist. “What the hell is going on?” He saw the fear in her eyes as she stood paralyzed unable to speak. Slowly she pointed to the other side of the waiting room. The doctor looked around and saw a large drooling wolfhound snarling in his direction. Panic filled the air as he slowly backed away towards the door of the ED. The waiting room had emptied. He slipped on the wet floor and as he scrambled to his feet, the dog grabbed him by the right leg, sinking its teeth down to the bone. Shots rang out and the dog fell to the floor. The doctor tried to stand, but his leg buckled beneath him as he dragged himself away from the dying dog.

He looked up and saw one of the Security Officers put his gun back into his holster as he walked towards him. “I thought you were a goner, Doc,” he said. The physician didn’t recognize him, and asked if he was new. “Filling in, Doc. Let me help you.”

The Officer led him to a cubicle where, to his horror, he saw a second officer holding another physician and several nurses at gunpoint. “What the…” he began to exclaim as he was helped to a stretcher where his colleagues tried to help stop the bleeding from his leg.

“Ok, who has access to the narcotics?” said the short security guy. “Tell me, or I’ll blow his head off”. The doctor realized he was the potential victim, and said, “Give then anything they want.” Suddenly the taller officer, who had been standing next to a curtain, let out a shriek and fell over with a knife handle sticking out of his back. Pandemonium broke out as nurses screamed and the shorter security guy ran from the cubicle looking for the knifer. The doctor was helped out of the cubicle and hopped into the corridor. An old homeless man wearing a ragged combat jacket was cradling the head of the large dog, and the security guy had his gun trained at him. Shouting at the man., the guard screamed, “YOU KILLED FREDDIE!”

Out of nowhere a gurney crashed into the security guard, his gun tumbling from his hand. The ED doc looked round and saw the gowned patient from earlier – a known schizophrenic – staring wide eyed at the security officer. Seconds later the SWAT team came crashing through the main door of the ED. Not knowing who was who, they ordered everyone face down on the ground and hog tied them with plastic cables. The doctor pleaded his innocence, demanding to be released. Unable to move, he remained immobilized, and lay exhausted on the floor, slowly bleeding from his leg and losing consciousness.

At 6 AM the ED physician was awaked from a deep sleep and a disturbing dream. He looked over at his partner as reached over to wake her when he saw that his hand was covered with blood………………

Friday Night Notes

A few quick thoughts from the wee small hours of Memorial Day weekend...

We’ve come up with two new lab tests for ED use:

The serum acorn level is used to assess patients who are nuts.

The serum conjugate acorn level is used to assess those who are f…..g nuts.

And two new clinical signs:

Chester’s Sign: If you’re eating a bag of Cheetos, your nausea and vomiting can’t be that bad.

The Burgos Summer Sign (named for the pediatrician who taught it to me): If a child’s headaches, stomach pains, or other vague non-diagnosable symptoms improve during the summer, they hate going to school.

Please send royalties. Thank you.

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

Last night we had a quiet moment at work. Silence in the ED is scary thing, because we’re not accustomed to it. So when it gets that way we literally band together, if only to hear the shuffling of feet. Of course, we don’t talk about it, because if we do everything will go downhill immediately.

So during our quiet moment last night, we were introduced to a medical song on You Tube by The Giggles entitled “I’ve Got the Clap.” The lyrics go something like this:

“I’ve got the clap and I’m giving it to you.
I’ve got the clap and I’m giving it to you.
I’ve got the clap and I’m giving it to you.
Who’s got the clap? I do ! I do!"

(Back in the day, we could establish this diagnosis without a word. We would walk out of a patient room, the nurse would ask what was wrong, and we would start to applaud. The nurse would then fetch the penicillin.)

It’s a very cheery tune, and before long Holly the Disco RN and I were clapping to the left and then to the right in time with the song. But sometimes we forget that there’s a clear generation gap, even in medicine. So we probably shouldn’t have been surprised when one of our younger staff members asked, “So what’s that song about? Is it that thing that helps you turn on the lights?”

Ah, for simpler times.

Things I Don't Know

About once a year I do something silly and buy a book on mathematics or physics. This act represents the height of stupid behavior on my part, because I know absolutely nothing about math, which is itself the language of physics. Math was the subject where I got I got C’s and D’s in high school, and I made it through medical school only because our program was top-heavy on biological sciences and didn’t require any college algebra or physics. The last time a math textbook passed through my hands (and generally stayed unopened) was in the 11th grade, when I was compelled to take trigonometry and analytical geometry. I’m convinced I got through that course only because 1) The teacher was also the football coach and the class was geared to the “student-athlete” 2) Pocket calculators had already been invented that did things like sines, cosines, tangents, and logrithims, eliminating the need to understand what they actually were or how to find them, and 3) There was a really big guy...an offensive lineman, as I recall…in the class. He was the only other guy in school named Howard, and his pure size and presumed power insured that nobody in class would distract my learning with appellations of affection such as “Howard the Duck.” (I have no idea whatever happened to him. I’d like to think he because some kind of professional hitman. He’s probably turned out to be a new age sensitivity counselor somewhere in California. Illusions die hard.)

But I keep thinking that a well-rounded person should know something about physics and math, so I keep buying these books. Three days ago I bought “The Physics of Star Trek” by Lawrence Krauss. I did so against my better judgment, but figured as a confirmed TOS fanatic (If you don’t know what I mean, you’re not one), I figured maybe at least I’d have a frame of reference to work with. And I understood Chapter 1, dealing the need for inertial dampers to counteract g-forces. But calculating fuel requirements for the impulse drive? That’s physics and math at the same time. I’m lost. And by the time I hit Chapter 4 dealing with microgravitational fields that warp space-time and allow interstellar travel, it was time to move on to a rerun of Jerry Springer.

For the record, here’s what I actually know about physics:

1) Newton came up with three laws. They are:

Lex I: Corpus omne perseverare in statu suo quiescendi vel movendi uniformiter in directum, nisi quatenus a viribus impressis cogitur statum illum mutare.

Lex II: Mutationem motus proportionalem esse vi motrici impressae, et fieri secundum lineam rectam qua vis illa imprimitur.

Lex III: Actioni contrariam semper et æqualem esse reactionem: sive corporum duorum actiones in se mutuo semper esse æquales et in partes contrarias dirigi.

Isn’t that helpful?

2) No, seriously, these are his three laws:

An object at rest will remain at rest unless acted on by an unbalanced force. An object in motion continues in motion with the same speed unless acted upon by an unbalanced force.

This law explains why after I sit down in my fancy comfy rolling chair at work, I have no desire to leave it for actual patient care. It also explains why, once I kick start the chair, it would roll forever if not slowed by unbalanced forces such as sticky soda residue on the floor and solid objects like walls when I hit them. It further explains everything about government and other avenues of administrative merriment.

Acceleration is produced when a force acts on a mass. The greater the mass of the object being accelerated, the greater the amount of force needed to accelerate the object.

This means that I will go faster down the hallway if Big Teddy and Matt the Brute pushes my roller chair than if Candi the Elfin Nurse does so. It also means that no matter who pushes it, the chair will go faster with me in it than it will with my personal hero, Dr. Gary Morrison, seated within it’s embrace. This is because his fund of knowledge is vast that it adds extra mass to his brain. As do brownies.

For every action there is an equal and opposite reaction.

This is why both Big Teddy and Elfin Candi will recoil just a bit on their heels when they push my chair across the floor. It’s also the rule underlying any intimate relationship. (Okay, maybe take away the “equal” part.)

3) There is something called Bernoulli’s Principal that allows airplanes to fly. It works but it makes no sense. I try not to think about it too much when I’m a heavy pressurized steel canister at 40,000 feet held up by air.

4) In high school physics class you got to shoot dart guns at tin cans and roll Hot Wheels cars down planks. That was fun.

5) I really like the “Gravity” episode of Schoolhouse Rock.

I know a bit more about math, but not much. That was brought home to me when I was first dating The Bride. In a moment of random affection, trying to be romantic and intellectual at the same time (I had already discovered that she was waaaay smarter than me), I said “I love you the square root of negative one.”

“Huh?”

“You know, the square root of negative one. A number that’s impossible to quantify. That’s how much I love you.”

She gave me that quizzical look she reserves for times when I’ve said something exceptionally stupid (as opposed to my routine ignorance)or when Duchess the Wonder Dog has decided that the greatest thing in the world is to chew up the pillows on the couch and can’t even being to fathom why you don’t share in the experience. (Which reminds me that I was the one who kept a straight face during the classic Who Can Eat a Doggie Liver Snack Contest of 2007. But I digress.)

“No you don’t,” she said.

I should have seen trouble coming, but the relationship was still new.

“Of course I do. I care for you so much I can’t begin to tell you how much.”

She shook her head. “No, you don’t.”

This was getting difficult. I’ve been in the scenario where one person says that they’re in love and the other person is not. Awkward, but workable. This one was new. I thought I loved her, but she was telling me that I didn’t. No instruction book for that one.

“No, you don’t,” she persisted. “The square root of negative one doesn’t exist. Therefore, your love doesn’t exist. You’re telling me that I mean nothing to you and I’m hurt.”

Have I mentioned that before she discovered the glories of musical theater, The Bride was going to be a math major?

“Can I love you infinity?”

“That would be acceptable.”

So the objective lesson for today is to not buy me any books about math or physics for my birthday, because I’ll never read them. And always learn about your girlfriend’s original college major before declaring your affections. It’ll save time.

Baby Tale

I recently learned of the retirement of Barbara Hunt. Barbara was a nurse I first worked with at Shands Hospital in Gainesville back in the waning years of the last millennia. Barb had been an ED nurse for over thirty years, which is amazing when you consider that, like most women, she is only 29. She was nursing even before she was gleam in her father eyes. Barb and I worked a lot of night shifts together. She was the Charge Nurse, I was the attending physician, and the chain of command reflected exactly the order indicated by the sentence. There are a lot of stories we shared, most of which have been forgotten in the wake of the daily battles, but one story stands out over fifteen years later.

