Friday, March 27, 2015

By Any Other Name

It's probably no surprise that great ideas are often nipped in the bud by the actions of others, and in today's society that Great Inhibitor in the Sky is often political bodies, bureaucracies, and courts that promulgate the flotsam we affectionately call "the law."  (I liked how in the sixties these groups were known as "The Man," but even given the  an increasing number of females in these bodies with no observable progress, "The Persons" just doesn't have the same ring to it.)  So it was that a law called HIPAA ruined my great idea for a blog post. 

For those of you unfamiliar with it (and I hope you are, because unlike Buddhism, in this instance mindfulness does not bring peace), HIPAA stands for the Health Insurance Portability and Accountability Act.  The intent was good, as it often is.  The idea was that if your employer provides health insurance, you should be able to keep your coverage between employers, with a "carry-over" period so if you lose one job, you get some breathing space to continue your current plan before it gets cut off or before coverage at your new job kicks in.  And it does this pretty well.

The other piece of it is the privacy component.  Health information is considered "protected data," and can only be released to those who "need to know," and only then with the consent of the patient.  I can readily understand the impetus for this, especially now that privacy has been enshrined by culture and the courts as an inherent right (often properly, sometimes not).  And none of us would particularly want our neighbors who happened to work at the local hospital looking up our medical records.  But HIPPA also means that it's hard to share information between hospitals and health care professionals without a host of written agreements; and the flow of data is essentially controlled by the patient, who determines what information can be seen or not.  While the difficulties in information sharing probably outweigh deliberate withholding by patients, both can lead to inefficient, duplicative, and more costly care at best. 

Clinically, however, HIPAA turns out to be a mess.  There are so many hoops to jump through, especially when electronic systems are involved or after business hours (which is, in the case
of the former at least, ALL the time), that time-critical information sharing is often non-existent.  In the ER, though, I'm most troubled trying to figure out what you can talk about in the room with the patient who is accompanied by family and friends.  I think most of us ER docs operate under the assumption that if others are in the room and the patient hasn't excused them, the patient's given implied consent for them to hear whatever discussions you're going to have.  That being said, we use a lot of discretion; for example, we'll find an excuse ("Registration need to check your address again") to pull family and friends out of the exam room when telling someone they're pregnant or they have a sexually transmitted disease, or when we want to get some history otherwise unavailable to us that might be embarrassing or (such as in victims of domestic violence or other abuse) frankly dangerous for others to hear.  But the whole area is still gray, if not quite in 50 shades. For example, there was a patient with a history of HIV disease in the records who came in with a fever.  The two are clinically connected, as the presence of HIV disease greatly expands the potential causes of the fever, and as a result your diagnostic net gets tossed farther out to sea.  But when asking him about his past medical history, he omitted the HIV, so I asked about the medical record entry. He became quite upset because he had not disclosed that to the friend who brought him to the ER and now sat in a chair in the corner of the exam room.  While clinically it was the right thing to do, I don't know what HIPAA would say.  Maybe we just need to tell patients up front that we're going to ask about everything and anything, and if they're not okay with that they should just ask their visitors to head to the waiting room.  (But of course, that would damage our customer service ratings...)

Of course, there was health care information available before HIPAA.  It was called medical records, reams of paper bounded by clips and filed away in the hospital basement in bulging manilla folders.  In the ER, when a patient hit the door you would routinely placed a request for medical records.  When it arrived, the first thing you did was listen.  If the records slid onto the desk with a slight "whoosh," there was a pretty good chance the patient was gong to be able to go home.  If they landed with a thud, you may as well prepare the admission paperwork, because anyone with records that loud had too many issues to go home.  If you actually had to read anything, you generally just looked at the last discharge summary because that was your best insight into the current issue. You could leaf through the pages trying to find the tabs that would lead you to a surgery three years ago, but why?  Plus if it was three years ago, chances are the records were somewhere in off-site storage, most commonly known as "the garage."  And records from a physician's office?  Please.

The other written records we had were much less formal, and ones that we would deny ever existed if asked at the time.  Every ER had their own version of the Recipe Box.  This was an index card file of chronic patients, repeat offenders, drug seekers, or others who were likely to be a problem.  When the patient was triaged, the nurse would clip the card from the box to the front of the chart so you new exactly what you were getting into.  The card is where we wrote down what was actually going on with the patient, as opposed to those benign phrases you put in the medical record.  Even I, as flinty as I can be, will fudge on that a little.  I usually use a phrase such as "While the patient may have an underlying issue, there seems to be a significant concern about the patient's medication use," to mean those folks who are looking for meds.    Similarly, I use these phrase "There may be a supratentorial component to tonight's presentation" to mean bat shit crazy.  And the polite way to refer to the neurotic patient in Room 4 is to softly whistle the first few bars of Patsy Cline's biggest hit. 

