Friday, June 3, 2016

Rooms for Rest

The Teen's now the High School Graduate, and in a college preparatory effort to elevate our conversations from how My Little Pony is Communist Plot to more lofty topics of intellectual heft, I've found that he is steadfastly non-committal in many of the great issues of the day.  Which is fine, I suppose, and probably keeps his mind at ease.  Unfortunately, I haven't learned that trick of respite, and I'm well aware that sometimes one thought will generate a virtual cacophony of mental activity.  And my need to share my opinions...repeatedly and in excruciating detail, especially during long drives with a captive teenage audience...often results in The Graduate burying his head deeper into his Nintendo DS.

So by now you're intrigued, right?  You're sitting there, asking yourself, "How does Howard Rodenberg, MD MPH, a fine upstanding member of the Northeast Kansas Medical Community and The Only Guy Who Verified his Age as 53 on a Children's Storybook App, stand on the critical issues of that day?"  Or at least, "Which bathroom should I use in the Charlotte Airport?"

I'm delighted that you asked.

I happen to be of the belief that anyone can use whatever bathroom they want.  I do not say that because of any inherent beliefs, one way or the other, about the rights and privileges of the transgendered.  My thoughts on transgendered rights mostly concern just which pronoun one uses when gender identification doesn't match the anatomy.  I don't want to say "it," or use a made up word like "shim," but I truly have no clue.  Given what I do for a living, where physiology beats identity every time, that's all I really want to know.

I believe that everyone should use the bathroom of choice because that's what's been happening for thousands of years, perhaps even millions, since the first band of Homo Erectus (and isn't that a great name for a species given the current discussion) decided to use a communal waste site and some were more dainty in their use of leaves than others.  It’s never bothered anyone before.  It’s not led to a rampant plague of bathroom oglers nor predators.  It’s not eroded the fundamental values of our nation (that would be urban music and cable television).  It's a non-issue, made into one by a  conservative, rural-dominated state legislature duking it out with hand-wringing urban activists in a large liberal city, magnified by a knee-jerk overreach by the federal government when it should have been left alone, to weasel it's way through the court system for a dozen years or so before the issue goes away by itself...meaning that everyone will continue going to the bathroom as they’ve been doing since the prehistoric scat pile. The whole thing is a chest-beating, cheek-puffing fight for dominance between two bands of howler monkeys hoping someone will pay attention while the rest of the zoo patrons are focused on those oh-so-cute river otters and ring-tailed lemurs.  It's the Transportation Security Administration of Excretory Politics. 

(As an aside, I've always found it interesting how many conservative legislatures, while promoting the autonomy of states to defy the federal government, are perfectly willing to limit home rule if smaller units of government, such as cities or counties, want to do the same. Government should be putting down floors to establish a minimal level of service, not limiting local initiatives by putting up ceilings.  I can live quite happily with conservatism as long as it's based on consistency and common sense.  I'm still waiting.)

If, as mentioned above, physiology beats identify, function beats form as well.  So here is a functional approach to what I think should happen with bathrooms.  Coincidentally, I suspect, it's what's been happening for the last several thousand years, with no discernible effect on public morals. 

If you are a guy, and you think you’re a guy, you go to the men's bathroom.  You may opt to stand near a urinal or enter a stall and sit.  In either case you excrete and leave.  This is not a place for lasting friendships to be made.  Socialization in is not permitted other than to say, "Hey, about those (insert team name here) and grunt in response.  

(I say stand near the urinal because there are people who grasp the urinal during use, which is sad and suggests a real need for human contact.  We do not encourage this behavior, and suggest those individuals subscribe to immediately.)

If you are a girl, and you think you’re a girl, you go to the women's restroom. You enter a stall, sit, and excrete.  It's my understanding that they must do something else in there, because they go in groups and it takes them forever.  But as I quite comfortably fit in the previous category, I'll never know.  Nor do I want anyone to tell me.

If you are a guy who think he's a girl or a girl who thinks she's a guy, it is true that you generally have to look the part.  But given that constraint, if you're a guy who thinks he's a girl and you look like a girl, you go to the women's room, enter a stall, sit, and excrete. You may socialize if you choose.  If you're a girl who thinks she's a guy and you look like a guy, you go into the men's room, enter a stall, sit, excrete, and hope Senator Larry Craig isn't in the booth next door because you're not that kind of girl.  Or guy.  It’s confusing.

If you've had gender reassignment surgery, you can absolutely use the restroom of your choice.  Anyone who has the intestinal fortitude to get things taken off or added on using scissors and knives deserves at least that measure of respect.  I will use the pronoun of your choice without hesitation.  However, if you were a guy who is now a girl and has subsequently developed fibromyalgia, I will address you as a female but will also take that post-operative diagnosis as prima facia evidence that you're most likely crazy as well.  

If you're a cross dresser, who just likes to wear clothing of the opposite gender but are also quite comfortable with your own gender, use the bathroom at home. Linebackers in heels won't fit in either gender-based rest areas.

Of course, if at all possible, individuals of any gender or gender identity should have access to a single-occupancy restroom. This not only obviates the issues of who else is nearby and their level of comfort, but makes it a lot easier to read, make cellphone calls or play Avengers Academy on the iPad at the same time.  Except in the Charlotte Airport, where the restroom attendants will knock on the door of the stall if you take too long and they hear Black Widow talking to Tony Stark from behind the swinging metal door.   Or so I've heard.

