Larger Problems

Have you seen this new piece of female lingerie from Victoria’s Secret? It’s called the “Bombshell Bra,” brassiere, and it raises the lucky purchaser two breast sizes when worn. It’s really quite remarkable, even if counterintuitive to the old adage of not making mountains out of molehills. But it makes me think of one of my favorite ED tales.

I had just started working in Daytona when a very attractive young woman came into the ED with abdominal pain. This was back in 1996, when I had first come back to the USA from working overseas, and this was my first job as an ED doc in the private world outside of academia. What that meant is that I was still trying to figure out how to best use my time to get in and out of the patient room as fast as possible, which is a skill that you acquire only in the world of community medicine. When you’re learning medicine, like in medical school and residency, that’s not an issue. You’re expected to be pathologically complete and glacially slow. And when you’re teaching medicine as I did at the University of Florida, that’s not a problem as there’s always someone lower on the totem pole who’s already asked all the right questions for you.

Even with the merciless push of technology, each medical encounter is still based on the patient’s history and physical exam. Each of these segments has it’s own constituent pieces. The history begins with History of the Present Illness (HPI), where you ask about whatever it was that brought the patient to the doctor. (This is actually often the trickiest part in the ED setting; patients have multiple problems, and you have to be able to politely tell them that, “Here in the ER we only deal with one problem at a time, so if there’s one thing that made you decide to come here today would that be?” You have to do so or you’ll never get on with the rest of the work.) You then ask about the Past Medical History (PMH), Medications, Allergies, Social History (SH), Family History (FH), and finish up with a series of general health-related questions called the Review of Systems (ROS). The ROS is really designed to uncover other related symptoms or problems you haven’t thought about before that might be related to what’s going on. However, if used incorrectly and not focused on the problem at hand, it provides you with far too much information to be really useful. (Have any problems with headaches? I had one last week after playing the Wii for three hours straight. Any chest pains? I climbed to the top of the Washington Monument two months ago and got short of breath. Difficulty with urination? Well, no, but they tell me that urine smells funny after you eat asparagus. I don’t like asparagus, but why is that? You get the drift).

The final piece of the history, at least according to those medical sociologists who never actually see patients and exist under no time constraint other than the time until tenure, is to ask an open-ended question such as “Is there anything else you’d like to talk about today?” to allow the patient to express their own concerns and expectations for care. This is a great question in a primary care office. It’s a rotten question in the ED, because getting the answer and trying to figure out where to go from there is often the kiss of death to any kind of efficiency in the ED.

But I hadn’t figured this out yet the fall day in 1996, and so when I asked if there was anything else bothering this particular patient, she replied, “Ever since I got my breasts done, I can’t sleep.”

This was new one on me. I knew that large implants can give women back pain; I knew about the alleged dangers of silicon implants; I had taken care of wound infections and even dealt with what happens when you get a blow to the chest and the implants pops. (It’s kind of funny, to be honest). And of course I had been party to discussions, usually…well, always…over beer about personal preferences for real or fake breasts, and had thought that women with well-crafted implants probably don’t need to worry about knowing if their airline seat can be used as a flotation device. But implant-induced insomnia was breaking new ground.

So I had to get more of the story. Turns out she was a dancer at one of our better men’s clubs here in town. (That’s not a joke…it was actually pretty nice in there.) In order to maximize her income, she had to maximize her assets. This was working out well for her, and she figured that in three years time she’d be able to quit. But in the meantime it was hard for her to sleep. She usually slept on her stomach, with her head turned to the side. But with the new, improved, and greatly enlarged breasts, when she tried to sleep on her stomach her head was too far off the pillow, and when she drifted off her head fell down, blocking her airway, and she would wake up with a start over and over and over again.