(In a related note, they've recently updated our electronic medical record and, in a nod to Recipe Boxes of Ages Past, have put a little marker shaped like a red airplane by the names of patients the system designates as an excessive user of ER services, or a "frequent flyer."  Rumor has it that the original idea was to put a small image of a turkey by the name instead to represent their universal sandwich request.) 

Once we get over the hurdles of HIPAA, today it's often much easier to get the information you need.  Good electronic medical records systems (EMR's) make it easy to select and view the most relevant portions of medical records, and where hospitals that use similar EMR's but are under different ownership put differences aside in the interest of patient care, that shared information is incredibly helpful.  (Disclaimer:  I'm fortunate to be working at a place that shares systems with the other hospital in town as well as a regional academic referral center, so I'm biased in that regard.)  And as hospitals and health care systems are increasingly owning physician practices and outpatient lab and x-ray facilities, that information is often now available for review as well.  While HIPAA does require patient consent to access this information, such consent if often buried within a more general document consenting to ER care, so fortunately that's usually not an issue.  When a patient does raise an objection to your asking other providers or hospitals for information, you already know that something's up. 

The best way to get information, of course, remains talking to people.  Most of the time, the patient is happy I can talk to another provider, especially if it's tog et more insight into the current problem to avoid spinning wheels or repeat tests, or if I can arrange follow-up for a problem beyond our scope of care in the ED.  There are a small minority of patients who don't want you to know anything, but they most often won't come out an say it.  They'll obfuscate, bringing up the out-of-town doctor who prescribes their medications, but not remembering how to spell his or name or what hospital they practice at.  Maybe they only know they were last in the hospital "somewhere in Texas."  Maybe they'll know the name of a nurse practitioner but not the physician they work with.  Maybe they'll know their doctor is on vacation or retired and can't be reached.  Any of these are red flags and, to be honest, a chance to play amateur detective in a break from the routine.  The game's afoot, and it's pretty easy nowadays to use the phone and the internet.  When you're able to reach someone, you get the real story and, to be fair, sometimes it's legitimate. When you can't, or that person doesn't exist, well, that's another tale.  One of my favorites was when a patient told me they get methadone from their doctor at a hospital in Pennsylvania.  Unfortunately, his prescription had just run out as he hit to city limits of our fair village.  He knew the doctor's name started with a P and was "not American," but he didn't know how to spell it or a phone number where I could reach either the doctor or someone on call.  So I printed out the medical staff list from the hospital's public website and asked him who I should call.  He departed the ER on his own accord a few moments later.  Elementary, Watson. 

(Pro tip:  Don't try this in my ER. Proving your story wrong is something I take extra time with because it's such a break from what I usually do.  It's really fun to call you out.  And I always ask others to come into the room with me to share in the experience.) 

So anyway, I had this great idea for a blog post about names.  I've noticed that I'm having increasing difficulty pronouncing then names of people under thirty.  I realize, of course, that names of choice change over time; it's been a while since we've seen any Cottons, Increases, Temperances, Goodwifes, or even the occasional Gouvernor.  But it did seem that for the first twenty years of my career, most names were related to the old classics, things that were self-explanatory to spell and pronounce.  Even nicknames, like Bob for Robert or Liz for Elizabeth, had a sense about them.  And foreign or otherwise unfamiliar names were most often reflections of local cultures and traditions.  No problem there. 

However, it does seem that over the last several years there has been an explosion of new names no one has ever thought of before, and some of them seem honestly to be more hindrance than help for the poor kid with that moniker.  (I'm pretty sure that no matter how open and multicultural our society becomes, you're still not going to see a Supreme Court Justice named "Placenta" any time soon.)  It's not the kid's fault, and it may be that as an AARP cardholder, I'm too closed-minded and need to open up a bit.  But you can't help the feeling that these names will hamper the kid's success in life.  One of things I still have strong feelings about in the of the few things I still have strong feelings about at when you see active, bright-eyed kids full of promise who are already doomed by their parents.  I think names can have that effect.  A unique name with cute spelling at age four is simply that.  At age 30, it becomes a handicap to advancing in the real world. 