Monday, May 23, 2016

The Theory of Everything

A few weeks back I mentioned nurse practitioners. These are nurses who have gone on to get a Master's Degree so they can work alongside or independently of physicians as higher-level providers of medical care. Nothing wrong with nurses wanting to get more education and advance their career, of course, and more power to them for doing so. What I didn't realize, however, is that much of the class time in spent in nursing research. This strikes me as kind of a fluffy topic (no traditional nursing-based pillow tasks pun intended), because I can't figure out what nursing research is. If we're trying to figure out what clinically works for patients in the real world, we're dealing with the same issues, and the same set of facts, whether the research is done by doctors or nurses. That’s why it’s called clinical research. It’s not doctor research.  So I don't quite get what nursing research is if it's not research into clinical care. And if it's not, then that means it's not fact-based, and risks getting lost in rubrics of good feeling and a cornucopia of psychobabble. This is not really a criticism; it's the nature of the beast when you try to quantify that which is inherently subjective. It's a problem when subjectivity becomes confused with fact, and extrapolations are made on unfounded assumptions. You know, like pain scales and patient satisfaction measures.

(For the record, research that is fact-based does not mean that it's useful or even worthwhile finding out. It's like those studies that appear from time to time as a Waste of Government Dollars, like the one in England a few years back that showed that the girls really do get prettier at closing time. Mickey Gilley knew that years ago, as did his cousins Jerry Lee Lewis and Jimmy Swaggert.  As well as anyone who went home at two with a ten and woke up at ten with a two. Not sexist; it works both ways.)
I was talking the other night with one of my nursing friends who's just finishing up her nurse practitioner degree, and she was telling me about their class research project. (This particular nurse is also savvy about why nursing research is so prominent in her curriculum. "The professors have us do a project, write it up, stick their names on it, and submit it to see if they can get published." Yet another way nursing academics are exactly like their physician peers.)  She and her classmates have spent the better part of a year trying to figure out why patients with emphysema (more specifically known as Chronic Obstructive Pulmonary Disease, or COPD) don't get the care they need. They've come up with the usual suspects: lack of access to health care, lack of financial resources, lack of health education, and the like. In the end, it seems like in health care, like everything else, it always seems to come down to that drives access to care, to medications, to resources, to education, and even to time to devote to health care and maintenance.  But as we discussed her project, we realized that in our rush to blame the system and absolve individuals from accountability...not a specifically medical issue, but a systemic one...we simply ignore all those factors that result from individual free will. There are those who quite actively choose to continue to smoke, to not take advantage of free health care resources, to not use their prescribed medicine as directed, to refuse home oxygen when suggested by the physician. In the shorthand of the ER, we term these behaviors as idiocy.

It seemed to me as we talked that we could make this problem a lot easier if we focused on money and idiocy as driving forces for healthy behaviors.  And we could do so in a diagram:
Yes No

Yes Bad Hooray!
  No Bad Bad
In brief, if you're an idiot, bad things happen.  If you're not an idiot, but don;t have money, bad things happen. If you're not an idiot and you have a few bucks, you'll be fine.  That's all of health care behavior in a nutshell. And depending on how high up the food chain we consider the idiot, probably explains a lot about the healthcare are system as well.
See how easy this can be?  

(In reflecting upon this solution, I recognize that I have now personally put any number of nursing, social science, and economics journals out of business, have destroyed tenure for countless academics, and have simplified doctoral theses for any number of graduate students.  The only thing left now is to define the extent and the operational mechanisms of idiocy, which in itself remains an expansive topic of study, one that women have been trying to figure out in men since the first Australopithicus said, "Hey, I can walk upright!  Guess that lion can't eat me now!"  And I have distilled the collected works of Will and Ariel Durant, Jared Diamond, and Yael Noel Harris, all excellent scholars of civilization, into a Cliff Notes version.  You're welcome.)

Tuesday, May 17, 2016

The New Pet

Today at the You Can't Make This Stuff Up Department:

Have you ever had a chance to fulfill a childhood dream? Has there been something you've longed for all your life, and now with hard work, effort, and a little bit of scratch you can finally live out your fantasy? 

Meet Bob. Bob grew up in the Midwest and now lives in sunny California, so when he comes to Kansas City in April and feels the hint of chill in the early morning air, he harkens back to the halcyon days of childhood. He thinks about laying in the grass under a cloudless summer sky, snowball fights on Christmas Day, and romping through untamed woods and gullies where endless gated communities now hold court. The only black mark in this nostalgic idyll is knowing that he never had the pet he always wanted. Sure there were animals in the house, but Nip the Dog was really his brother's boon companion, and Tab the Cat...well, belonged to herself, as cats will do. No, he never had a pet that was just his, something that he could hug and pet and squeeze and pat and rub and caress just like Hugo the Abominable Snowman and his Pink Bunny.

Fast forward thirty years. Bob's a success. In demand, well respected, flying all over the country to add to his riches. He's got a wonderful wife, two great kids, two cars, and a few pets that, just Iike before, seem to love someone else in the household more than him.

So he wakes up one morning in the Midlands, having finished his work a day early and with a full twenty-four hours to himself. He gazes around his hotel suite, the expensive one with the the soaking tub and the mini-bar that doesn't charge you every time you jostle a Pepsi, and he thinks, "Today. Now."

He goes to the specialty pet store. There's something specific he wants, and he's spent the morning researching where to find it. He buys an airplane carrier for it, too, because he's going to take it back to California to show his wife and kids, hear their squeals of delight and their sighs of admiration, and hug it and pet it and squeeze it and pat it and rub it and caress it.  Buying this pet is Bob’s ultimate act of self-actualization.