The problem was easily solved by asking her to use three pillows for support at night…we trialed this in the ED for her, comprehensive folks that we are…and while I have been telling this story for years, I didn’t really understand it until last month. The Bride, who is fairly well put-together to start with, got one of these new Victoria’s Secret bras to see what it would do. (To be fair, I certainly encouraged her in the shopping.) Let’s just say the effect was an impressive demonstration of textile engineering. But we’re out late one night, and we’re both a little beat so we’re having a late night cup of tea at a seaside coffee shop. She’s so tired she starts to put her head down on the table. But she can’t, because…yeah, I finally got it.

Plumbing Surprise

Here’s the weird note for the day. The bathtub wouldn’t drain after my shower yesterday morning, so I got a handy guy to come look at it. Turns out that when he removed the stopper and the supporting grill, there was big ball of hair blocking up the drainage pipe.

Talk about mixed feelings. On one hand, I’m supremely embarrassed that a total stranger is extracting huge plugs of hair form my shower. One the other, to be 47 and be able to spontaneously shed that much hair from my head and still need a thinning out and a cut every month just to keep things manageble...we’ll, that’s just something to be proud of.

Soccer News

World Cup Update: Paul the Octopus is now six for six. Having predicted German victories over England and Argentina, the clarivoyant cephalopod correctly selected Spain as the winner of today’s semifinal match. Congratulations to Paul for finally making the right choice.

That being said, I’m kind of dissapointed that we’re not having The War of the Guays (Para and Ura) in the World Cup Final. But as they say, you go Uruguay and I’ll go mine. (I’ve been waiting for years to use that line). But fortunately, as we learn from Ryan Wilson at BackPorch.com:

Despite Paraguay Loss, Larissa Riquelme Will Still Run Naked Through Streets

Paraguay made it all the way to the quarterfinals of the 2010 World Cup before losing to tournament favorite Spain, 1-0. Not a surprising outcome...but upsetting nonetheless, particularly for those individuals who were looking forward to lingerie model Larissa Riquelme's naked romp through the streets if Paraguay had won the whole thing.

All is not lost, it turns out.

According to Metro.co.uk: "Riquelme has confirmed she'll go ahead with her promise - even though her countrymen fell a couple of wins short of the target she'd set them."
"It will be a present to all of the players, and for all the people in Paraguay to enjoy,' she said. "They tried as hard as possible and gave it their all on the field." That's called taking pride in your country.

In related news, Diego Maradona will be forced to run through the streets naked as punishment for Argentina's no-show effort against Germany in the quarterfinals.

(And from my own visits to Buenos Aires, I know that the Avenida 9 de Julio is one big street.)

Higher Power

There’s this bit from the Bob and Tom Radio show about getting on in years. I forget his name, but one the featured comedians notes that one of the signs of age is that when you’re checking out hot girls at the Food Court in the Mall, they run to security because there’s a creepy old guy looking at them. This is why I’m now publically declaring that when I pace the floor at Barnes and Noble, Borders, Starbucks, or an airport staring at your feet , I am not a frustrated late forties guy with an unsatisfied fetish or hoping to spy a reflection off polished leather. I am instead a frustrated middle-aged guy searching desperately for an outlet in which to plug in my laptop and feed my Facebook addiction, because the child has burned out the battery playing Civilization IV in the car, having named his four cities Hamburger, French Fires, McNugget, and Happy Meal, and hoping to build combat units called Big Mac and Mayor McCheese. (I understand he’s saving Filet-o-Fish for the first city he builds near the coast.)

Thank you in advance for your understanding.

Set 'Em, and Forget 'Em

The fear of missing something weighs heavily on every doctor's mind. But the stakes are highest in the ER, and that fear often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomachaches.

Many ER doctors say the No. 1 reason is fear of malpractice lawsuits. "It has everything to do with it," said Dr. Angela Gardner, president of the American College of Emergency Physicians.

The fast ER pace plays a role, too: It's much quicker to order a test than to ask a patient lots of questions to make sure that test is really needed.