That being said, I'm not necessarily promoting all older names.  One name that, I think, can probably be done with is Howard.  I've never liked it.  In grade school is was "Howard Cosell" or "How-weird" or "Howard the Coward." (In reference to the latter, I admit to flinching when hit with a dodge ball or run over playing sandlot football.  However, in the one fight I was in I never flinched.  That's because I didn't even see the punch coming before it laid me out on the concrete.) I suppose it got a little better when kazillionaire E. Howard Marshall bagged Anna Nicole Smith, but by that time the damage was done.  Now I can't even get friends or family members to name their kids Howard, Howardina, or Howardette even with the promise of free college tuition.  I once asked my parents why they gave me that name.  They explained the Jewish tradition of using the first letter of a deceased relative's name for the name of a new child, which makes sense,  Then they noted that they gave me a better middle name (David), so I could just use the H as an initial like famous Watergate conspiriators G. Gordon Liddy and E. Howard Hunt.  "So why didn't you just call me David growing up?" I asked.  The deep and insightful parental reply?  A sort of grin, a sly smile, and a sheepish, "Ummmm...we never thought of that." 

And so I've complied a list of names I was hoping to share with you under the title of "Names You'll Never See on a Harvard Diploma But Will See on a Nametag That Says Serving You Since 2016."  And that's where HIPAA has ruined my blog post, because the names I was hoping to share with you are so...well, interesting...that no one else would ever have them, and given where I live there would be little doubt about who I meant.  That means you would have been able to identify the patient, and that means a HIPAA violation and relegation to those remote ER's where they're just happy you speak English as a first language, let alone got out of medical school  I can tell you that the list as it currently stands is over 110 names long.  And all compiled in just the last two months.  However, my study has given me some insights, which I would share with you as "Naming Rules for Children:  2015." 

If you're going to name your child after geography, please spell it as it lies on the map.  There is no "h" in Dakota.  There is no "ph" in California.  And there is no extra "s" in Kansas.  If you insist on adding a letter, may I suggest a directional indicator such as S or N, as in "S. Dakota Smith."  That even sounds distinguished.  While I'm sure it's a fine and upstanding member of the Community of Nations, please avoid honoring the country of Niger, especially if you're a weak speller. 

If you're going with a theme, stay consistent.  If four of your children are named after flowers, one should not be named after a cartoon rodent.  If the names of your first six children all start with the letter "J," naming the seventh one with an "E" will not help you keep them straight at the dinner table.  While I admire George Foreman for his contributions to grilling technology, he is not to be emulated here. 

If you intend for there to be punctuation in the pronounciation of your child's name (such as a hyphen, apostrophe, or comma) in your child's name, please put it in writing.  But do not make the punctuation part of the pronounciation. There's a reason "D'Artangian" is not pronounced "Dapostropheartangian." 

No child should be named after breakfast foods or cereal products. 

Unless you are of Eastern European extraction, or have an inordinate fondness for the people and culture of Krygygzstan, there should be no more than three consonants in a row in a child's name, and then only in extreme conditions, such as nuclear holocaust or a nationwide lack of Hostess cakes.  Similarly, unless you can document ancestry from the islands of the South Seas, no more than two vowels in a row, please.  And "y' counts as a vowel. 

No child should be named after current pop music or hip-hop chart-toppers, especially those whose hits use the terms "anaconda."  Unless it's Katy Perry or Paul McCartney.  There should be more of those. 

More children should be named "Leland Melvin."  He's very cool. 

I would also welcome more children named "Neil Armstrong" and "Ann-Margaret."  Oh, and I would be okay with a few more Gouvenors. 

No one should ever be named "Honey Boo-Boo."  Ever. 

If you want your child to make his or her flights and not get held up by the TSA, do not put a "Kh" or an "Al-" at the start of their name. 

Heaven backwards is not Neveah.  It's Hell. 

And above all, as goes the Internet meme, "Don't get pissed off at me for mispronouncing your child's made-up name."

(Here's a happy afterthought, probably only of interest to sadly underemployed English majors or writer wannabes like me. In everyday conversation, we actually call the law by the wrong name.  Everyone thinks the abbreviation is HIPPA, and it means the Health Insurance Portability and Privacy Act.  In either case, the title contains a nice bit of alliteration with either two A word or two the P words in a row.  We had a similar alliterative episode in the ER a few months back.  A patient...WHO SHALL REMAIN NAMELESS ACCORDING TO HIPAA...presented after passing out in the bathroom in the performance of a "Numero Due."  When someone shows up with a complaint that might be even vaguely cardiac-related such as syncope (a clinical term we use for no other reason I can think of other that it sounds better than "passing out"), there is a knee-jerk reaction to get an electrocardiogram just in case this might be a heart attack.  This tracing is supposed to be evaluated by a physician within moments of being done, no matter what else the physician happens to be doing at the time.  In a busy ER such as ours with multiple doctors on duty at any one time, the acquisition of the EKG sets off a mad scramble to find a physician to lay eyes on it (even though the nurses themselves are pretty good at telling what's what.) It always feels like I wind up looking at the lion's share of them, probably because I either lack the work ethic or are not fast enough to get up from my desk and hide in a patient room.  Once the EKG is read...basically to make sure there's no obvious signs of a heart attack or a life-threatening problem with the heart write on the EKG something like "No STEMI" (which stands for "no ST-segment elevation myocardial infarction, if you're keeping score") or, in my case, "NGD" ("not gonna die") and occasionally a happy face to brighten up the process.  The EKG then vanishes within the Unit Clerk's Forest of Papers, to be sought again by the actual treating physician another hour down the road. 