He buys it and names it Bosco. He keeps it in the box from the pet store nail the next morning, when it's time to enter the pet carrier and get on the plane. But Bosco likes the box, and is young, and afraid, and so Bosco bites. And chews, and won't let go.

Did I mention chews? Oh, right. I forgot to tell you. Bosco is a Gila Monster.

Here's the scoop on the Gila Monster. It's one of the two poisonous lizards native to the United States , the other being the Mexican Beaded Lizard. They are found wild throughout the American Southwest. For the record, that's not Kansas. Our native lizards could be fine domestic companions, which can be surmised by the fact that nowhere does the word "monster" appear in their names.

Gila Monsters normally live underground, are generally shy and retiring, and it seems to take a special effort to get bit by one.  This says something about Bob.  But you don’t have to take my word for it:

“I have never been called to attend a case of Gila Monster bite, and I don’t want to be.  I think a man who is fool enough to get bitten by a Gila Monster ought to die.  The creature is so sluggish and slow of movement that the victim of it’s bite is compelled to help largely in order to get bitten.”  -  Dr. Ward, Arizona Graphic, September 23, 1899

(While we're speaking of Hispanic lizards, and especially in this Trumpian moment, I'm reminded of a display at the Oceanographic Museum of Monaco. There's a tank of small amphibians from Mexico, really cute little fellows that run about and jump on sticks and eat bugs and look out at the tourists. The adjoining wall is adorned by a cartoon version of one member of the company, dressed in a sombrero and holding a pair of maracas, greeting visitors with a warm, “Hasta la vista, muchachos!”  It's so cute that not only do you not want to build a wall to keep them out of the country, but you'll even gladly consider setting up terrariums along the Rio Grande and provide them with free sticks, bugs, health care, and college tuition for those eggs that hatch. Of course, it would never fly in America, but I suppose when your version of undocumented aliens from south of the border are Syrians you can get away with that.) 

Bosco is chewing. He likes this. He has yet to bond emotionally with Bob, and for the moment thinks of Bob not as his pal for life, but as a probable threat that just happens to be soft, fleshy, and possibly quite tasty. Bob is macaroni and cheese, meat loaf, cream gravy; Bob is comfort food. So Bosco keeps chewing, and won't let go until Bob grabs the carrier with one hand, sticks his other arm, (Bosco attached) into the box, and whacks his newfound friend against the rigid plastic walls of the enclosure to make him break his group. Bob thinks things are going well as he quickly clips the door shut.

Did I mention that the Gila Monster is poisonous? And that the reason he chews is because, unlike rattlesnakes who inject their poison through their fangs in less than an instant, the venom of the Gila Monster slowly flows into the bite along grooves in the lizard's teeth. So the only way it has to kill it's struggling prey (or his new best friend) is to chew like there's no tomorrow. Which, with the life span of a Gila Monster being about a quarter that of a human being, there may not be.

The swift blows having done their job, Bosco is back in the carrier and it's time to head to the airport. Except that as Bob drives, he notices his hand swelling. A lot. And it's turning colors, reds and blues and purples that he's only seen in formal photos of the British Royal Family. So Bob does what any normal person would do in our technological age. He asks Siri to find him the nearest ER.

The clinical care here is really an afterthought. There are local effects such as pain and swelling, and more general effects that include weakness and drops in blood pressure.  The physician evaluates the extent of the swelling to determine if there's vascular compromise that will require emergent surgery (fasciotomy, a particularly nasty procedure) to release pressure on the blood vessels of the hand. You get some basic lab tests, start some fluids and give pain medication, and wait. If things seem to be getting worse, with more swelling, increasing pain, or unstable vital signs, it's time to find out where the nearest anti venom is. If not, you are often able to discharge the patient home. Above all, you get everyone you know (perhaps even flagging down a couple of truckers at a nearby rest stop) to come see the patient because...let's be honest...Gila Monster bites are cool, and patients need to be gawked at to be fully engaged in the Teaching Moment of Animal Safety. As paperwork is always important, it's my understanding that in cases like this the American Medical Association has concluded it is not a breach of medical ethics to use the terms "stupid" or "idiot" in clinical documentation.

What's more fun is imagining the next day. His right hand freshly bandaged and splinted, narcotics on board, Bob gets on the flight home. It's an airline where you can bring a pet onboard as long as it fits in a carrier beneath the seat. So could be sitting next to Bob. There's an angry Gila Monster near my feet, longing to chew through the walls of the carrier and quite possibly my shoe, sock, and second metatarsal. For me and my fellow passengers, it's the most nerve-racking three hours in the air since Samuel L. Jackson had to cope with airborne serpents. 

Meanwhile, Bob is trying to figure out how to explain to his wife that not only did he purchase a Gila Monster, got bit by a Gila Monster, and almost lost his hand to that very same Gila Monster, but he is also bringing home that very same Gila Monster to hug it and pet it and squeeze it and pat it and rub it and caress it and watch it bite Nip the Dog and Tab the Cat and Delores the wife and Anna the Daughter and Bob Junior the Son, because there's nothing that brings a family together like poison-produced pulpy purple puffy painful wounds, even without the added fun of possible necrosis. And Bob's also reviewing his grade school knowledge of fractions, so he can figure out exactly how much he's going to have left in his bank account when Bosco crawls in and Delores walks out.

And as for me, sitting alongside Bob, my eyes in constant vigil as an evil hiss works it's way towards my ears from under the seat in front of me? 

I f-----g hate Gila Monsters on a plane

Monday, May 9, 2016

IKEA This!