It was about 2 AM when a woman in labor was brought to the door. Contrary to popular belief, delivering babies is not something we do in the ED. We do not seek out the opportunity to usher new life into this world, or to have an infant named after any of us. If you’re in labor, our goal is to get you to the delivery suite as soon as possible, because a delivery is the ED is either something that happens all by itself or is an absolute disaster, and there is nothing in between. It’s one of the few times in the ED that we actually run. (I reviewed this paragraph for accuracy with Matt Forester, one of our ED techs, who scoffed at me. He noted, “Hey when you’re a tech you run all the time. It’s just you lazy ass doctors who don’t. You just roll around in your office chairs.”) Unlike Prissy, while we do know something about birthing babes, it’s nothing we’re particularly interested in doing.

But there are exceptions, and one of them is if there is obvious crowning. Crowning occurs when the top of the scalp can be seen in the perineum (lay term: “Down there.”) Most of the time, in the name of patient decency, we don’t really check this in the waiting room. We don’t have to. We know a baby is crowning when the mother yells “IT’S COMING!” in a particularly shrill tone that is only heard during childbirth and never reproduced in any other exclamatory setting.

(There are two other noises we use as clinical clues during labor. These are known as “tachylordy” and “bradylordy,” from the Latin root words for “fast” and “slow.” Tachylordy is seen in the early stages of labor, when the woman will wail “LORDYLORDYLORDYLORDY!” in a quick, statacco, high-pitched voice. More ominous for imminent delivery is bradylordy. When you hear a deep, long, guttural. “LORRRRDY. LORRRRDY,” there’s a kid on the way.)

So when this woman made the noise, we knew we were going to have baby. Well, maybe not us directly, but we were at least going to be put in the position of standing about gawking as nature took it’s course. While I am not an obstetrician, one of the things I do remember from medical school is that primates have been having babies for millions of years, and in general they’re pretty good at doing so no matter if there’s a physician around or not. (They seem to be even better at the process of conception, but that’s another story). So after a hurried conversation between Barbara and myself as the ED techs struggled to get her on a bed, we determined that our best strategy was to stand by and provide reassurance and say soothing things like, “It’ll be okay,” and “It’ll be over soon,” and “Steve Spurrier will be back next season, you’ll see.” (It was Gainesville, after all.) While we did this, another nurse went running for an instrument pack, just in case we had to do anything. To be honest, Barbara did most of the reassurance. My job was to stand up straight, look concerned, and quietly try to figure out how to avoid doing anything more.

Working with remarkable speed (for they didn’t want to be part of this any more than I did), the techs got her on the bed, and got her clothing off. (We said a little prayer of thanks for stretch pants.) Unfortunately, the brakes on the bed were locked and we couldn’t get them to loosen up. So we shovel her onto the bed, one side of her plastered against the wall which she was now beating with her fists while calling out the name of an unidentified male in an “aggressive” fashion, all of us standing on the other side in no position to do anything useful at all. (As embarrassing as it is to say, there’s no way to do any effective work in the pelvic region from the side. No snickering, please. Thank you.)

After twenty years on the job, there are very few sphincter tone moments in the ED. (Sphincters are circular muscles that control flow through the gastrointestinal tract. There’s one between the esophagus and stomach, one between the stomach and small intestine, and one between the rectum and the outside world. It’s this latter one that concerns us here.) When they do occur, it’s usually not when people think it might be. Running a cardiac arrest or major trauma is simple, and there’s really not a lot of risk to it. The patient’s in bad shape, and in general all you can do is improve the situation. It’s not like you can make someone who’s dead a lot deader. Everyone’s list is different, but here’s part of mine:

The moment you’re waiting to see if fluid comes out of the needle you just placed in someone’s spinal canal.

The moment you defibrillate someone who had a pulse, but needed electricity, waiting to see if the pulse comes back.

The feel of the needle bumping down the collarbone as you try to start an IV in a vein you can’t see. (Tone doubles if the patient has a blood clotting problem to start.)

Being told that a patient who came into the ED walking and talking isn’t doing so anymore. (This is ALWAYS bad.)

A colleague or risk manager calling to say, “Remember that patient you saw last night?”

Needing to catch a baby.

Needing to catch a baby.

Needing to catch a baby.

So there I am, peering over he left knee, looking at the top of an infant head. She’s pushing hard. Really hard. The head’s not moving. All sphincters hit overdrive.

The equipment pack has arrived, and I’m looking through the contents. I already know what’s in there. Looking to check my equipment is a stall tactic. I know that if the baby doesn’t come, I’m going to have to do something called an episiotomy, which is where a small slit is made in the lower portion of the birth canal to give the baby’s head more room to move. I did exactly two in medical school. I managed to avoid doing deliveries during my ob/gyn rotation during residency by volunteering to see all the gynecology consults down in the ED while those folks who actually wanted to do this for a living happily took all my experience. So while I know technically what I’m supposed to do, I am absolutely terrified of having to do it.

She’s pushing to no avail. I’ve got to do something. So I fondle the instruments absent-mindedly while Barb gets out some sterile towels and places a bedpan between the patient’s knees. We’ll reposition this under her hips at the time of delivery under to catch any fluids (There will be fluids. Delivery is not pretty).

It’s been a few minutes. It’s time. I start to pick up a syringe full of local anesthetic which I’ll inject into the area to be cut.

I don’t know what it is about the ED, but sometimes just the threat of care makes things better. It can’t tell you how many times people have come in with severe problems that resolve the moment they hit the door of the ED, or the number of parents who swear their child had a fever of 136 degrees but now are doing just fine under the glow of the hospital lights. And I think what happened here is that she saw the syringe and the needle, gave one last push, thrusting her hips in the air as she exhorted her infant to join the world in (once again) “aggressive” language. And as she did, we saw an infant sail out of her pelvis, shoot two feet up in the air in a parabola that would make a mathematician proud, and land with a resounding THUNK in the bedpan. It was a three point shot from behind the arc at the buzzer, and there was nobody happier than me as I suctioned the baby, got it breathing, cut the cord, and wrapped him up in warm blankets. Crisis over, mother and child were whisked to labor and delivery for further care and clean-up. Rumor has it the child was named after the unidentified male without an aggressive prefix.

“You were going to cut her, weren’t you?” I remember Barbara asking me later that night.

Truth be told, I have no idea what I would have done. Would I have kept stalling? Would I have been brave? Fifteen years later I still don’t know. But I’m certain that given the same situation, my sphincter would react exactly the same way.

 

Internet Doctorin'

I used to think it was hard to get into medical school. I’ll never know if it really is, because I got in as an accident of fate. (More on that another day…if I’m going to be blogging every day, I can’t blow all my stories at once. Got to have a few for backup on those days when writing takes a back seat to…well, almost anything.) But I bring this up because it turns out that it’s a lot easier to get into medical school now than it ever was before. It’s not the need to turn out more primary care physicians that have led academia to swing open their gates, nor a sudden demand on the part of college students to enter a career where you can work harder and make less money than ever before while always at risk of being sued. (Who wouldn’t find that attractive?) It’s because the internet now allows everyone to go to medical school. Armed with a fresh diploma from the Wikipedia College of Doctorin’, patients are now just as qualified as physicians to tell us what’s wrong with them, what tests we need to get, and how they should be treated.

Let me say up front that I really have no problem with informed patients. They actually make life easier, especially when they understand their own disease process and recognize what we can and can’t do for them. They make better decisions regarding their care, and it’s truly more fun to work with a partner in the process. But I’ve come to believe that the internet is often a rotten source of health care information because it’s voluminous, unfiltered, and unchecked.

I’ll give you an example of what I mean from within the House of Medicine itself. Many hospitals have protocols that require nursing staff to contact the Regional Poison Control Center to notify them of any overdose patients you’ve received. There are a couple of reasons for doing so. One is medicolegal, to say that we called if something goes wrong. The second (and I suspect most valid) reason is that the more calls the Poison Control Center receives, the more they can justify their continued funding. Enhancing clinical care is not really one of the reasons to call, because what most often happens is you get a nurse or a trained technician who simply reads off or faxes you a list of every single adverse effect that has ever been reported to occur with that drug, in no particular order, and suggests a plan of care that is often impractical at best. You get too much unsorted information that may or may not actually be relevant to the case at hand.

So here’s what really happens with most overdoses. It’s surprisingly easy, and surprisingly generic. You support the patient’s vital signs by managing their respirations and blood pressure. If they have ingested any one of the handful of medications that has a specific antidote (there are less than ten you actually use) and their condition is life-threatening, you give it. You have them drink a solution of activated charcoal to bind up any spare medications floating around the gastrointestinal tract. And then you wait four to six hours, until the peak effect of the medication has likely passed by, and if they’re doing fine you send them wherever they need to go. If not, they’re admitted. Pretty easy, which is why I never really mind taking care of them. It’s a lot more straightforward than people who claim to be “weak and dizzy” (the two words we hate more than anything in the ED, even more than the phrase “accreditation site visit”). Plus, there’s usually a pretty good story that goes along with that, and if Lady Luck is on your side you can keep a bed occupied for up to eight hours by the time the psychiatric staff gets a chance to look at the patient, insuring that you won’t have to see an extra patient any time soon.

Looking for health care information on the internet is like getting it from Poison Control. There are huge volumes of information, all of it unfiltered and unweighted, and most of it without oversight. (This is why I have less of a problem with pharmaceutical ads on television than I do the internet. At least the FDA tries to regulate the content of the former, while anyone can say anything in cyberspace.) And if you look at the distribution of the information out there, it’s slanted away from science-based knowledge and much more towards hype.