"It takes time to explain pros and cons. Doctors like to check a box that orders a CT scan and go on to the next patient," said Dr. Jeffrey Kline, an emergency physician at Carolinas Medical Center in Charlotte, N.C.

Patients' demands drive overtesting, too. Many think every ache and pain deserves a high-tech test.

"Our society puts more weight on technology than on physical exams," Gardner said. "In other words, why would you believe a doctor who only examines you when you can get an X-ray that can tell something for sure?"

Refusing those demands creates unhappy patients. And concern that unhappy patients will sue remains the elephant in the emergency room.

Associated Press, June 21, 2010

Lots has happened in medicine in the 21 years since I finished my training in emergency medicine, but the changes in our field are probably less than in other medical specialties. Because of the limitations of the ED setting, we most often don’t have access to all of the advanced tests, tools, and techniques that can be used in diagnosis and care during normal daytime hours. But that’s okay, because with the exception of emergency cardiac catheterization for heart attack and drug therapy for early stroke, things like MRI’s, serum levels of just about anything, and advanced surgical techniques rarely make much difference in the care we provide. Lives are saved by doing old-fashioned stuff like giving oxygen, keeping airways open, and use of fluids and maybe a dozen select medications which are essentially the same as they were two decades ago. One of the fun things about ED work is that there’s still some room to be a medical detective, as long as the investigation is limited to looking for an emergency and not definitively diagnosing everything else.

But that doesn’t mean technology isn’t invading our practice. It’s more than just tests and x-rays we do for medicolegal purposes, although that’s one of the most commonly held notions. (And realistically, while extensive lab tests and CT scans may find more things might expect, they often don’t affect the actual disposition of the patient; you usually already knew what needed to be done. A surgeon I respect…and for me that’s saying a lot…once told me that CT scans in trauma patients find a lot of injuries, but nothing you’re going to do anything about.) The article cited above is one of the few that talk about other reasons for excess testing, including effects on workload and patient demands.

Here’s an example of what I mean. A couple of weeks ago I saw a very pleasant 28 year old woman with pain in the right lower part of her abdomen. The basic approach to the problem…a history and physical exam…haven’t changed. You ask a set of questions, listen to the answers, and then poke, prod, and have a look around.

During my residency, the initial workup after exam would have consisted of a urinalysis and a urine pregnancy test. The one major emergency you always watch out for in a woman with one-sided lower abdominal pain is an ectopic (tubal) pregnancy. If the pregnancy test was positive, the patient had a possible ectopic until proven otherwise. Ultrasound was relatively new, and even when available you weren’t going to get one in the middle of the night. So you’d next get a blood pregnancy test, because most of the time levels of the pregnancy hormone b-HCG don’t rise above 2500-5000 with an ectopic pregnancy. If your clinical suspicion was still high, and if the b-HCG level was very low considering the date of the patient’s last period, you would call up the obstetrics resident who would come down to the ED and explain to the patient the need to do a culdocentesis. A culdocentesis is a needle puncture through the back wall of the vagina just under the cervix to see if there’s any free blood floating around the pelvis suggestive of a ruptured and bleeding tubal pregnancy. If it’s positive, the patient needed to go to the operating room for repair. That being said, most women would understandably decline the procedure (I’m not a woman, but it just sounds painful), and there would be some extensive patient education and counseling about the uncertain nature of her pain and the need to return immediately if worse in any way.

Today it’s different. Same patient, same presentation. But now once the pregnancy test is positive, we get an MRI to look for an ectopic (and avoid radiation exposure to a potential fetus). If it’s negative, we get a CT scan to see what else might be going on. Most of the time, we find nothing, and the patient is discharged with a diagnosis of “pelvic pain of unknown cause.” It’s a more definitive process to actually be able to visualize the area of pain. But is it better medical care?

