Friday, July 9, 2010

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.

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