The Dental Empress and I recently made our second trip to an IKEA store. For those of you who are not familiar with IKEA, it's a Swedish company that...well, I'll let them tell you from their website.

"The IKEA Concept starts with the idea of providing a range of home furnishing products that are affordable to the many people, not just the few. It is achieved by combining function, quality, design and value - always with sustainability in mind. The IKEA Concept exists in every part of our company, from design, sourcing, packing and distributing through to our business model. Our aim is to help more people live a better life at home."

Kitty litter also accomplishes the same goals, but that's not what IKEA does.  What they really do is design and sell ingenious thematic, space-saving, low cost, build it yourself furniture and related home accessories for urban living. My understanding of urban living might be tempered somewhat by the fact that I've never been a resident of a core urban area, but I think it means residing in extremely tiny and outrageously expensive cubicles in neighborhoods alive at night with the noise of millennial lamenting the capitalism of their parents that got them their college degrees and the lack of safe spaces to whine about it, or in places you probably shouldn't hang out after dark.

IKEA is very a cool place. The showroom...and it's huge, not just like a really big Wal-Mart Superstore but Donald Trump laid out in a way that you have to see everything is order to get anything. (This promotes impulse buying of things you never knew you needed, which is why I now have an eight-pack of wooden hangers new kitchen tongs, a battery-powered alarm clock, and two stuffed animals. A fluffy puppy and a Daddy fox with a kit, if you must know.) The products themselves are often quite clever. Designed to maximize function in minimal space, they open, close, expand, contract, twist, and turn, and are able to be mounted on walls, floors, and ceilings in ways you'll never expect short of a zero-G space station. My favorite part of the store is where they've constructed a model apartment with a full kitchen, bathroom, bedroom, living/dining room, and a spare alcove bedroom in less than 600 square feet. It's brilliant stuff.

(Just so you know, I didn't buy everything. For example, I put down the fire-engine red heart-shaped pillow with arms that I think are supposed to enfold your child to give them a big hug. Instead, I picked up the pillow and made the arms flail me about the head and face, telling the Empress it was a heart attack. That didn't go over well.) 

It's also important to note that everything belongs to some sort of complimentary set, and that each set has a Swedish name. None of these are Swedish words you may have heard of. There is no ABBA four-piece place setting, no Garbo entertainment center, no Vasa sink, no Stockholm Syndrome. Instead, the collections have names like. Oppland, Liatorp, and Stocksund, which according to the Google Translator seem to be made-up words to describe the style, kind of like I'm pretty sure the made-up word "Frito" is a descriptor for the real-life noun "Bandito."

So as I was idly looking about while the Dental Empress was taking careful notes to make sure we got the Malm dresser rather than the Hemnes one, I noticed that all the books on the shelves used to fill out the displays are the same. It seems there are about ten individual titles in the entire store, but each one has been used hundreds of times on the shelves. And these are not hollow plastic imitations of scholarship; they complete hardcover books fully printed on each page, umlauts and all. You almost get the sense that IKEA is single-handedly supporting the entire Swedish publishing industry, making works such as "Smultron och Svek" a perennial best-seller. It reminds you of one of those late-night 1980's commercials for Slim Whitman, who reportedly outsold the Beatles in Bulgaria. In a similar vein, you could also say that Annica Wennstrom has sold more than one million books worldwide, without mentioning that 987,000 of them serve as unread fodder in IKEA stores.

(Interestingly, where CD's are supposed to be represented, there are only empty jewel boxes. Which means that I have more Swedish music in my home than does IKEA, because I not only have ABBA Gold but also a 1990's CD by Tomas Ledin featuring the song "Du Kan Lita Pa Mej," which I think means "You Can Lita on My Mej."  I know this because I also used to watch late-night 1980's commercials for the children's game Husker Du.)

The way IKEA works is that as you work your way through the store you pick out what you like, and if there are things that don't fit into your basket you go to the attached warehouse to load up the big items so you can build them yourself at home.  And so few hours later, a bit of Sweden has been dragged into the house.  ("Look!  It's like they're pooping!" exclaimed The Empress as we opened just the end of an eight-foot box, tipped the unopened side skyward, and watched the pieces cascade, one by one, out onto the floor.)  Buried within each carton was a set on instructions.  The thing the remember is that as an international brand, IKEA has to be able to communicate with anyone regardless of language.  So the instructions use pictures only, and the first page begins with a few introductory cartoons. The cartoons show the wrong way to do things on the left, and the correct way to do them on the right.  It's kind of like Goofus and Gallant in the old Highlights for Children.  ("Goofus leaves as quickly as he can while you're asleep and doesn't leave a phone number.  Gallant makes coffee in the morning and says he had a wonderful time.")  So one of the cartoons shows a person sobbing because there's a crack in his project from building it on the hard floor; the corresponding picture shows him smiling with the project safely cushioned by a carpet.  Another one shows a puzzled man looking at the instruction book; the adjacent drawing shows him calling IKEA for advice.  And them there's the picture of one unhappy person looking at a stack of prefab pieces and parts next to two happy ones gazing at the same pile. The message is clear.  It takes two.