So anyway, this middle-aged woman passes out while pooping.  Her initials...well, I can't tell you that, because someone reading randomly during the four hours they have power each day in Baghdad might be reading and happen to have been in Northeast Kansas visiting this lady just last week, and heard the whole story, including probably bathroom details I did not care to know or ask about, and now can IDENTIFY THE PATIENT.  But I think I can safely say we found an opportunity for alliteration. So what started out as (patient first and last name) became Plump perky puffy (patient's first and last name) prematurely pooped, paled, and passed out with precipitously plunging pressures as a potential presenting problem.  This would be a lot funnier if I could put in her real name or even her initials, but HIPAA, and Baghdad, would prohibitively proscribe that pun.  By the way, the same Nurse Practitioner who helped with the alliteration project also came up with Little Blind Warren and the Heaving Pannus as a good name for a rock band.  She also has shooting medals and can kill from 200 yards. I'm glad she's my friend.  You are my friend, right?)

(In the Great Minds Think Alike Department, please see this related post from GomerBlog:

Friday, March 20, 2015

Medical Helicopters Revisited

(To all: This one is fairly esoteric...some thoughts I put together while revising a chapter on Air Medical Transport for a textbook of Emergency Medicine. I wrote it like I was going to send it somewhere for publication, like actual smart people tend to do. Turns out I was going to send it to me, which undoubtedly says something...)

Twenty years ago, I wrote the first chapter on air medical transport in a major textbook of Emergency Medicine. Every few years there’s a revision, and that’s why in the second edition I asked my colleague Ira Blumen to join in the effort. I did so because Dr. Blumen is a prolific writer and a respected authority, and because his participation meant that it was my turn to revise the chapter every six years instead of every three. But the years have gone by, and now it’s my turn again.

The chapter is pretty much what you would expect. It talks briefly about the history of air medical transport, rotor wing and fixed wing vehicles, crew configurations, and the like. For me, the fun of the working with the chapter has always been the sections on indications for transport and the efficacy of air medical care. So it was with a mixture of delight and dismay that I found that it was virtually unchanged from last millennia’s work.

When I was a young academic and prone to pronouncement, pontification, and polysyllabic pontification (not to mention alliteration), I used to give lectures about rotor wing air medical transport to other health care professionals. At the time, air medical transport was…and I suspect it still is…a private club, where only those who hold membership know the secrets. So while I would talk to EMS groups and referring physicians about all the wonderful things helicopters could do for them and that just like voting in Chicago they should call us early and often, to those inside the walls I would show this slide that said everything we definitively knew about air medical transport:

Helicopters are fast.
Helicopters are expensive.
Helicopters crash.

That was it. The bottom line was that anything that seemed to be an indication for transport was related to speed, either to get the patient to definitive care or to bring needed resources, such as ALS, to the patient’s side. And I think we can accept the latter two propositions without lot of fuss.

Now it’s twenty years later. Professionally, I’ve gone from academics to private practice to public health to being a State Health Officer, and now I’m back in the ER again. I’m on child #1, wife #2, and dog #3. I wrote articles, then wrote columns, then reviewed legislation, and now I blog the ramblings of an aging mind ( But the more things change, the more they stay the same…or even more so. That’s why today’s slide would read:

Helicopters are fast.
Helicopters are expensive.
Helicopters crash.
Helicopters are even less useful today.

It gives me pains to add that last line. My first job out of residency was as the Medial Director for the ShandsCair Flight Program in Florida. (Over the years, I’ve also worked with a private, fee-for-service program in South Africa, and with a law-enforcement HEMS unit in Daytona Beach.) I loved everything about it. The flight team…pilots, nurses, paramedics, dispatchers…were the closest group of folks I’ve ever worked with, and in the tight circles of ER life that’s saying something. I miss them every day, just as I miss the adventure of jumping a flight or the thrill that comes acting the airborne angel, swooping in from above to save lives with powers and abilities far beyond those of mortal men. I miss the fact that we often left the door to the helicopter unlocked, and that I could take University of Florida coeds out there at night to see MY helicopter and make out in the back, praying that the team wouldn’t get scrambled and we’d need to run off into the bushes nearby.

But there’s no escaping the reality that the utility of air medical transport, and especially that of helicopters, is less than it was. This isn’t the fault of the industry. I truly believe that the ANT community has been doing everything it can to provide service and to find new niches were they can be of use. The issue has to do with the fact that the medical landscape has changed radically within the past two decades.