Let me give you two examples of what I mean. The first is from an article entitled “UK Bans Doctor Who Linked Autism to MMR Vaccine” by Marrecca Fiore (AOL Health, May 24, 2010). It concerns Dr. Richard Wakefield, an English physician who described an association between vaccines and autism, and whose work has now been considered as invalid and unethical. (I’ve addressed this issue in a previous blog; in brief, I don’t think a firm link between the two has been established, and the risks to the population as a whole of withholding vaccination clearly outweighs any unproven ideas.) As you’d surmise from the title of the article, Dr. Wakefield has now lost his medical license in his home country. But to read the article, there are 7 paragraphs of quotes from Wakefield and his supporters, and one from an actual scientist. There is also a video clip of Dr. Wakefield defending himself, but none of anyone representing the scientific community. The comments that follow the article are bitter, vituperative, and focused on destroying vaccination programming; woe to the one or two brave souls who comment that Dr. Wakefield is in the wrong (as he clearly is…yep, I’m taking sides.) This is supposedly an impartial “news” source. So what’s the message here?

It’s even worse if you do an internet search. There is an alleged condition called Morgellon’s Disease, in which people claim to have crawling and burning sensations in the skin, persistent sores that don’t heal, and small fibers emerging from some of these lesions. I say ‘alleged” condition because nobody’s sure if it exists. Promoted by media coverage, the CDC is investigating the problem, but most dermatologists think this “disease” is really a type of delusional parasitosis (a mistaken thought that there are parasites within the skin). But if you look at the web, there is no question that this is a horrible, debilitating, epidemic disease. Of the first ten hits that came up when I did a web search, one was a Wikipedia article (which was actually reasonable) and one was a microbiology site. The other eight were all sites convinced that the syndrome exits, with quotations such as:

“Morgellons is an unexplained and debilitating condition that has emerged as a public health concern…”

“Morgellons Syndrome. A Horrifying and Fascinating Skin Disease is affecting thousands of people in the Bay Area, along the Gulf Coast, Florida…”

“Morgellons disease, or Morgellons syndrome, is a new and frightening disease that is yet to be recognised by medical science…”

“For years, doctors denied the suffering of skin parasite victims. The days of Morgellon's Syndrome denial are over. Join us and learn more.”

There’s no reason to assume the other web pages (there are 86,900 results) are any different. So what’s a patient to believe, and how does a doctor explain, let alone fight, that number?

When patients bring up information they’ve read on the internet, I can sometimes defuse the issue. I can explain that while it’s good to use the internet as a resource, you’ve got to keep in mind that it doesn’t reflect the real world or their case in particular. I’m often able to correlate their information with my clinical findings, and to direct them to more appropriate websites. But still, it’s a conversation I wish I didn’t need to have. And it’s very frustrating when the patient says, as they often do, “The website told me you would say that. You doctors are all alike. It’s because you get paid off to say stuff like that.”

Where do you go from there? You want to ask the patient if they knew they were going to get an answer that they didn’t want, why were they here in the first place?

Is it because they couldn’t find a licensed practitioner from the Wikipedia College of Doctorin’?

Animal Crackers

Last week a pharmaceutical representative came by with lunch. This is a pretty rare event in the ED. Dug reps tend to market newer, more expensive agents, but given the financial resources (or lack thereof) in the majority of our ED patient population, we tend to focus on using older, low-cost generic drugs whenever possible. When we do prescribe medications, it’s most often for an acute condition, and the patient will be on the medication for a limited time only. We rarely prescribe any chronic medications for conditions such as high blood pressure or diabetes, and if we do it’s to refill the patient’s current meds, not to start them on anything new. So most drug reps will cordially wave at us in the hallway while spending their time with physicians who are more likely to use their products. It’s simply good business.

But today’s rep actually had a drug that could be useful in the ED, and Free Lunch Etiquette demanded that I spend at least five minutes hearing about the product. (It would be ten minutes if I got a pen.) Today’s product was a new pain medication, something in between ibuprofen and a narcotic. The rep was very articulate in explaining that the drug influenced both mu-opiod agonist ascending pathways and norepinephrine reuptake inhibitor descending tracts, and I was very dutiful in nodding my head. (Truth be told, I have no idea what these things are. I’ll be looking them up later tonight.) But I did notice that the mascot for this new drug is a lion with a rose in its’ mouth.

Somewhere in between hearing that the drug falls into Pregnancy Category C and that I should not use it with MOA inhibitors because it may cause serotonin syndrome (got all that?), I asked a question.

“Do I get one of those?”

“One of what?”

“A lion. If I use this drug, can I have a lion?”

“You mean like a stuffed lion?”

“No, I mean a lion. You can skip the rose. I want a lion.”

Anyone who knows me would expect this kind of thing. I‘m the guy who orders drinks by color just to see bartenders fall all over themselves trying to figure out what I’m up to. (Although sometimes the bartender gets the better of me. I was with friends at Harry’s in St. Augustine and I asked for something orange. The barman said he could make something called a Big Easy, and I said I didn’t care as long as it was orange. What was delivered to me was a VERY orange drink created on the spot called the Little Difficult.) Plus, I had done this before.

When I first came back to this ED full-time, there was a young drug rep who was marketing a new antibiotic. Their mascot was a tiger, and in the promotional literature you would see a doctor walking down the hallways of a hospital with a tiger by his side. I thought that was very nifty, and so I asked the drug rep if I used the drug, can I get a tiger? The tiger could help scare the bacterial infection into submission, and it could be pretty useful in the ED as well. “You don’t think you can find a ride home tonight? Well, okay. Why don’t you spend the night in this small windowless and locked exam room with my TIGER that I haven’t fed yet today. Oh, and that topical ointment we put on your scalp? It smells like fresh kudu.” The poor drug rep had no idea what to do. She fell back on her training, saying something about the 30s ribosomal unit and in vitro activity and Acinetobacter baumannii and other stuff I still haven’t gotten around to looking up, and I would keep asking if I got a tiger. There’s probably a reason she doesn’t come around anymore.

I explained to the rep that this was a serious request for a therapeutic lion. I thought that, like the drug, he could be a useful adjunct in the mitigation of pain. “You say your pain is unbearable? Let’s try a comparison. Which is worse…your pain, or being bitten by my LION? I will only give you narcotics if your pain is worse than being bitten by my LION. How bad’s that pain now, boss?”

This rep had been in the business for a while. She thought for a moment. “You know, twenty years ago we probably could have arranged that. But with these new marketing restrictions, all I can offer you is a pen that makes a really loud and scary click. Please, help yourself to the lo mein.”

Last Thursday...

Early one Thursday afternoon Marylou Gravley came to call. Marylou was a chronic visitor to our ED, having decided to overdose on her multiple psychiatric medications five times in the last few weeks and still not having figured out how to do it right. (Perhaps that’s a fringe benefit of a personality disorder). She was also unable to figure out when she decided to end it all. She said she took her overdose on Sunday; when asked why she came in four days later, she said she felt like this was a Monday, so why wouldn’t it have been on Sunday. (And yes, Carpenters fans, it was raining, the usual 4 PM Florida afternoon summer thunderstorm in full roar overhead). Sometimes drama is everything.

You always ask patients why they took their overdose. Mostly you do so to better understand their true risk of suicide, but if we’re honest a small part of asking is voyeurism. In Marylou’s case, it was because her father, who had previously indicated he was going to provide her with an apartment while he and her mother cared for her child, had decided that at the tender age of 34 it was time for her to fend for herself in this cold, cold world of ours. “What do you think of that?” she asked.

While patients who delusional often fare better and are easier to manage, at least in the ED setting, if you accept their hallucination as a temporary reality, those with personality disorders sometimes need a forceful dose of reality.

“I think it sounds like he wants you to take some responsibility for yourself.”

She immediately requested to see another physician.

Later that day I met Christian Tabarez, a portly man in his is mid-forties who fell in the shower that morning and was complaining of worsening chronic back pain and new right rib pain. He smelled of alcohol, but denied drinking. “Maybe a few on the weekend, chief” he noted with deference to my clear Native American heritage. (I am a Member of the Tribe.)

Unfortunately, his statement was at odds with his blood alcohol level, which was time and a half the legal limit. “I thought you told me you didn’t have anything to drink today.” I said.

“I didn’t drink today, chief.”

“Well, then how did the alcohol level in your blood get over the legal limit?’

“I might have been drinking last night, boss. (A welcome change in syntax.) But I got up and went to work today.”

“So how much did you have to drink last night?”

“Oh, maybe three or four beers.”

Alcohol levels drop an average of 25-30 points per hour. So just for the record, if his alcohol level was leftover at 100 at 10 PM, and he stopped drinking at 2 AM the night before, his alcohol level after his last drink the prior morning would have been 600. That would have likely saved him a visit to the ED, but not one to the morgue. So call me dubious, but something’s not right.

“I don’t think that’s the case. But you drank last night, right?

“Right, chief.”

So what day was last night?’

“Wednesday.”

“I thought you said you only drink on the weekends. Is Wednesday a weekend?’

No answer. Not even a “chief.”

“So did you lie to me about your drinking?

“Yes, yes I did.” He shook his head in self-disgust. “But if you give me something for pain, I’ll never lie to you again.”

My turn. “Honestly, chief,” I said, “you’re not going to get the chance.”

I’m just waiting for the administrative complaints on both of these cases. Our administration is usually pretty good about these. They have a process to do, but they also realize the scenario is never quite what it’s billed to be. Nonetheless, they don’t want to see your name on too many complaints, no matter how accurate your observations may be. Of course, the legal profession feels no such need for due diligence.