There is no question that a CT scan or MRI is less invasive and less painful than a culdocentesis. Direct imaging does take the guesswork out of medicine, which is probably a good thing as well. Perhaps it provides a more definitive diagnosis (or at least a more definitive way to say there’s nothing wrong), and maybe there’s some reassurance value in that. There’s no question that medicolegally, you’ll be taken to task for not getting a test no matter how much time you devote to patient education and discussion. (And this is in a sample case where the test might actually be indicated, but physicians run the same risk if patient demands are not met regardless of clinical need. And believe me, it’s easier to give in to testing than explain why not.)

But sometimes I wonder if the sheer ease of getting tests and scans is a way of excusing ourselves as clinician, making us sloppy, and makes us really unable to communicate and talk with patients in the ways we used to do. Maybe we use the medicolegal excuse as a crutch for not wanting to make the physician-patient connection, but I doubt it. I don’t know anyone who went into this business purposefully to not talk to people. I think what testing does allow us to do, especially in high-volume ED’s where speed of patient turnover is often prized over compassionate and personal patient care, is to allow us to keep the system moving. I can spend twenty minutes talking to you, or I can order a CT scan and your case becomes a Showtime Rotisserie Oven. I set you and forget you until the timer on the CT scanner dings and then we sample the results in front of a studio audience. And all for three easy payments. But wait! There’s more…

Pet Sounds

Ms. Wilson was a 54 year old woman who, by her overall appearance, looked as if she had been walking on the wild side of life for quite some time. (The politically correct term for this is “looks older than her stated age.” The Joplin, Missouri term, taught to me by my old friend Dr. Michael Joseph, is “rode hard and put away wet.”). When someone looks that way, you never know quite why. Maybe it was a life of hard luck, of working two jobs and barely scraping by. Maybe it was selfless service to those in need, of bearing the pain of others on her shoulders. Maybe it was living like Bike Week was a full-time job. But regardless of the cause, with folks like this you know there’s always a story out there somewhere.

She had come in complaining of left rib pain. The pain had been present for two days since she fell out of bed and landed on a toolbox. The reason she fell out of bed is that she rolled onto her pet who was on the bed, the pet yelped, and she was startled.

Up until now, I’m with the story. I’ve had a pet sleep on the bed (most notably the late lamented Jimmy Leemer the Dog, aka The Amazing Furry Walking Garbage Disposal.) Indeed, this is a fundamental part of The Second Axiom of The Dog Rules of a Relationship, which are:

1. You must love my dog.
2. The dog is going to sleep anywhere it wants, because the dog was there first.
3. If we get into a fight and you ask who I love more, you or the dog, you don’t want the answer.

But here is where the story changes, because the pet in this case is a rat. A domesticated white rat, she was quick to point out; a dear member of the family that has been scurrying about the house and climbing into bedclothes for the past two years.

And you do you get a rat for a pet? Well, they were going to feed it to the snake, but it just gave her this look…

Pain, Drugs, Rock 'n Roll

The woman in Room 34 has been here 27 times this year alone for the same abdominal pain, and it’s only June. I asked one of our nurses what was wrong with her as I strolled towards the room. The nurse struck a pose, hand on her hip, hand grasping the stethoscope and holding it close to her lips.

“She’s a drug seeker!”

Her smile turning into a rocker sneer, another nurse stood to mirror her and grabbed her own stethomike.

“Narc eater!”

Together they swivel on the balls of their feet, pop their hips, and swagger around the desk.

“I’m the nurse so you don’t mess around with me!”

Suddenly we’re all rock stars, as the ED choir…two sopranos and me...begins to wail.

“Hit me with your best shot! C’mon, hit me with your best shot. Give me some Diluadid! Fire awaaaaaaaaaay!”

(Pat Benatar is not the only musician we adapt in the ED. For psychiatric patients, we usually bring in Gordon Lightfoot:

“If you could read my mind, Lord,
What a tale my thoughts could tell
Just like a schizophrenic
On some Haldol and not too well.”

He’s also good with bowel issues:

“Sundown, you’d better take care.
“Cuz when I’m constipated I ain’t goin’ down there.”)