Let’s take a couple of high-profile examples. It’s always been maintained that helicopters save lives of trauma victims. This was undoubtedly true, and especially so in rural areas where field care was often BLS at best, and the diagnostic capabilities of rural hospitals was essentially non-existent. But even early on it seemed that the advantage was not so much with the helicopter itself, but with the fact that it often brought ALS care to the patient, and most specifically airway management skills. It also seemed clear that whatever advantage was accrued by HEMS was a result of the aircraft being integrated into a complete trauma system, with a Trauma Center at its core, rather than as a single, isolated asset. And there appeared to be no real logistical or clinical advantage to using rotor wing EMS in the vast majority of urban responses, essentially limiting the efficacy of air transport for trauma to the rural setting.

Fast forward to today. Many rural EMS services have now upgraded to ALS, and many of these ALS services can use advanced techniques such as rapid sequence intubation. Even BLS services now use advanced airway modalities such as the laryngeal mask airway and the Combitube, giving them the ability to hold airways open in the field. These skills in and of themselves mitigate one of the major benefits of air medical transport. In addition, the majority of small rural hospitals…even those Critical Access Hospitals (CAH)…now have CT scanners with teleradiology review of both plain films and scans. While there are clearly some unstable patients who need to get to a trauma center as fast as possible, I would argue that there is an increasing subset of patients who can be initially stabilized and evaluated at a small local facility. And while there are some injures that, after evaluation, would mandate immediate transfer to a Trauma Center, there are other injures (extremity fractures and soft tissue injuries come to mind) where I would argue that it’s nearly impossible to discern any clinical difference between patients transported by ground or air.

I believe the same phenomena to be true with acute medical emergencies such as acute myocardial infarction and stroke. There is a body of literature indicating that some acute MI patients in outlying areas can benefit more from being given a thrombolytic in the rural setting before being transported to an interventional center than they can from simply a longer before catheterization and angioplasty. (This advantage rises with greater distances to definitive care.) And once you get an initial thrombolytics, how much more myocardium is saved by air transport versus ground? Does the extra time equal any amount of tissue? Do we know?

A similar scenario is seen in those with acute stroke, where the advent of remote CT scanning allows physicians at rural hospitals to check for bleeds before administering thrombolytics. Once administered, the patient needs to be monitored for bleeding, but if the patient is stable does transport to a stroke center by air offer any further advantage than transfer by ground? Do we lose any more brain cells? Do we know?

(It’s also important to note that when we talk about time saved, we need to compare air transport to ground transport total mission times. Given that ground EMS is often nearby versus air transport, which needs to be “called in” from afar while the patient merely waits, time differences become even more negligible.)

One might point to the proliferation of published works in air medical transport as a way to counter these thoughts. But if you were to look closely at the literature (which I’ll be doing every six years or so when it’s my turn for the revision), the vast majority of clinical works are case series that can be summarized as “Look who we can safely transport by air.” (Granted, “safely” is a relative term given the accident rates for air medical transport as opposed to general and commercial aviation statistics.) Much of the remainder of the literature is devoted to studies of air medical programs, crews, and equipment…demographics, human factors studies, and the like. These are valuable, but they still don’t get us to the key question of efficacy. Efficacy can only be evaluated in comparison studies, and given the proliferation of AMT programs within this country, the opportunity to do head-to-head studies out outcomes in patients transported by air or ground may have been permanently lost. In brief, the literature is very good at illustrating what we CAN do. It does a poor job of indicating what we SHOULD do.

Let’s be honest, as members of the club. In the majority of cases, air medical transport is used mostly as a taxi service to either make a doctor’s life easier by getting a patient out of a facility or not having to see the patient at all, or to help EMS avoid a long drive. (I am willing to accept that in some cases, it’s probably in the patient’s best interests to get away from the doctor or EMS crew as well. As the old joke goes, they still call the guy who graduated last in his med school class “Doctor.”) But neither of these factors has anything to do with if the patient actually needs transport by air or would do equally well by ground. And so we enter a vicious cycle. If AMT programs were to do the academically correct thing and screen calls based only clinical efficacy, volumes drop, as do revenues, as does the viability of the flight service itself. And if objective efficacy becomes the standard for payment…which, as a former policymaker, I would certainly make a condition of reimbursement in an overhaul of government-based fiscal payment schemes…well, you get the picture.

There is no question in my mind that there will always be a role for rotor-wing and fixed wing transport in rural areas, with need rising in proportion to distance to definitive care. There will also always be a need for rapid deployment of specialty teams, such as those caring for neonates. And it should be noted that my comments are rather specific to the United States…in nations where CT scanners are not ubiquitous, roads are spotty, and ground-based EMS is few and far between, my thoughts may, and probably should, be radically different. But it seems that in many ways, air medical transport remains like hyperbaric oxygen…a “therapy in search of diseases.” The sooner we find those diseases, the better off we’ll be.