But I’m at a loss as to how you can do medicine as it’s intended…to work for the good of the individual and, in doing so, for the good of society…and not tell patients the truth, even if it’s not what they want to hear? And why is it that we can’t insist on the truth from patients we’re trying to help as a condition of care?

There’s a reason why physician don’t say what they need to, despite the exhortations of academicians, health researchers, and policymakers to do just that. It’s that once we decided that medicine was not a science or an art but a business, and our patients began to morph into customers, we accepted the idea that “The Customer is Always Right” not as a guide for service, but as a rule that must be obeyed. And concomitant with the rise of an entitlement society, where justice is defined as what can I do to others to build my own self-esteem, the truth becomes unacceptable if it means that health care may not give me what I want, but only what I need.

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

It dawns on me as I’m writing this that you may think the above kinds of patients are all I see each day. While some ED shifts may feel that way, it’s a far cry from the truth. In reality, most folks who come to the ED are essentially nice people looking for help. And while their definitions of an “emergency” and mine are likely to differ, I’m able to help the majority of them (even if only with reassurance), and whether they’re admitted or discharged most leave the ED feeling better.

So just to make the record complete, here are the other folks I saw, in order, during an admittedly very slow Thursday evening eight-hour shift:

Loraine Duppstadt is a young woman with diabetes placed in our local psychiatric facility for depression and suicidal thoughts. She was sent to our ED because of elevated blood sugars. A little detective work revealed that she had not had her diabetic medications since she entered the treatment center. Some fluids and insulin in the ED got her sugar down to an acceptable level. Prescription written, problem solved.

Tia Mitts had radioactive iodine treatment for an overactive thyroid last week. Two days later she developed nausea and vomiting, both of which were worse (or at least seemed worse) because of her underlying anxiety problem. She also felt that her children weren’t sleeping well over the past week, and could this be due to the radiation? Turns out she did have a urine infection, which is a perfectly good reason to feel poorly. Some IV fluids, Zofran for vomiting, Ativan (“Vitamin A”) for anxiety, and a some reassurance got everything under control.

Daryl Odea was younger than I am but has already had his first two stents placed in his coronary arteries. He had a major heart attack last year, and arrived in the ED with chest pain similar to that of his previous episode. Two nitroglycerin tablets at home didn’t help, and it took a healthy dose of morphine in the ED to get his pain under control. His electrocardiogram (EKG) looked okay, and while we were able to relieve his pain there was still the concern that his pain was related to a lack of blood supply to the heart. The best way to assess him was to admit him to the hospital for further evaluation (sometimes to only way to detect heart damage is through consecutive measurements of specific chemicals released by damaged cardiac tissues). Having already started down the barrel of the gun, he was more than willing to come in.

Max Giannone had been admitted to the hospital last week for chest and upper abdominal pain. Once a cardiac cause had been ruled out, a CT scan of the abdomen revealed a large bleeding tumor in the liver. He was doing well, at least as well as you can be when you’ve been you’re harboring a cancerous softball in your gut, and was scheduled to have a biopsy the following week to figure out what kind of tumor it was and what treatment might be of help. But earlier that morning he had seen a lot of blood in his urine. As the liver is involved in manufacturing proteins which are critical to the proper clotting of blood, this could have been bad. But his labs looked good, and he no further episodes of bleeding. Didn’t know what it was, but if it ain’t broke we tend not to fix it.

Neil Tedrow also had chest pain, but he was a newcomer to the Coronary Artery Sweepstakes. His EKG and labs were fine, but he smoked for thirty years and had a family history of heart attacks. You can’t beat both nicotine and your DNA. He was admitted for observation and a stress test. If it’s negative, at least we know what his pain is not. If it’s positive, better to have the plumbing fixed sooner rather than later.

Ted McGlamery has a rising (not an arising, nor an uprising) between the cheeks. He’s had it before, and the last time it needed surgery. He decided that this time he would come in earlier and avoid the knife. Good idea, because at the base of his spine was a swollen, red, hot area just brimming with infection. But there was no abscess, and I’m not going to cut someplace where I’m not sure there’s pus. So antibiotics, hot packs, and sit on an inflatable swim ring. I always advise the ones with the squeaky ducky heads. It’s such a conversation piece.

Hilary Swoope was a high school junior who took five sleeping tablets because she felt she was a disappointment to her family. She had never done this before, and her family was incredibly patient and understanding with both her and us. I explained to her that as long as she was able to work with us, I would be able to avoid placing her under a “Baker Act,” a legal maneuver in Florida that allows us to involuntarily hold a patient who poses a risk to themselves or others. It didn’t seem to accomplish anything to assign this label to her so early in life. That worked until we discovered that the only way we could have her admitted for help was to do the paperwork. They were even gracious about that. Don’t know that I would’ve been.

Katherine Schwartzman has what we might call a “personal” discharge. Her pelvic exam was a difficult proposition, with much writing and pulling away and gnashing of teeth, which raises the question of how in the world she was able to get a ‘personal discharge” in the first place. But pregnancy test negative, prescription written, problem fixed…until next time.

Hugh Procter has had asthma all his life. It’s well controlled with his medications, but when he runs out…which is about every three months, as he doesn’t yet have a doctor of his own…he comes in with a flare of his respiratory disease. Asthma is one of those fun things to treat in the ED. The diagnosis is clear and straightforward. The exam features a symphony of wheezes, which most often go away after a couple of breathing treatments and a steroid shot. The lungs clear up, the patient feels better, and you feel like you’ve actually accomplished something. Three asthmatics per shift would make me a very happy doctor.

Allan Sevin had just finished his daily workout in the exercise room of his seaside condominium. He got into the elevator, felt faint as he pushed the button for this floor, and woke up on the floor of the elevator as it opened on nine. Unable to get up, he reached for the button with a G, and on arrival the doors opened and he was found by a maintenance worker. Negative labs and x-rays, but he still couldn’t stand without falling to the right. Sometimes strokes don’t show up right away on a CT scan, but that’s what his symptoms suggest. And, as the old ED saying goes, “If you normally walk, talk, eat, drink, and know what’s going on, and now you don’t, you need to stay.” So he does.

Liza Pixley was young woman with left lower abdominal pain. The worst emergency to miss in a young potentially fertile female is tubal pregnancy, which can rupture and cause internal bleeding. She was able to tell me the date of her last period, but not when she last had unprotected sex. She said that pregnancy was not something I need be worried about. “Guys aren’t my thing.”

Darren Allioto was transferred to us from another hospital. As a referral center, transfers are a common part of our day. No matter what’s wrong with them, transfer patients are a piece of cake. Someone’s already done the work-up, the diagnosis is made, and my job is to simply walk into the room to make sure someone’s still breathing before I call the physician who accepted the patient for transfer to tell them so. I’ll even tell the patient that this is my job, and most of them are happy to help out by continuing to respire.

Allyson Beckerman was seen the previous day for nausea and vomiting, and she’s back for more of the same. One of the ED Rules is that if a patient comes back within 24 hours, they’re either giving you a second chance to find out what’s really wrong with them or they’re playing games. It’s up to you to figure it out. Allyson wasn’t playing; an abdominal x-ray showed signs of an early bowel obstruction, clearly different than the night before.

Serena Plotner was anxious. She was anxious about being anxious. She was anxious to know if I thought she was anxious. She wanted to make sure she had blood tests to show if she was anxious. I explained that tests could not show if she was anxious, but might help her to be less anxious about her anxiousness being form anything other then being anxious. She anxiously agreed to the tests, anxiously awaited the results, and anxiously listened as I told her that all her labs were normal and I thought she might actually be anxious. She was anxious about taking any medicine for anxiety, but anxious about waiting to see her own doctor as well. She left still anxious about her anxiousness and what was making her anxious. I stopped trying four anxiouses ago. (I also just like the sound of the word “anxious.” It’s one of those words that just sounds funny, like Dave Barry points out about the word “weasel.” Anxious Weasel would be a great name for a band.)

(As I’m writing out this list, I recognize that each of them has a story, as well as a “medical thought process,” that might be of interest. The tales aren’t as strange or funny, of course, but they do reflect the reality of what we do. Maybe I should write up more stories of normal people. What do you think?)

The Lost Career

I was talking to one of my colleagues who’s an orthopedic surgeon and was reminded of how I made sure I would never be an orthopod.

When I was in the first year of my Emergency Medicine residency and even more flippant than I am now (hard to believe, right?), I was doing an orthopedic surgery rotation on the service of the Chairman of the department. The Professor was an ex-military martinet in the very worst sense of the word, and given that at that time in my life I thought of myself as the Hard Rock Café of medicine (love all, serve all), some conflict was probably inevitable.

One morning he put up the x-ray of a patient he had operated on the day before. He was praising the wonderful realignment of the bones, the way they matched together, how the screws in the plate locked into the bone just enough to provide security but not too much to put the bone itself at risk. I was doing my routine post-call yawn when he turned to me. “Dr. Rodenberg,” he said with the scorn that only a Professor can muster for an intern who does not recognize the absolute primacy of his own specialty and the insignificance of anything else, “why am I remarking about the fine alignment of this fracture?”

“I don’t know sir,” I replied. “Maybe it’s self-gratification.”

Other than a steely glare from The Professor, there was no further comment on the X-ray, and another resident saved the moment by smoothly transitioning into the next case. But I was promptly informed “through channels” that if I ever decided a career in orthopedic surgery was my destiny, there would be no letter of recommendation forthcoming. Go figure.

Vegas Vacation, Part III

All in all, our time in Vegas was lots of fun. Perhaps a bit more placid than I might have anticipated, but we were all middle-aged and most of us married, the occasional one respectably so. With that in mind, here’s the true highlight of the trip.

