Thursday, May 13, 2010

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.


  1. A Family Medicine catch phrase might be:
    take two aspirin, if its no better in a week , come back

  2. The FP would say , looks like a duck, might be a duck, lets wait a week and come back. If its still there its probably a duck.