First project is the dresser. The Empress has a tool kit in her house. It contains one ladylike lavender hammer, eight flat head screwdrivers (all the same size) and one narrow Phillips head item, a pair of pliers, a packet of Allen wrenches, and forty plastic cable ties in a rainbow of colors and hues. She also has one cordless drill for which there are no drill bits, but she uses as a power screwdriver. Because I try to obey the admonitions on the right side of the Highlights page (Gallant says "Please use the cordless drill and save your delicate hands;" Goofus says "Go screw yourself"), every minute or so I hear a chirpy, "I'm done! It's because I have a power tool!" Meanwhile, I'm still working on upgrading from moderate to severe carpal tunnel syndrome ratcheting in the second of eight screws, Part #10863. Because I am a supportive boyfriend, I look up and smile at her every time she does this, fighting every urge I have to make some sort of remark about her and power tool (and you can guess where this might have gone, especially in a commuter relationship). 

We made it past the drawers in good order, carried the dresser into the closet where it will reside, and put together the storage unit with a minimum of fanfare. The entertainment center, however, was another matter entirely. Multiple boxes, misplaced rods and ratchets, and difficulties fitting pieces together made it a less than joyous coulee experience. The pot came to a boil after I asked her to tip the piece as a whole up so I could attach the top, and as it did I heard the sickening crack of particle board, splitting the wood over both of the bolts that would secure the bottom of a piece backing up the TV to the rest of the structure.

"F--k a duck with a f-----g duck f---k.!" I exclaimed. (Even when I curse, I like alliteration)

She peered at my with Marlin Perkins interest. "You're mad."

"No, I'm not. I'm frustrated. That's different," I lied.

"Well, it's not my fault. I helped just like you told me to."

I can see where this is going. I'm going to try to bail out the sinking ship, but still make my point. Bad move.

"You're right. I should have told you to keep a hand on that piece while it was moving so it wouldn't fall backwards. I thought you would do that and I didn't specifically tell you to. It's my fault."

"Yes. Well, it's fine." (Fine is never a good word in a relationship.) "It's on the back and nobody will see it."

"No, it's not okay. It's not fully structurally intact. I don't think it's a major problem but it's not okay."

I'm not the most self-aware person, but one thing I do know is that after the initial explosion, my voice drops a few scales and I start talking in a slow, measured fashion. I'm now in full James Earl Jones, deep Mississippi mode. She knows this. She thinks it's hysterical that this is the only thing that can shut up my otherwise constant chatter. 

"You're seething." There was that a note of glee in her voice.

Still looking straight ahead. My teeth are set, my mouth doesn't move. I'm like a bad ventriloquist looking to project my voice somewhere, anywhere at all. 

"No, I'm not. I'm frustrated. That's different." 

(I've also officially run out of new things to say.)

It's now the sound of triumph tinged with just enough righteousness. "No, it's not."

It's at this point that I'm looking around the room for some kind of distraction, and my eye falls upon the last page of the instruction book. And it's at that moment that I realized why there was no cartoon of happy people rejoicing over the finished product after the final step. The Swedes may be many things, but they are not liars. For not only have they lured you into buying their products, they are now going to play the ultimate Nordic prank on you, the one that makes up for them all having Seasonal Affective Disorder and being unable to uproot Julian Assange from the Bolivian Embassy. They knew that the after picture should show only the finished project, and not the carnage in blood and relationships that follow.

Despite the temporary setback, the Empress and I set things right. We managed to back the entertainment center into a corner so the broken piece is leaning against a wall. And then we went to a local bistro and had two bottles of wine and smoked a hookah flavor called 50 Shades. Afterwards it was 1 AM Steak N Shake for Takhomsak Chili Mac with extra cheese. Gallant says, "May I pour you a nightcap?"  And The Empress says, in her best Eva Gabor voice, "Of course, dahling."  It's all good.

(PS: For more information about Sweden, I would refer you to The Suite Life on Deck, "The Swede Life."  In a related note, The Teen tells me that the question of London or Bailey is this generation's version of the "who do you choose" quandry. And just so you know, the correct answers to the classic questions are Mary Anne, Julie Newmar, Veronica Lodge, Jennifer Marlowe, and the Green Orion Slave Girl.)

Monday, May 2, 2016

Baby Come Back

Death is final. The end.  El fin.  It's the existential dread of Homo sapiens, the only species we know of that contemplates it's own mortality.  So it's surprising to me how many people come to the ER and say they want to die.  Their numbers keep rising, and it's a fair argument to try to figure out why and to assign the requisite blame.  (I've even heard the suicide rates of middle-class white men being tied to the rise of Donald Trump.). But while there are truly desperate people out there who need genuine help, it may be surprising to learn that they're usually not the ones who I see in Sinatra's wee small hours.

That is not to diminish the very real pain of those who are truly hopeless.  The ones we're talking about those for whom an attempt at suicide is just an event.  People who actually want to commit suicide see it as a resolution.  They are they ones who often present in advance, recognizing their suicidal thoughts but not wanting to surrender to them.  These are the true "cries for help," and with a bit of experience you can identify them almost immediately.  Their despair is palpable, the air between you thick with emptiness, and as you talk you begin  to feel that suicidal thoughts are probably not a sign of illness, and that suicide is a conscious, rationale, and even reasonable option.  And there are truly suicidal patients who are found by friends or family unconscious and unresponsive, keeping everyone in the dark about their plans, and who are genuinely disappointed that it didn't work and often puzzled by their failure because they've done their research in advance.  These are the people in true crisis for whom we should bend every rule and twist every arm to get them the help they need.

Ah, but then there's the rest, the ones who make up bulk of our "suicidal" clientele.  These are the folks who respond to life's stressors by chasing down some vodka and few Tylenol, perhaps guzzling down a handful of their psych medications for good measure, and then call everyone they know (and especially the ex) to let them know they're killing themselves.  There is wailing, thrashing, and tears.  There is also a lot of texting and cellular calls.  This is not a cry for help.  This is attention-seeking behavior, or (to use a technical term) a "dramarama."  It's the ER equivalent to the Security Theater performance of the Transportation Security Administration.   