Thursday night we were at The Rio (fine scenery) and it was time to head back to home base. There were six us and a rental Hondo Civic that seats five. So one of our number (who shall rename nameless because it was such a stupid thing to do) volunteered to get into the trunk so there would be enough room to fit all of us in the car. The trunk was popped open, Kevin (oops) folded himself in, and I took four photos for documentation. The door was closed with the appropriate “thunk,” and the rest of us piled inot the car. There was some thought of lingering a while and getting a drink before we left, but we were uncertain of the oxygen content of automotive trunks. Besides, nobody was really looking forward to giving him mouth to mouth ventilations. He doesn’t brush real regularly.

(By the way, this decision was made without the benefit of significant amounts of alcohol. I’m thinking that we had been drinking, transport of the extra person would have involved a spider monkey, a party hat, gelato, and duct tape.)

We came out of the parking lot, pulled into a turning lane, and found ourselves immediately adjacent to two of Clark County’s finest law enforcement officers. It was probably a good thing we weren’t trying to jam us all in the care by sitting on laps, as I’m sure that would have violated some sort of traffic regulation. (Turns out it does…Nevada Revised Statute 484D.495, to be precise). So we were very glad that Kevin had chosen to stow away in trunk. On the other hand, we were a bit afraid of what would happen if at that moment he decided that the combination of exhaust fumes and disorientation were too much and pulled the glow-in-the-dark level to pop out in full view of the gendarmes.

(It turns out that I didn’t need to worry about disorientation. I thought he might get motion sick through a “sensory mismatch”…the semicircular canals in the inner ear that that control balance would tell him that his body was moving in space, but his eyes would see only darkness, and the two conflicting inputs would induce nausea and vomiting. I had no idea how we would get that stuff out of the trunk. Plus, Kevin had been to the buffet with the rest of us, so I knew whatever came up would not be just liquid that make evaporate in the desert heat before it was time to turn the car on the following day. But Kevin did a great job of focusing, continually texting us from the trunk, keeping himself oriented by the glow of the cell phone screen and noting, “I’m okay. I’m okay,” just like Jodie Foster did in the movie Contact before she was dropped into the alien machine and became a reclusive lesbian. Or maybe it was the other way around.)

We’re nearing the hotel, and then we’re past it. Suddenly our anonymous chauffer (let’s call him “Armando”) realizes he missed the turn. So it’s time for a you-eee (no idea how to spell that) to get back to the main entrance. He takes the turn, and suddenly we hear pounding behind the back seat and a small muffled voice shouting, “Hey! You didn’t tell me about that!”

The car stops, and the bellhop asks if we need help with our bags. We motioned him around to the back of the car. Imagine his surprise when we popped the trunk and Kevin jumped out. (I’m not at liberty to use his exact phrase, but let’s say it had, lots of something to do with sacred excrement.) And of course he didn’t get a tip, because the luggage walked inside on its’ own. For my part, I was just happy it was Kevin who came out of the trunk and not an angry naked Chinese mobster with a tire iron. I’ve seen “The Hangover.”

It’s Vegas. Things happen. And maybe they stay there…unless it’s a really good story.

Vegas Vacation, Part II

No matter where I go, I like to make new friends. For a while, my best friends at the Prairie Band Casino just north of Topeka were a group of dwarves who spent their days Bustin’ Barrels. I was also lucky enough to be invited to the Village People Party on several occasions, and got to experience Lobstermania as well. But the problem with casino friends is that they’re never faithful.

(Uncompensated plug: The Prairie Band Casino is really a very nice set-up. The layout is open, the staff is friendly, the place is well-run, and the slots seem looser than most. The Three Fires restaurant has very nice steaks, but lots of places in Kansas do that. What really sets it apart is the adjacent hotel, which is unexpectedly opulent and features outdoor hot tubs around burning council fires. A really nice overnight getaway even if you don’t gamble. Very cool.)

I’m not really much of a gambler, but I’m surely not above dropping a twenty into the penny slots every now and then. That’s how I met The Frog Princess on my first trip to Vegas. The Princess and I have had a thing going on for two years. (The Bride, bless her, is not only understanding of our relationship but in fact encourages me to spend time with The Princess as a way of strengthening our marriage through a mutually enjoyable pastime and stop me from fretting over her shoulder while she plays slots for real…and most often wins.) The Princess Looks like a green Orion slave girl from Star Trek (TOS: The Menagerie) with Jessica Rabbit curves and a somewhat more puffy face. When the reels line up just right, she wiggles her hips, winks at you, and puckers her lips as her generous amphibian bosom heaves, pleading with you. “Spin some more, big boy. Come and get my bonus. Max bet, 100 lines, five credits per line. Go on, take it. You’re a man. Take it from me. Get my bonus. And bring me a big bag of flies.” Which of course you do, because she’s The Princess. You do the single line, one credit bet for the Lady of Wal-Mart. The Princess is royalty.

I will here state for the record that I was unashamedly in love with The Princess. I would spin her dials over and over, shout the word “Princess!” when she herself showed up on the reels, and would stroke the console with a touch reserved for only the most intimate moments when she would grace me with a credit here and there. Even when I was not playing, when I passed her in a casino (she exists in many different casinos, a situation which I can only attribute to her powers over the space-time continuum), I would touch the screen as I walked by and whisper, “Pretty Pretty Princess” or “Princess, I love you,” or some other phrase that would, under any other circumstances, get me a nice healthy dose of Thorazine and an immediate appointment with the psychiatrist of your choice. But this was Las Vegas, where the presence of pole dancers is said to affect the way cards lay out on the blackjack table, so a guy fondling a slot machine is really no news at all.

I truly believe, based on results, that for the first two years of my affections The Princess loved me back. But this visit was different. I felt the same, but while she was just as accommodating as always, I could tell something had changed. She would still take me for a spin, but there were no more rewards, no more wiggles, winks, giggles, or grinds. I tried to ask her what was wrong. Did she need time? Did she want commitment? But I never got an answer as my heart slowly fell to pieces, twenty dollars at a time.

I was at a loss. I appealed to Zeus, who had often heard my prayers and responded in a creditable fashion. But the mighty Olympian was no help at all. I made an offering at the altar of Zeus II. I made a repentant pilgrimage to the Palace of Riches. I tried to find myself in the Tiger’s Realm. I spent time watching the Nursing Follies. I even looked to befriend the Dam Lumberjack Beavers. But none could help me lift my despair.

It was later that I saw him. The Frog Prince III. Newer, flashier. More ways to win. Bigger bonuses. And I was still The Lonely Human I.

If you’re reading this, Princess, I still love you. Every time I hear a croak, I think of you. Come back soon.

Vegas Vacation

I’m out here in Las Vegas on a “guy’s trip” with a few friends from work. I really like Las Vegas. While it’s all plastic, in no way does the city pretend to be anything else. It’s an oasis of insanity in the normalcy of the desert where nothing makes sense and everything is intentionally out of place. It’s a fake city of fake cities, of New York and Paris and Luxor and Venice and Rome and Camelot. It’s a place where untold miles of dust are suddenly punctuated by the brilliant vegetation of a golf course, but where the grass itself is limited to the tee and the green because it doesn’t want to grow, and you can’t tell a sand trap from the fairway because, well, they’re both sand. It’s a place where every hotel has its’ own mall, every mall has a Tiffany’s, and every buffet serves everything just in case they can find someone to eat it. (And they do.) It’s a place where with one glance I can have my self-esteem both inflated and shattered at the same time. And I’d be untrue to myself if I didn’t insert a small man-oriented note and say that there are more exquisite breasts (and other body parts) per capita than any city in the world. (I’m told that per woman, there are actually the same requisite number of breasts, so perhaps this is a function of volume.)

I say all this about Las Vegas not to denigrate it any way. In many ways, it reminds of a grown-up version of my own Daytona Beach, another tourist mecca that simply is what it is and doesn’t lay any pretentions to being anything else. I’ve heard that Las Vegas is actually a pretty good place to riase a family, with good schools, low taxes, and a low crime rate off The Strip. But so are places like Ulysses, Kansas (a very nice town, with no disrespect whatsoever), and nobody road trips to Grant County.

(At one time I considered applying for the job of Director of the Health Department for Clark County, Nevada. I can’t recall if I sent in the application or not, and I don’t know if I would have taken the job even if asked. At the time, I was commuting two and a half hours back and forth by air from Kansas City to Tampa every other week to see The Child, and that just about killed me…no idea what a five hour commute each way and a three hour time change would have done to my biologic clock. But I would have been perfect for the job. As the former Director of the Health Department of Volusia County, I was in charge of the Sanitation of Sin for the Eastern Time Zone. Why not take the same job up for the West?)

Anyway, here’s a few “Vegas Tales” from the trip. Hope you enjoy them. Parts II and III to follow.

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We all decided that a fun thing to do on Wednesday would be to go sit by a pool. The first step in this process is to figure out which pool you want to sit by. There are specific criteria one uses in this selection process. Here is a partial list:

1) The number of hours of sun the pool received in an average afternoon in order to facilitate the conversion of 7-dehydrocholesterol to Vitamin D, promoting bone health and preventing rickets.

2) The probability of finding enough chairs for seven people to sit together to build camaraderie and gawk in unison at the more shapely passers-by.

3) The temperature of the water so as not to induce contraction, shrinkage, and possible future fertility issues.

4) The likelihood of seeing hot women with exceptional breasts (volume and/or quality) who will most likely not talk to us because we are

a. Fortyish
b. Flaccid (at least visibly)
c. Dweebs
d. Not internet kazillionaire dweebs

5) These may or may not be in order.

In order to properly inform the selection process, we had to view at least eight pools to get an appropriate panel to choose from. As it takes forever to get between the casinos on foot (“We’re sturdy! We’re men! We can WALK! ), this means that by the time we chose a pool, it was too late to get back to the hotel and get our swimsuits that afternoon. So the actual pool visit was put off until the following day.