I want air medical transport to survive. I want it to thrive. But there are hard times ahead, and we may as well face it. Only by doing so can I insure that my son, should he chose to go into medicine, will have the opportunity to make out with a coed in the back of a helicopter. Gotta tell you…it’s pretty cool.

Thursday, March 12, 2015

Sgt. Pepper and the Cpls.Gibb

(From time to time, I run across something I wrote but never edited and published in the year or so we were “off line.” Here’s another one of those. Hope you enjoy.)

As many of you know, my son has been a steady contributor to the Blogosphere. His forte is movie reviews, and previous blog readers and Facebook friends know that I’ve been pushing his work at In watching his writing over the past year, he just keeps getting better and more creative. Proud father talking.

The presence of his blog also means that there are now new ways for Father and Son to interact. (He’s too old for me to use the the terms Daddy and Boy anymore…though my head has made the transition, my heart’s not quite there.) We’ve always liked to go to the movies, but now that he’s a critic we not only sit and watch, but review.

We’re not only going to the theater. In what must be one of the most nerd-like things we’ve ever done…and given that we go to GenCon very year, that’s saying a lot…we’ll sit at home on a weekend night, pick a movie on pay-per-view and man the couch with sodas, popcorn, and notepaper in hand. It’s actually lots of fun to compare notes and views. The only difficult part of the exercise is deciding what movie to watch. He’s on a roll where he likes to review obscure, bad films because it’s just fun. I’m pushing for classic films that everyone knows because I think he’ll have an interesting take. I want him to be a young Roger Ebert; he wants to be a literary Ed Wood.

This conflict often results in the tow of us watching movies simply because neither of us has seen them before. Which is how we wound up seeing the “Sergeant Peeper’s Lonely Hearts Club Band” starring George Burns, Peter Frampton, and the Bee Gees.

To someone of my moderate years, that’s all I should have to say for you to know this film is going to be awful. But just in case you’d like a plot synopsis, here it is. Having brought about the end of World War I with a small brass band, Sgt. Pepper comes home to small town America and leaves his magical instruments in trust so the inhabitants might always be happy. Some years later, the band reforms in the persons of the three Henderson Brothers and The One and Only Billy Shears, and sets out for Hollywood. However, their departure leaves an opening for Mean Mr. Mustard to steal the enchanted musical mechs. When the boys find out, their search for the instruments leads to encounters with Alice Cooper, Steve Martin, and Aerosmith. In the final battle, Steven Tyler does something unspeakable (like that’s a surprise) and Billly’s girlfriend Strawberry Fields dies. As Billy is then preparing to commit suicide from a towering six foot high porch, a weather vane comes to life as Billy Preston and makes everything right. The movie ends with everyone who ever signed a contract with the Robert Stigwood organization singing the title track in a bizarre precursor to “We Are the World.” The whole movie is underlined by Beatles songs redone by the characters of the movie. All, that is, except George Burns, who sings something vaudevillish but nowhere near as good as “Simon Smith and his Dancing Bear” and does nothing diety-like in the slightest, even when he could have done so much more to rescue this tale than the weather-vane guy.

As I said, to someone of my era, this disaster could be seen coming form miles away. To The Teen, however, this is all new and unexplored territory. So at the end of our two hour odyssey that even Joe Walsh then (and probably now) would have difficulty fathoming, he had six pages of notes.

Here’s all I had:

Brendan knew immediately what country Frampton was from when he looked at his teeth.

I had to explain that the Bee Gees were the Bee Gees because they were the brothers Gibb but not all the brothers Gibb, because Andy died, as have Robin and Maurice, so now the Bee Gees are the singular Bee Gee but still share an An Everlasting Love.

I never liked big frizzy 70’s hair on girls. Big 80's hair is still hot.

Billy Shear’s girlfriend’s name is Strawberry Fields. In the movie she dies. Which is stupid, because Strawberry Fields FOREVER.

My Lord, I had a sweater vest just like that.

Steve Martin was in this? And George Burns? And they still had careers?

The fact that these are my only thoughts is why I’m not a film critic. Compare these to his review, and you’ll see why he is. ( Please, read his blog and feel free to comment, about this movie or anything else he’s written. But if you don’t like his stuff I know guys who live under a bridge who’ll do anything for a twenty and a pint of Mad Dog 20/20. Kind of like Harry Truman who went after that critic of Margaret's piano playing in that regard. Proud parent. You’ve been warned.