ABC ETOH

Mr. Frisen was found lying on the sidewalk outside the ABC Liquor Store. I’ve always thought that they should put a bench outside of ABC, because it seems to be a favored place for some of our ED clientele to relax and recline. Perhaps they could even build a small, self-service hostel as a way of building customer loyalty. It makes sense to keep your best customers close at hand. You could call it Motel 6 Proof.

(By the way, have you ever noticed that you never see an ABC Liquor Factory Outlet Store at the Outlet Mall? Is there no such thing as seconds or overruns? “By gosh, we put just a bit too much alcohol in that bottle. Maybe we can sell it at half price?”)

However, the passers-by tend to frown upon live bodies obstructing the sidewalk. So the police brought Mr. Frisen in to see us to make sure he was okay. They left him in our care, but with a note to please contact them before he was to be released. This is the polite law enforcement way of saying “We’re not leaving an officer here with you, but when you’re done he’s going to jail.”

Unfortunately, Mr.Frisen was not a patient man. He had people to see, places to go, and things to do, and apparently all of them were quite urgent matters for 2:27 AM on a school night. So when he demanded to leave, it was with great regret that we informed him that this was not really going to be possible, as the police wanted a word with him after we were done. He must have been displeased with the news, because he decided to tear out the plexiglass walls of the exam room.

When someone goes ballistic in the ED, there is generalized bedlam. The charge is led by well-muscled young guys seething with vital hormonal secretions, who are able to secure the patient from harm by subduing them with gentle, patient-friendly techniques learned from watching cage fighting. But these are social occasions as well, where every free staffer gathers to offer commentary, complement particularly creative holds, gossip, and generally observe the fun. In fact, when we know of an upcoming event (such as when we hear security paged to certain room), we all tend to gravitate towards our next shared experience.

This happens on a reasonably frequent basis, and is not really news in and of itself. But what makes Mr. Frisen’s case worth noting is the sheer volume of good lines that came out of it, and the large number of staff who got in on the act.

There’s the nurse apply leather restraints, saying “Most of the time I get paid for this.”

There’s the tech who has one knee on the small of Mr. Frisen’s back and his arms engaged in holding down his right wrist, noting “If I stay here, I can’t send you any more patents from triage.” Mr. Frisen utters a profanity as he tries to wriggle out from under him. The tech tightens his grip and smiles. “Sure you wouldn’t like me to stay here for a while?”

There’s our registration clerk, who pops into the struggle to notify us that he has spoken with Mr. Frisen's sister and has been told 1) If he needs life support, don’t do it; and 2) If he dies, we should call her in the morning.

Once in restraints, Mr. Frisen calms down. (They most often do.) His alcohol level comes back at 398, almost five times the legal limit in our fair state. This prompts someone to note that he should have his own liqour license. In turn, our female-unit-clerk-in-a-committed-relationship-with-another-woman notes, “Hey! I want one of these!”

(It’s a sound-alike joke. Keep working on it. Thank you.)

The jail won’t take him until his alcohol level drops below 200, which is about eight hours away. He’s asleep, and I think we’ve run out of one-liners for the evening. Besides, it’s close to 7 AM, and Waffle House is calling my name.

Sleep well, Mr. Frisen. But come back tomorrow night. We’re here all week. And be sure to tip your techs. They’re out there working hard for you.

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

A few other quick takes on a very slow night…the kind where you’re paid to socialize (and the kind I can never get enough of):

“Mrs. Payne is 88 years old. She’s been a pain for a long, long time.”

Phone call taken at 6:30 AM by our Unit Clerk. “You said you need a wheelchair to be waiting for you when you get here? I’m sorry, but we can’t have someone sitting outside just waiting for you. We’ll be happy to help you if you need it when you get here.” A pause. “And you’re driving yourself?”

“I’m looking forward to July 4th. It’s Redneck Natural Selection Day.”