The swimming pool at Cesaer’s Palace is a magnificent thing to behold. Nestled within the “Garden of the Gods,” there are a whole series of pools named after the Roman deities themselves. Lots of space, very decadent padded loungers and cabanas, attentive wait staff, blackjack under a waterfall, excellent scenery. There is even the “Venus Pool Club” featuring “European-style bathing.” In the name of decency, this pool is screened off from the other, more family-friendly (In Las Veags, that’s a relative term) dunks. It turns out, however, that if you have a telephoto lens on your digital camera you can see over the screens form two pool terraces up. And I’ve been led to believe that inside the Venus Pool what you will find is thirty pale bald and flabby men who are not ashamed at all to be topless, three similarly coiffed and attired women (who may equal the men in breast size, but it’s a close call), and one incredibly nice piece of plastic work whose sole job I think was to serve as bait.

What I like to do at a pool is sit. So while my compatriots were splashing around threatening to do cannonballs in four foot water (WARNING: I do not bring spinal immobilization gear nor skull tongs with me on vacation) and finding out which bartender couldn’t add well to source the cheapest drinks, I was perfectly happy to watch over our towels and tennis shoes. I had a few drinks, read my book, got some sun, and talked for some time about what I was reading to a charming young twinkie two chairs over with a budding interest in science fiction. Four and a half hours later, the shadows from the hotel had overlapped my chair. I had finished my book, my face looked tan, and I had a nice red stripe down my chest and stomach from where I kept my shirt on to avoid getting my shoulders burned, but forgot to button it up the front.

So I heartily recommend the pool at Cesaer’s Palace. Because who knew that “Starship Troopers” by Robert Heinlein was such a chick magnet?

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Here’s what medically-oriented marathon runners (clearly not me, whose exercise is confined to squinting) talk about around the pool:

Running a marathon in the desert would be tough. You’d need lots of hydration, and lots of an electrolyte replacement fluid such as Gatorade to put sodium and potassium back into you. But running to the side of the course to pick up a drink might slow you down. And what if the Gatorade has been diluted? That would be even worse, and would surely cause cramps and make you drop out of the race.

The solution, of course, is to take a frozen banana and place it in your lower GI tract. As the banana thaws, it melts, and presumably the potassium in the fruit gets absorbed into the blood stream. No need to stop for a drink, your times improve, and you finish strong.

I think they’re going to flip to see who tries this first.

The Pleasure Palace, Part II

(Since I'm currently with some friends in Las Vegas, and since there is a fair amount of adult content in this fine community, putting up the following post seemed the proper thing to do. Real travel notes tommorrow.)

One of our ED nurses, the ever-chipper Lori Stephenson, told me this tale last week.

She was caring for a young man with back pain. Not a big deal, got a shot for pain, felt better, getting ready to go home. His girlfriend, who was being seen in another part of the ED for a similarly minor complaint, ventured into his room as Lori was talking to him about back care. (The “family plan” visit is a common phenomena. The latest addition to the Rodenberg Canon of ED Rules is that the number of family members who want to be seen at any given time is inversely proportional to the severity of illness of any single person.) There was an uneasy tension in the room, with the woman glaring at the man, the man shifting uneasily on the exam bed.

“Well did you ask her?” she said.

“Hmmm...ummm,” was his nondescript answer.

“Did you ASK her?” It was not really a question now.

The man replied, irritation in his voice. “Well, you go and ask her then.”

Lori had been droning on, doing her best to provide some patient teaching as well as read the required hospital paperwork to him, a task complicated by the fact that within the health care system of the United States, sound medical advice and institutional policy are often totally different things. Admittedly, she hadn’t been paying a lot of attention to the conversation. This was about to change.

“Nurse. Hey, nurse,” beckoned the woman.

Lori, always polite, said, “Yes, can I help you?”

“Is his back pain from having relations?”

“Excuse me?” Still polite.

“Relations. He always wants to be havin’ relations. He wakes up in the morning and wants to have relations. He comes home from work and wants to have relations. I think his back pain is form having too many relations.”

Being an exceptionally bright spark, Lori immediately recognized that she had suddenly dropped into the abyss known as the Canyon of TMI, or Too Much Information. Nonetheless, she doggedly kept moving ahead, trying to regain her footing on this treacherous ground. Just like medicine, nursing is both a science and an art. So this nursing scientist tried to break the problem into its’ constituent parts.

“Is your concern about positioning or frequency?”

“He wants to lift me up when we have relations. And,” she pointed out, hugging her stomach in a peculiarly affectionate way, “I ain’t no lightweight.”

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

And then there’s the story told by a social worker about a patient seen by her husband, a retired paramedic. He had been called to a home in the early hours of the morning to be greeted by a man clad only in what might be politely called his “tighty whities.” “Hurry!” he shouted with alarm. “I was doing it with my woman, and now her cummer is stuck!”

Turns out she was having a seizure.

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Which in turn reminds me of a tale of long ago, when I was an intern called to the ED at 3 AM to admit a young woman who had a seizure and passed out while having “relations.” It’s bad enough to have to get up that early, but even worse when you spend an hour trying to get information from the patient only to have every questions answered an overzealous boyfriend.

I tried one last time to get some information from the patient herself. “So what do you remember about what happened tonight?”

Once again, the boyfriend took over. “Aren’t you people LISTENING to me! We were having sex and she started to scream. The she started shaking and having a seizure, and then she passed out. What’s WRONG with you?’

A medical student with me, who had much more self-control than I at the moment, looked directly at the boyfriend. “Sir, what she had was called an orgasm. And it’s pretty obvious that you’ve never seen a woman have one before with you.”

Enraged, he grabbed the girl by the arm and dragged her from the ED. But as they were leaving, she lagged just a bit behind. “It’s okay” she whispered to us, turning her head behind his back. “I was faking anyway.”

Safety Patrol

Security screening at the airport still drives me as crazy as it did eight years ago when I first wrote about it in a column for jems.com. I’ll spare you the painful details of a reprint, but essentially my objection is not that we do screening, but that we do so in a fashion based not on any science or risk-based assessments, but on the need to be politically correct. I forget where I heard the term, but someone once said our airport screening process in nothing more than “Security Theater,” and I think that’s just about right.

I was fretting about this today as I pondered if my two prepackaged fruit cups with natural juices (8 oz by weight, uncertain by volume) were going to get through the “no fluids” rule. Would they think that the pieces of grapefruit floating in the extract was real fruit, or a clever ruse to hide kerosene? I also wondered if my bottle of cologne, which says it contains 1.4 ounces but somehow needs a three inch block of glass to contain it, would pass muster as well. Fortunately, I passed, and Seat 23C has never eaten healthier or smelled better.

(Do you ever wonder how much the confiscation process depends on the immediate thirst or hygiene needs of the individual TSA screener?)

Anyway, this reminded me of my favorite stupid security story. When I first moved back to Kansas in 2005, I was flying back to Florida a lot to see the Pre-Bride and The Child. One one of these trips, I literally blew a tire while turning into economy parking in Kansas City. (No ,I didn’t go over the exit grid the wrong way, but that’s an excellent guess. You know the polls that say 90% of drivers think they have above average skills on the road? I’m the other 10%.) I had a spare tire in the trunk but no jack, and was running very close on time and couldn’t wait for a repair truck to come from the service station on airport grounds. So I figured the best thing to do was to buy a car jack in Florida, and take it back with me in two days time. That way I could fix the flat in the parking lot, avoid the cost of a service call, and have a new jack in the trunk for any future needs.

Once in the Sunshine State, I went to see the Pep Boys and got my jack. (Pep Boys. Manny, Moe, and JACK. Get it? It’s now 10:15 in the morning and I’ve been up since four driving over from Daytona to pick up a nonstop flight and a cheap fare in Tampa. Cut me a break.) The jack was the kind has a base plate on one side and a lifting plate on the other enveloping a screw that you turn to make the jack go up or down. Fully rotated, the screw allows the jack to lie flat, about four inches tall. Perfect for carry-on, I thought, as I approached the security screening in Orlando (an airport which has still not talked to Walt Disney World about how to move people through an attraction.)

In retrospect, I should have seen this coming. It’s only a few years past 9/11, and here’s this disheveled guy taking a late night flight halfway across the country with car repair equipment and a Dave Barry book as his carry-ons. I undoubtedly fit somebody’s profile somewhere. (I still remember a picture book my parents had about the Kennedy assassination called “Four Days.” There was a picture of Oswald’s perch atop the Texas Book Depository. There was a fast food bag next to the windowsill, with a caption noting that “The assassin dined on fried chicken ad pop while patiently waiting to shoot the President.” I must have been that guy.) There’s no telling what I might have done with the jack if forced to spend the next two and a half hours seated next to someone who wanted to talk and talk and talk and talk and talk and didn’t have really great…yeah, ummm, yeah. (I was still single, at legally, back then). So I would have been annoyed, but probably would have understood, if the whole kit and caboodle was taken away.

(By “whole kit,” I mean the jack. It’s hard to justify the book as a dangerous airborne weapon. “Prepare to discuss Dave Barry’s treatise on exploding toilets or I’ll take this plane down and all the inflight magazines with it!” On the other hand, if you tossed a book out the window from 36,000 feet, physics tells us it would hit the ground 47 seconds later at a speed of 1035 miles per hour. And there’s that whole explosive decompression thing as well.)

The jack actually came in two pieces. One was the jack itself, which was the heavy lifting base with the screw that raises the car up and down. The second piece was a ten ounce forged metal handle that you used to turn the screw. So what the TSA Officer did to protect the skies was to confiscate the handle, allowing me to take the ten pound steel jack itself on board without any problem whatsoever.