While experience gives you a gut feeling abut who's really suicidal and who's not, there are some objective clues to guide the neophyte.  First, there's no lethal mechanism involved.  This might not have been a clue in the pre-Internet era, but today anyone with a cellphone can figure out how much of what medicine to take to kill themselves.  Similarly, if you want to kill yourself by jumping, or with a gun, you don't sit on the railing of a bridge and think about it until someone pays attention, or wave your gun around to make sure it gets noticed.  And speaking of cellphones, if you've texted and called people (especially the ex...that wasn't a joke) to let them know what you're doing, you're not in it for real.  And they don't put it on a "to do" list, as did one patient whose list, on a thin notepad festooned with flowers and tiny kittens, included things like "buy groceries" and "kill myself."  (I'm not making this up.) People who truly want to commit suicide just get on with it.

A second clue is that the patient, when confronted with the fact that their "attempt" is going to result in consequences, is suddenly no longer suicidal.  Patients with psychiatric disorders can certainly have labile moods, but you can't turn depression on and off like a light switch ("It's a clever little Mormon trick."). You don't go from wanting to quit life to laughing and smiling when friends and family (and especially the ex) arrive, ideally to fawn over your poor lost soul.  One of the questions I always ask patients is, "If I gave you a clean and painless way to kill yourself right now, would you do it?"  It's the ones who immediately answer "yes" in a firm voice, no tears, looking me straight in the eye that I worry about. If you're investing your energy in weeping and wailing and calling and texting (there's that cellphone again) and wondering where your beloveds (mother, father, boyfriend, girlfriend, or ex) is, you've got no intestinal fortitude for what you claim to have done.

A corollary to this is that patients who are not truly suicidal refuse to cooperate with care when informed that labs may need to be drawn and they may be held in the ER for psychiatric screening, claiming they have "rights' and we can't "make them do anything."  We do inform them early n that since they made a suicidal gesture, the law obliges us to hold them for their own safety until they are cleared; and that we hope that they'll cooperate with us in what we need to do.  The truly suicidal accept this with resignation.  They're beyond caring what happens to them or why.  The dramatists rebel, and sometimes it gets ugly.  They're also the ones who specify what hospital admissions and discharge plans are acceptable to them, and threaten to call their lawyer.  (Standard response:  "Go ahead.")  But no matter what they ask for a meal tray and a Sprite within 45 minutes of arrival.  You can time it.

It also shouldn't be forgotten that there are other kinds of secondary gain from claiming suicidal thoughts or tossing down a few pills.  There are a number of "regulars" who are quite skilled at playing the "suicide card."  If you have no place to stay, you now get food and lodging for at least a night at a local psychiatric clearinghouse.  If you were going to jail, perhaps now you don't.  If you're lucky, maybe you even get admitted to the hospital and Case Management invests time in finding you a place to live or getting you signed up for benefits and services.  And if nothing else, at least you have time to sober up in a warm, clean place.  The psychiatric clearance process often takes time, and at night that usually means you're with us 'til sunup.

So for many patients who come is with a suicide attempt, especially involving an overdose, they know it's all about attention just as we do.  But our medicolegal system, as well as our cultural belief that no one is responsible for their own actions, means that we have to maintain some kind of fiction that something needs to be done rather than just simply calling someone out on their script.  That fiction is called the psychiatric screen, and the resultant "Contract for Safety," where the patient agrees in writing to call for help as needed and to follow-up with counseling., because every truly suicidal person is going to be help up by a signature on copy paper.   

But here's the paradox of clinical practice.  I really don't mind taking care of these folks.  It's fun to watch the show.  It's admittedly kind of a power trip to tell people what they can and can't do know that they're on your turf, and watch their faces as they realize they've set events in motion far beyond their control.  They're easy patients as well; with very few exceptions, modern overdose management is simply watchful waiting.  And from a workload standpoint, it's great. They often need several hours of observation based on the peak blood levels of the drug they took, and then several hours after that to arrange a psychiatric disposition.  Which means they clog your rooms up for quite some time, decreasing your patient turnover and ultimately your overall workload.   The bean-counters who have never touched a patient but still grade you on throughput time as a measure of "quality" hate it, but from the standpoint of the working doc they prolonged ER stay in entirely justifiable and quite welcome, thank you very much.  

(This is where I take moment to lament the loss of a what we might call "educational"  therapy.  It is often true in medicine there are both easy and hard ways to achieve the same result.  For instance, I can resolve a case of gonnorhea with with a shot in the butt of an antibiotic called Rocephin or with a large oral dose of a different antibiotic.  Which one you get depends on how you've treated the ER staff, and if I think you're the victim or the perpetrator.  If I think you need a strong disincentive to your continued risky behaviors, or you've been a jerk yo the nurses or to me, you get the shot.  It's educational, in that you learn the difference between acceptable and unacceptable behaviors.  Twenty years ago, we had a lot of "educational therapy" in overdose management.  We'd take these huge half-inch plastic tubes called Ewalds and shove them down the patient's throat into their stomach, under the premise that we were going to wash out their stomach with a tube big enough to get out all the pill fragments.  Or maybe we'd just give them a nice big slug of ipecac so they could vomit and puke and upchuck for hours on end.  These actions would not only be therapeutic, but serve as disincentives to engage n the same behavior in the future.  Alas,science has deprived us of some of it's fun, as it turns out that with rare exception there really re no pill fragments to go after, and by the time the patient gets to the ER there's really nothing left in the stomach to barf up.  About all we get to do is make you drink some grainy powdered charcoal...just like in your grill but without the impregnated lighter fluid...if you show up within an hour of your overdose.  Maybe if you refuse the urine test we restrain you and pass a catheter into your bladder, but that's about it anymore.  Sigh.)