Sunday, March 8, 2015

Thoroughly Modern Me

I’m one of those people who likes to think that, despite the fact that he’s a skinny white boy from the hard-bitten suburbs of Des Moines, I can occasionally manifest some street cred. This, of course, is a fallacy. I cling to it nonetheless as a last remnant of youth and of my still flickering liberal urge to let the oppressed masses know I identify with their struggle. But unlike most commentators from the left and the right, who have the luxury of being able to hide behind the walls of their gated communities and yet are able to be in intimate, Marvin-Gaye-sexual-healing touch with the hearts and minds of America, I freely admit I have no claim to know what's going on in the street. The closest I come is knowing which bars in Topeka are likely to be open at seven in the morning, in recognizing the names of most of the street drugs (a work hazard), and…well, nothing else. Once in an effort to prove myself hip, I came up with a gang sign for Southwest Topeka (three fingers pointed down towards my right hip, kind of like southwest would look on a map). It didn’t fly.

On the other hand, if you want to know what’s going on in white upper middle class 50-54 years old suburbia, I’m your guy. Just as long as it doesn’t involve Twitting, Tindering, Ubering, Instagramming, People Magazine, any reality programming that involves housewives (real or imagined), Dancing with the Stars, television except the Big Bang Theory and The First 48, or music post Love Shack (1989). I just found out several weeks ago that I was supposed to clap my hands if I was happy, especially about open-air rooms and the truth, which I think is just a cheap rewrite of “If You’re Happy and You Know It Clap Your Hands” (public domain = no royalties).

I think it’s no secret to anyone who’s read this blog or my Facebook friends that I reserve a special place in my personal Axis of Evil for the Transportation Security Administration. However, I do need to recognize that several weeks ago, they gave me a golden opportunity to show how “street” I really am.

You’re probably aware that the TSA makes you take off your belt when you go through security. When I do this, being a thin guy with long legs so I can’t buy off-the-rack pants with both a snug waist and the proper length, my pants fall down to my hips and you can, if my shirt floats up at just the right angle, see my underwear. And it occurred to me, as those Guardians of Air Travel were able to know that I do, in fact, have a pair of Captain America boxers, that my pants were at last low and sagging, like the homeboys on the streets that I drive through very quickly in my left-leaning SAAB.

Just for a moment, I understood what it was to have street cred. I was cool. I was a groovy hep cat, in tune, a resplendent wearer of the cat’s pajama’s, BMOC in raccoon road-kill coat. But then I tripped over my cuffs, and facing the prospect of continuing to try to strut my stuff and dropping trow entirely, I hastened through the scanner with one hand on my pants as I raised the other in surrender to the scanner. But just for that one moment, I was sooooo down with my funky bad self. It felt good.

Wednesday, March 4, 2015

A Land Down Under

Let me take a fact, let us all take a reflect upon our bowels.

Are we through yet? Because when it comes to my esteem for bodily fluids, GI products are at the bottom of the list, and my discomfort rises the lower down we go. Like my feelings for Justin Bieber, I find nothing intriguing about the intestines or their output. And my distaste does not concern itself exclusively with current bowels, but also those of antiquity. I am aware of scientists that study coprolites, on fossilized dung, in order to discover the details of prehistoric flora and fauna; if it was there, so the logic goes, something must have eaten it. Despite my fascination with all things ancient (including, if some are to be believed, my tastes in comedy, music, and pop culture), I'm perfectly content thinking that half the dinosaurs ate plants and the other half ate them, and that the earliest mammals thrived on Ding Dongs and RC Cola. I really don't need to know.

(My dislike for the topic is so extreme that when I heard I was about to be beat out by a medical school classmate in the race to claim the first scientific publication from our group, my angst disappeared when I learned that he was writing on the mechanisms of diarrhea. Perfectly happy to be in second place...or is that Number Two?)

Bowel issues fall into one of two categories. The first, of course, is diarrhea. Diarrhea in the ER is like a hand grenade. It either goes off, wreaking havoc everywhere, or sits there benignly, flirting with you to remove the pin. So nobody has just a "loose" bowel movement. Patients describe them in terms of volume, and "scant" or "trickle" is not an option. Instead, the range of acceptable adjective goes from "torrent" to "biblical deluge." ("Explosive," which defines every episode of diarrhea, is so common as to mean nothing unless accompanied by a match-lit plume...which I've not seen done, but have seen the aftereffects of, and found that it's the kind of thing you sort of admire someone doing just to prove Darwin right.)

Most diarrhea has something to do with either disagreeable food (in a physiologic sense, not in terms of personality) or a viral illness. There are multiple other causes, of course, from bacterial dysentery to inflammatory diseases to problems with nutrient absorption. The one thing all causes of diarrhea have in common in the ER is that once declared, the patient will be fully unable to provide a stool sample for analysis. It doesn't matter that they've been in the bathroom every 15 minutes at home. In the ER, there will be no output. (This is the same principle that governs why children with fevers of 187 degrees and nearly dead at home have no fever, are eating Cheetos, and vigorously protesting your interruption of SpongeBob in the ED.)