Now that’s security.

Primary Colors

A friend of mine recently said that she was watching a pod of right whales off of Flagler Beach. I had no idea that all whales were Republicans. Does that mean there are left whales swiming off the coast of the Blue States?

It reminds me of the time someone asked me where Liberal, Kansas was located. The answer, of course was ten miles to the left of Conservative.

Reader Contest!

As much as I simply like to write, I increasingly recognize writing as work. That impression is reinforced by writing exercises I’ve done from time to time. The way these exercises work is that you’re given a scenario and told to write something about the characters motivation, to develop a back story, or move the episode to an unexpected conclusion. It’s a lot tougher than I ever thought it would be.

But as misery loves company, here is today’s writing exercise, based on real life:

At 7 AM on a Saturday morning a physician walks into an Emergency Department. As he turns the corner to head towards his workplace, he sees a tall, sultry, dark-haired female nurse carrying a full plastic urinal in each hand and a younger, taller, and beefier male tech with his hands full of leather restraints walking side by side.

I need a minimum of 500 words. Best answers posted on The Blog. Begin.

Consult Note

Here’s the latest from the Department of Inappropriate Use of Psychiatric Services:

Ms. Parsons is an extremely nice elderly lady with a history of heart disease and mild dementia. She was brought to us early this morning from the nursing home for agitated behavior. The nursing home transfer sheet said she had assaulted her roommate and “needs evaluation for altered mental status.”

Here’s what actually happened. There was another resident of the nursing home who simply couldn’t keep quiet. She would be talking at all hours of the day and night, her screeching often littered with profanities. She had already been moved out of two rooms, and was finally placed with Ms. Parsons because every night she took a sleeping pill, and it was through that she could doze through the verbal hijinks in a pharmacologic-induced haze.

Problem is, it didn’t work. The new roommate’s voice broke through her serene slumber, and she couldn’t get back to sleep. After three hours of this, something inside her snapped. By her own admission, she got out of bed, grabbed the new roommate by the shoulders, and started screaming, “I told you to shut up or I’d slap the (excrement) out of you!”

No need to see psych on that one…

More Vocal Software Follies

Some months ago I wrote about our new voice recognition software system for dictating medical records. Here’s a few more ways the system has been mistranslating my colleagues and I…or maybe the system knows something closer to the truth?

What the doctor said:

“The patient is subsequently discharged from the Emergency Department.”’

What it heard:

“The patient was sexually discharged from the Emergency Department.

(For the record, it’s usually the other way around. The patients may come in with one, but hopefully they don’t pick one up while here. That being said, there’s been an awful lot of canoodling in the exam rooms lately, and if the patient restrooms are large enough for wheelchair access…)

What the doctor said:

“The patient will be admitted by the Volusia hospitalist.”

(Volusia is the name of our local county, and the name of one of our hospital-based medical groups.)

What it heard:

“The patient will be admitted by the delusional hospitalist.”

(Which may or not be a true statement. He’s a new guy in town. We’ll see.)

What the doctor said:

“There are no factors noted that increase or decrease his symptoms.

What it heard:

“There are no fractures that increase or decrease any symptoms…

(I would think a fracture would influence something, wouldn’t you?)

What the doctor said:

“I evaluated the patient…”

What it heard:

“I violated the patient…”

(Again, depending on the doctor, one never knows.)

I was telling my charming and esteemed peer Dr. Tara Wilson about these miscues, and she came up with another brilliant concept. (Tara is especially esteemed because she is one of those rare physicians who will actually say “The patient is exhibiting drug-seeking behavior” on the medical record rather than push the patient off on someone else. Brilliant.) She wondered what would happen if we changed the tone of our speech to reflect the medical word being said? Maybe male physicians should raise their voices to a falsetto when we say the word “vascectomy,” or female docs ought to drop into a deep bass when they say “hysterectomy.”

That’s an experiment for next shift. Medicine is a science, after all.

(Author’s Note: I’m writing this as I sit in the communal grill area in the complex where I live. At the table in front of me is a group of college students celebrating a birthday by smoking cigars. Before they lit up, the birthday boy asked me, “Do you mind if we smoke? “It’s cool with me,” I said, “but just make sure it’s something that won’t show up on my drug screen at work.” And suddenly it was a different box of cigars being passed ‘round.)

Medical Cliff Notes

Like most restrooms in North America, the one in the ED physician’s locker room occasionally features reading material. Most often, it’s whatever pop culture magazine was left over from the week before. I’ll plead guilty to the occasional read. This is why I know there’s someone out there named Heidi Montag who has had 13 plastic surgeries and is still not happy with her 36 DD breasts.

Given that I’ve been spending a fair amount of time in the restroom retching lately (the HIV exposure prophylaxis meds…see the earlier post, “A Really Bad Day”), I’m pretty used to seeing the bevy of pronoun magazines (“Us, We,” etc). So I was genuinely surprised on Monday night when I found the June 19, 2009 copy of the Journal of the American Medical Association (JAMA) perched on the lid of the trash can abutting the throne. As I had a bit of time between spasms (you know those three minutes after one episode when you know it’s going to happen again so it’s foolish to leave…of course you do), I leafed through the magazine as was floored to find a review of a book about Emergency Psychiatry that ran 530 pages.

For the life of me, I can’t figure out why a book on emergency psychiatry would have over 350 pages. I think you could get it all into a pamphlet in a fairly large font. I think this is because all I ever really needed to learn about ED psychiatry was taught to me by Ted, a rotund, Louie Anderson look-alike social worker in Maine more than a dozen years ago. Here's all I really needed to know:

If the patient tells you their story and you’re confused, they’re schizophrenic.
If the patient tells you their story and you’re depressed, they’re depressed.
If the patient tells you their story and you’re pissed off, they have a personality disorder.
If the patient makes too much noise, give them Haldol until they stop.

I’ve seen thousands of psychiatric patients in the ensuing years, and to this day these lessons are still correct. I’ve also reviewed these rules with some real live board-certified non-psychotic psychiatrists (harder to find than you might imagine), and they also agree that these tenets cover 95% of ED work. Admittedly, they may have had a few drinks on the hospital before I asked them…you’ve got to love staff recruitment dinners. Perhaps I stacked the deck but, as they say, in vino veritas (in wine, truth. This is another rule, but one that applies to all of life, not just medicine. Just like, “The girls all get prettier at closing time.”)

I’ve always liked the idea of being able to simplify medicine into just a few phrases. For example, here’s what I was told long ago constitutes the summed knowledge of four years in dermatology training. (In these rules, “it” refers the rash, or lumps, or bump, or whatever else is showing on the skin and generally looking gross.)

If it’s dry, wet it.
If it’s wet, dry it.
If you don’t know what it is, don’t touch it.
If you know what it is, you don’t have to touch it.
If it’s black or blue, cut it out
Above all, give it steroids before it goes away by itself.

(I learned these rules well over twenty years ago. I’m certain that now there’s probably a seventh rule, which is, “If it sags, give it botox.”)

A five year general surgey residnecy is even easier to summarize :

When in doubt, cut it out.
Nothing ever metastasized from a jar of formaldehyde.

And three years of internal medicine? Easier still.

Health is only the absence of a sufficient number of labs and x-rays.

So how do you sum up three years of training in Emergency Medicine? Well, we’re not established enough as a specialty to have our own catch phrase. So, being the jack of all trades and the master of none, the guys who treat you before we actually know what’s going on (because the disposition…what we need to do to you to keep you alive…comes before an actual diagnosis of your specific problem), we’re best summed up as the punch line to a joke:

An internal medicine physician, a general surgeon, and an ED doc are out duck hunting.

The internist hears what he thinks might a duck, sees what he thinks might be a duck, and consults his Book of Ducks to confirm that there is a high probability of the duck actually being a duck. He then takes a BB gun and shoots the duck, singeing the feathers just enough to bring the duck fluttering gently to the ground. He politely asks his old and trustworthy Irish setter, who has been waiting patiently by his side, to kindly retrieve the duck. The dog goes out into the field, lifts the duck by the uninjured wing, and deposits the duck in the soft grass near the internist’s feet. The internist calms the duck with words of comfort and gets out his Book of Ducks to confirm, in fact, that this really is a duck. He then gently tells the duck that while he may never fly again, he’ll do all he can to make sure he has a good quality of life.

The surgeon hears a duck, sees a duck, whips out his rifle, and delivers a kill shot to the bird while it’s still on the wing. He grabs his pit bull by the collar and goes down on his knees to get in the dog’s face, screaming “GET THE DUCK! GET THE DUCK!” The dog goes out into field and clamps down on the lifeless carcass, blood and feathers flying everywhere. The dog brings the duck back to the surgeon who whips out his field knife to clean and dress the bird, throwing the entrails to the now-ravished dog. He kicks open the cooler, one hand placing the duck on ice to send to the pathologist to see if it really was a duck while pulling out a tall cold one with the other.

The ED doc hears what he thinks might be a duck, sees what he thinks might be a duck, puts on a blindfold, and picks up two sawed-off shotguns. He twirls in a circle and blasts away, shouting, “Did I hit anything? Did I hit anything?” Meanwhile, his cocker spaniel runs around his heels, barking happily at nothing in particular.

Your specialty certification exam will be in three weeks. Study hard.

Secret Codes

The back of the identification badge at the hospital where I work lists different hospital-wide emergency announcements as “codes.” Some of these are familiar, such as Code Blue for a cardiac arrest. (I’m not sure why it’s called a Code Blue, other than presumably when you go into cardiac arrest, your color is your code.) Some codes are intuitive, like Code Red for fires. Others take a bit more imagination, but still make sense. For example, Code Pink is an infant abduction, and pink is a baby-type color.