Most of the one-act plays we see are attempts to curry favor in a relationship.  I've never been able to figure that out.  It seems to me that if I'm dating (or have just broken up with) someone who takes a bunch of pills in an effort to make me feel bad, the long-term prospects of that relationship are pretty poor.  Whenever I think about this, I'm always reminded of the college student I saw while working in Daytona Beach.  He was down there for Spring Break, and found his girlfriend walking the beach with another guy.  By the time I saw him, he had already taken a few swings at a paramedic, which meant now he was spread eagled on a cot in four-point restraints, and not in a fun, Stevie Nicks, leather-and-lace filled way.  

As I recall, our conversation went something like this:

Me:  "Hey, I'm Dr. Rodenberg.  What's going on?"

Him:  "Fuck you, man."

That's as far as I got in Round 1.  The paramedics filled me in on the rest.  His girl had gone off with another guy, and he decided to get back at her by taking four...count 'em, four...Tylenol.  For the record, I take four Tylenol for a headache.  (Yes, I know that's technically an overdose, but I can calculate my weight-based toxic dose so I'm good.  The lethal amount can be found online by anyone who's serious about suicide.  See above.). He took the Tylenol, then called the girl, who called the police but, in what I can only assume is a flash of insight and maturity,  did not return to their hotel room to offer comfort or solace.

There are other educational interventions besides tubes and purgatives.  Reality testing, for one.  

Me:  "So I hear you took some pills to piss off your girlfriend.  Where is she?  is she here now?"

Him:  "She's fucking Bobby."

Me:  "So how's that working out for you?"

Him:  "Fuck you."

The truth is a harsh mistress.  Maybe even worse than an Ewald tube.

(While this particular entry into the blogosphere addresses those who say they want to die but really don't, let's not forget that there are two related groups in this discussion as well.  The first are those people who don't want to die but have done everything in their power to do so.  These are the morbidly obese, the ones who can't be bothered taking their medications or seeing the doctor.  It's those whose eating habits and lack of exercise are practically invitations to death.  It's the smokers, the alcoholics, the drug abusers.  You can make a case...weakly, in my opinion, but at least more than for fibromyalgia...that these people have different physiology, that they react differently to stressors and stimuli, and that they are subject to unique and oppressive psychosocial and economic factors resulting in health issues that are not really their "fault."  There may perhaps be some truth to that, but there's also truth to the fact that we can choose a healthy lifestyle and that we can take advantage of community resources to help us with our issues.  Because we're no longer willing to build personal responsibility into our health care policies, we keep wasting time and effort giving first class medical care to those who don't care enough to do their part.  I have no problem caring for someone who's done damage to themselves but is now doing their part...quit smoking or drinking, losing weight, following-up with their own physician.  For those who accept no responsibility for their own well-being, at some point our expenditures have to stop.  The devil, or course, is in the details.  The solution lacks the clarity of what we might call the Jean-Luc Picard Limit.  (The line must be drawn here!  This far, no further!  And I will make them PAY for what they have done!)

Sadly, there's also the other category of people with terrible illness who want to die and you absolutely understand why.  There are people with terminal cancer in perpetual pain, those in end-stage heart failure or emphysema where every breath is agony, and patients with degenerative neurologic disease who can't move, eat, or speak. If they say they want to die, it's because it's the last moment of control they have over their own lives when disease has stripped them of everything else.  We don't do physician-assisted suicide in the ER.  But I will ask these patients and their families if they really want to be fully evaluated and admitted, or can we just do something kinder and gentler, like give you some pain medicine for home and perhaps a bit of steroids to improve your appetite? You'll be surprised how many of these kinds of patients just want to go home and be in peace, and they seem grateful that someone's willing to join them on the plank.  And I'll confess that, when I sense that's what going on in a patient who can't speak for themselves, when I see that look of resignation in their eyes, I'll choose a tone of voice for the family that suggests the right answer. Sometimes you need to go gently into that good night.)

Thursday, April 21, 2016


I recently saw on Facebook (which is my main source of information concerning cute animals, illustrated recipes, and childhood photos of people I don't recognize and, I think, never did) an advertisement for the Eko Amplified Stethoscope.  (Eko, because in  America spelling doesn't count, and English majors stay unemployed.). At first glance, this is a great thing.  The built-in receiver detects even the faintest heart beat or Korotkoff sounds (yes, I said that just to be pretentious...go look at up, and then recall Dr. Nikolai Korotkoff, who was a Russian surgeon during the Russo-Japanese War. And whom, like Rene Laennec and other folks who came up with some audible medial clues, died of tuberculosis at a young age.  I need to get this cough checked out.) The idea, and it's probably true, is that the amplified stethoscope improves the accuracy of your exam in noisy environments like the cacophony of the ER or amidst the siren's blare of the ambulance, which one might think of as the Official Folk Song of the ER. 

(Speaking of which, I just placed an order for a doormat that says, "Ring the Bell and Let Me Sing You the Song of my People." It's signed, "The Dog.")