(I should note that what we think of as "diarrhea" in this county means nothing in the undeveloped world. I've seen and cared for people with cholera, lying on mats under a tent, and let's just say that our concept of diarrhea is simply a First World construct.)

In the vast majority of cases, diarrhea is self-limited, and treatment consists pretty much of rest, lots of fluids, and the occasional antibiotic. But there's one kind of diarrheal illness which is really a problem. It's called c. diff colitis, and it can be truly debilitating for the patient. The illness is caused by a toxin secreted form a bacterium named Clostridium Difficile, and it usually follows antibiotic therapy.

How does an antibiotic lead to an infection? It turns out that our guts are home to a multiverse (accounting for string theory) of bacteria. They're mostly helpful to us, contributing to the process of digestion and generating methane, allowing us to play "Pull My Finger" and make personal contributions to global warming. When you take an antibiotic for any reason, it doesn't just kill off the bacteria causing your infection. It kills off any bacteria that is sensitive to the antibiotic, anywhere in the body, whether or not you actually want that particular strain to hang around. So in c.diff colitis, you've killed off all your good gut bugs and are left with only the bad bacteria to cause you problems.

(It is interesting to think that the methane in your flatus...a byproduct of all that beneficial bacterial, as a simple hydrocarbon, likely one of the building blocks of life. Distant worlds have been found to have layers of methane clouds circling their equators and vast oceans of liquid methane forming endless, restless seas. If you believe, as I think is reasonable, that all of us are made up of the elementary particles originating from the Big Bang ("starstuff"), then it's intriguing to think that your personal expulsions of gases replicates the early history of the universe. The odor you're detecting after that burrito? It's the aroma of creation.

So if the problem with this disease is that the good bacteria have been cleaned out, why not put them back in? And that gives rise to the newest proposed treatment for c. diff colitis, namely the fecal transplant.

(EDITORIAL NOTE: You would be proud of me. I just deleted three paragraphs of fecal transplant jokes, mostly because I realized that just the concept of the fecal transplant is funny enough that I can't really add to it in any significant way. Unless we start to talk about donors and recipients. Talk amongst yourselves and be prepared to discuss in class.)

Which brings me back to why I was thinking about bowels in the first place. The other day an older man comes in complaining of constipation. I've never had constipation bad enough to come to the ER. and I hope I never do. While it's an easy clinical problem to deal with, it's beyond me why people are not only not embarrassed, but eager to share their bowel trials with me. Frankly, I'd be kind of ashamed. In fact, I've told my colleagues that if I ever have constipation bad enough to make me call and ambulance and go to the ER, I want them to slap the shit out of me, which will correct my behaviors and resolve my problem.

There are some people who have genuine issues with constipation. These include folks with severe neuromuscular disorders such as Parkinson's Disease where the bowel simply don't move along, or cancer patients on strong narcotic medications which has decreased bowel activity as a side effect. These folks look truly miserable, and it's the one time I'll give someone an enema in the ED. We use Milk of Molasses for an enema, which works wonderfully but permanently takes away any taste you had for a certain type of Archway cookie. (It also begs the question of what exact part of the molasses you pull on to milk it.) Otherwise, if you're stopped up just because your idea of fiber is a Frito, you get a plastic jug containing a powder of Go-Lytely to drink at home. Go-Lytely, by the way, is the finest example of the pharmaceutical labeler's art, as it should be called go voluminously, go frequently, and go now.

(There's also a subset of patients who are convinced they're constipated but they're really not. Clinically, the easiest way to check to see if someone's really packed up is to take a plain x-ray of the abdomen. Impacted stool shows up as grainy, hazy material within the walls of the colon. In these patients, when you tell them the x-ray shows nothing, they will vehemently disagree with the your assessment. These patients pose a true quandary, because while you know they're full of shit, the evidence says otherwise.)

But this guy simply hadn't had a bowel movement in a few days, and was quite vocal about his needs. One of our nurses tried to placate him, letting him know this wasn't so bad. She told him how, when she and her husband were raising horses, they would take a newborn foal and gently give it an enema to prevent colic and get it to drink.

The patient looked at her and said "I'll whinney for you."

Do you recall in elementary school gym class, where you learned the difference between hopping, skipping, and galloping? I hadn't used that knowledge since third grade. But it came in handy now as whenever I would spy her dutifully charting with her head down over the desk, I would enlist a few mid-level providers in galloping a circle around her, making equine noises as we go.

Whoa, big fella.