(Speaking of abductions and other criminal activity, about two months ago there was a robbery at a bank within walking distance of the hospital. There was a rumor that the villian had been wearing medical garb and had run onto hospital property in order to hide. About the same time I’m hearing this, Sean, one of our ED techs, comes whizzing through the back of the ED. Sean is usually a pretty controlled guy, so when he runs it usually means that he was in triage and found a patient who is seriously ill or injured and needed to be seen yesterday. But this time there was no wheelchair holding a body in front of him, so I jumped in front of him in full flight.

“Hey, what’s going on?”

“Man, you heard about the robbery right?”

“Yeah, I did.”

He sidestepped me and kept on moving. “In my neighborhood, they’re always looking for the black man first.”

Oh, and just for the record, Sean and I are also trying to work out some kind of specific race-baiting incident so we can get invited to the White House to have a beer with President Obama and Vice-President Biden. We’re both leaning towards imports.)

Sometimes, however, the folks who designate the codes might want to talk to those of us on the street. Code Brown is used to represent a weather-related emergency. But in the ED, Code Brown is called when a patient unexpectedly releases intestinal contents within the exam room. So if you ever walk into an ED and notice a strong aroma of coffee, you can be sure there’s been a recent Code Brown. That’s because a filter full of moist ground coffee soaks up the smell. We’ll be talking to Heloise about this.

Wordplay

Has anyone else noted that there are only two letters separating the word “toil” and “toilet?”

Does anyone in Mexico note that there is a single letter difference between "casado", or married, and "cansado," which is tired?

Coincidence or hidden truth?

You be the judge.

The Pleasure Palace...Adults Only

I’ve noted before in this blog that the ED is a great place to restore your belief in love. Just when you think you’re terminally single and can never be wanted by anyone, you see couples in the ED that truly prove there’s someone for everyone, regardless of race, religion, ethnicity, dental health, hygiene, or tonnage. Young love is most often on display, either in the form of couples canoodling on the exam bed (especially true when the vomiting party is sharing potato chips with their beloved) or when an unexpected new pregnancy is discovered.

But, as Whitney Houston reminds us, learning to love yourself is the greatest love of all.

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Mr. Conrad was brought in by the ambulance because four days ago he had bent over to pick something up and had hurt his back. His pain was so incapacitating that he had managed to walk to a pay phone in order to call the ambulance. When I went to see him, however, the room was darkened and the privacy curtain pulled; and the expression on his face was not one of pain, but of ecstasy. Using my acute powers of observation and years of clinical training, I quickly deduced that it had something to do with the fact that his pants were unzipped and his hand tucked inside his wasteband, with a rhythmic motion to his right arm not unlike a focal seizure.

“Are you having a seizure?”

Startled, he looked up at me from the bed.

“Huh?”

“A seizure. Are you having a seizure?

“No.”

“Are you sure you’re not having a seizure? I ask because your arm is going back and forth like you might be having a seizure.”

I will hand it to Mr. Cooper; he was a quick thinker. “I’m holding in my hernia.”

That was a good answer, but not one above reproach. While I’ve never had a hernia myself, I’ve seen plenty of them. When someone has a hernia, they may sometimes support their scrotum with their hands, lifting the sac in order to prevent further discomfort (Please, no jokes about not being an athlete, but always being an athletic supporter. Thank you). But usually this is not a particularly rhythmic, or pleasurable, thing to do.

“Well, let’s check that out while we work on your back pain.”

So I did, and found no evidence of a hernia. He said, “I only see it when I sit up.” So I sat him up, and there was still no hernia. “I REALLY see it when I stand up and cough. But I can’t do that because I have back pain.”

Call me inherently suspicious, but I generally believe that if you’re able to walk to the pay phone you can stand up in the ED. So I made him stand up and cough. And still no hernia. He look puzzled.

“Hmm. It’s usually there.”

“I’m sure it will be there again soon,” I reassured him. Because a man has needs, don’t you know.

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Mr. Cooper reminded one of our nurses of a rotund African-American woman she had cared for last week who had taken similar liberties with her own contentment in the ED. When caught in the act and informed that this was perhaps inappropriate behavior for the health care setting, she said, “This is an EMERGENCY Room, and I’m gonna take care of my EMERGENCY.” She then proceeded to the restroom to relieve her emergency condition. At least it was assumed that she did, if the noises that were heard coming from the water closet by the nurse…and the rest of the ED…were any kind of reliable indication.

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About a year ago, the police brought us an intoxicated man who had been found in the public forum. His care was pretty routine…exam, blood tests, an intravenous alcohol “rally pack”… until one of the nurses came to me and ask me to make him cease his onanistic practices in the exam room.

Having reached deep into my soul for any latent Puritanism, I adopted the sternest visage possible when dealing with a scenario with the possibilty of reducing this seasoned professional to a giggling eight-year-old, and entered the room. There he was, eyes open, looking right at me, and continuing to raise his own personal flag in a most diligent, dedicated, and patriotic fashion.

“You know, you’ve really got to stop that. Makes the nurses nervous.”

He looked up at smiled, a broad grin highlighting his remaining teeth. He continued to hoist his banner.

“No, really, I’m serious. It’s inappropriate, and that kind of behavior will get you thrown out of here. Sleeping in the street isn’t worth getting off, right?”

”Hmm-hmmm.” Too deep into his patriotism to hear me.

I left the room, shaking my head. There is only so much you can do as a physician. You can provide the best counsel ever, but it’s up to the patient to act on your good advice. And clearly this man was getting a second, five-inch opinion.

“Did you get him to stop?’ asked the nurse.

I shook my head. “Nope, he’s still at it. But,” I added in a moment of reflection, “I’m not sure if I should be upset that my authority meant nothing, or feel proud that I’m such a sexy guy that he sped up when I was there.”

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I mentioned breaking down like an eight-year old when presented with funny conditions just below the beltline. No matter how much you’ve been in this business, that feeling never goes away. This is why I’m not a urologist, even though they do lots of cool procedures and I’ve always like the phrase “Urologist is my ologist.” Two examples of this phenomena:

Two days ago I got a call from a colleague at another hospital who needed to transfer a patient to our facility. The patient needed to see a colon and rectal surgeon for rectal bleeding. He had rectal bleeding because he was out turkey hunting that morning and needed to move his bowels. When he lowered his trousers to squat, a sharp stick had reportedly penetrated his rectal area. The stick was not there when the patient arrived, of course, but the bleeding was quite severe and the patient genuinely needed specialty care.

I’m taking this report on the phone and being very professional about the whole thing. But after five minutes of “Hmmmm,” and “Yes, I see,” and “Oh, my,” I was about to lose it. All kinds of visions were running through my head; besides I knew that when I was in Boy Scouts, I always looked at where I was putting my nethers in the forest. So I finally said to the doc on the phone “Hey, are you having as much trouble keeping a straight face right about now as I am?”

There was a small chortle, and then a full-fleged laugh.

“It’s been a tough hour of not smiling over here. A really tough hour.”

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

The second patient came in with a fractured penis.

(You’re laughing already, and I haven’t even started the story. Let’s try again.)

The second patient came in with a fractured penis. A bit of anatomy here. Although men do get boners, there is actually no bone in the penis. There is a bone in the penis of certain reptiles, which may give rise to the term “Lounge Lizards,” but not in human beings. What causes the penis to rise to attention, besides the attention of a desirable partner (or with enough beer, any partner) is that along the top of the penis there are two cavities called the corpus cavernosa that fill with blood when stimulated. When engorged, the cavities become rigid, and that’s what really causes the male member to demonstrate it’s intent. These rigid chambers have the consistency of Styrofoam; and as anyone who’s dropped a full cooler knows, given enough force of impact Styrofoam will break.

Personally, I think that there are noble and ignoble ways to suffer this kind of injury. The noble way is to be working the hospitality suite at a nymphomanic convention. An ignoble way is to do what this gentleman did, which was to take a rigid plastic penis enlargement pump (see “Austin Powers: International Man of Mystery”), wedge it between two of the cushions on your couch, and simulate a stress-relieving interaction. As you might guess, rigid plastic doesn’t respond particularly well to affection. One wrong move, and the corpus cavernosa go snap.

So this guy has a fractured penis. What you see clinically is a huge bruise and swelling on one side of the penis with the tip pointing at a 90 degree angle in the other direction. There is a small amount of blood coming from the tip of the organ. The real problem with these injuries is not only related to sexual function, but also a possible tear of the urethra, the thin tube that carries urine from the bladder to the external world.

What you need to do to evaluate these injuries is get a retrograde urethrogram, in which you inject a small amount of dye into the tip of the penis and take an X-ray film to make sure the dye stays within the urethra and does not leak out into the surrounding tissues. This is not a routine procedure, so I called the radiologist to make the arrangements. I told him the story. His response was “Really? Can I come see?”

Well, of course he could. It only makes sense for a physician to be able to completely evaluate the patient. So he came down to the ED. He saw the patient, and then motioned me around a corner.

“He was banging a penis pump?”

“Yeah, I think so.”

He looked at me. I looked at him. And we both reverted to eight-year olds, and we both began to snicker.

The urethrogram was negative, but there was still the issue of the fracture. These injuries often need surgery in order to restore normal “position and function,” as it were. So we called the urologist, who came to the ED, saw the patient, motioned the radiologist and myself around a corner, and all three of us began to snicker.


About two months later I was in the Doctor’s Lounge grabbing a soda. The radiologist and I had already been chatting about nothing in particular when the urologist walked in.

“Hey, whatever happened to that guy…you know who I mean.”

He did know. It turns out that the patient had refused surgery despite being told that without operation, his penis would probably heal with a 90 degree bend in it. Useful if you want to pee around corners, but not too good for romance.

The radiologist’s eyes got wide. “Really?”

And all three of us began to snicker.