I don't want an amplified stethoscope.  The reason for this is that I'm pretty sure that it will make me hear things I've never heard before, and then I'll have to think about what to do with all those extra splishes and splashes and noises and squeaks.  Given that ignorance has long been my bliss, I'm convinced the amplified stethoscope will give me too much information, most of which I ahve no idea what to do with once I know it.  While I can think deeply when pressed to do so, I',m porne to be intellectually lazy, and there are lots of things in this world that I jsut don't want to know.  It's kind of like thinking of your parents not as the paterfamilias they've become, but as the young and hormYou know you're a product of their coupling, but you have no desire to know any of the whys and wherefores and certainly none of the how.  It's simply too much information, and painful to boot.
Too much information seems to be a pervasive theme of modern life.  Too many channels. Too much media.  Too many pundits.  Too many websites (though I do give my highest recommendation to I F---ing Love Science, Too many commercials.  Too many infomercials.  Too many options for loans and insurance and retirement plans and mortgages and credits cards.  Ron Burgundy said it best, just before the knife fight:  "There's too much news!"  (For the record, The Teen and I are hard-core devotees of the Anchorman franchise.  When we think about science, of course we think about Madam Curie.  We can't see a cat without thinking "Chicken of the Rail Yard."  This would seem to unnerve our dear departed Baby the Cat, who seemed to understand English just enough to know that while we loved him today, in the event of of a famine he was the first to go, breaded and fried with  a side for Whammy Slaw.  He...The Teen, not the cat... has also agreed, if he ever gives a public speech of note, to include the phrase "together we can defeat voodoo" as a tribute to dear ol' Dad.). While the surplus of information is probably nothing to the members of Generation X, Y, Z, or DD ( sidetracked) it's overwhelming to a guy who grew up with four TV channels, the local paper, and the triumvirate of Time, Newsweek, and US News telling me all I needed to know.  If I wanted to get shouted at, I didn't read an e-mail or text in all caps; I just turned on The McLaughlin Group.  (Moor-TON!  Bye bye!)  Any thing else you needed was found at the public library in the depths of the Reader's Guide to Periodical Literature and that thirty volume Internet we called the Encyclopedia.  You didn't need to research all your consumer options, either.  Your pharmacy was local, you grocery perhaps just a bit farther away, it was a big deal to go downtown to a department store, and the local bank that handled all your financial needs and gave you a free toaster with a new account.  Was it better, living in a relative degree of ignorance?  Maybe, maybe not.  Was it easier?  Unquestionably.   

(Okay, time for a bit of a rant, because I NEVER do that on my blog. I recall when I was thirteen and got a paper route, I went down to the local bank to open a checking account.  It was a pretty proud moment. I put in my initial deposit...probably in the two my checkbook, and learned how to use the ledger.  So when I thought about opening an account for The Teen at our local bank (and I will call out names...CoreFirst in Topeka), I figured it would be the same process.  Oh, but it's no so easy anymore.  I've recently received a letter form the bank entitled "Exciting Checking Account Changes are Coming!"  The changes, of course, are more fees.  There's a $7.00 fee if you don't have a total of $5,000 in savings, checking and D's; an active credit card; or 20 or more debit card transactions per month.  In addition, if you don't sign up for electronic statements, it's another $3.00 per month.  So there's $120 per year in fees to gain  access to your own money.  It's like someone intentionally sat down to come up with every possible punishment for those of lower income, like young people and the poor, to use banks all the while knowing that they're forced to do so because everyone needs to deposit their paycheck somewhere.  It's legal, no doubt, but it's totally heartless.  And I'm looking for a bank with what I think are better ethics to move my money, but guess what? They're all the same. Perhaps the theory is to teach kids early on that the banks are out to screw them.  That way, there's no surprises when your faith in an institution gets shattered later in life.

Here's another example of how screwed up banks have become.  Remember the crash of 2008, mostly fueled because banks were giving home loans to people who couldn't afford their mortgages or had poor credit?  Two months ago I went to finance a home purchase. I felt pretty good about the financing, especially because I had heard about "physician loans" that would allow you to purchase with only 5%, or even 0% down.  What a deal, right? But as I called around to banks, it turns out those loans were available only for doctors just out of residency or in the first 10 years of their practice.  
So as I now understand, if you just got out of your training program without any track record of holding a long-term job and have several hundred thousand dollars of student debt, we'll give you a loan up to the high six figures with nothing down.  But if you've been out a while, have a good credit score and some resources built up, we're going to make you pay 10% up front.  The whole thing makes no sense, and with loan polices like these...this a "reputable" lender...and the fact that nobody who helped to engineer the financial crisis has been made to take any kind of personal responsibility for their actions it's just a matter of time of time before the next crash. 
I just realized I sound like Senator Sanders.  Didn't see that coming.  But sometimes you just have to Feel the Bern.)
My professional life is not spared this deluge of data.  There are a few reasons for clinicians to love Electronic Medical Records (EMR) and a lot of reasons to hate them.  TMI (Too Much Information) is one of the latter.  Your typical EMR can be thought of as a list, or perhaps a timeline, that captures everything that happened to a patient from prehistory until now.  It documents every prescription they're on, any medications they've had before, any encounter with the healthcare system, and any phone call they've ever made.  This is great if you want to look up a past hospitalization or an old lab test or X-ray report, or just bill Medicare or Medicaid out the wazoo; it's awful if you want to try to sort out what's going on wth the patient or why they are there to see you today. The EM does not organize, stratify, or prioritize; it does not differentiate current from past problems and therapeutics; and the data presented, in simple shower of output, often bears absolutely no inherent relation to clinical care.  While it's true that if you're familiar with the system and you know what you're looking for, you can eventually find it (click click click G-d dammit click click click), if you're wanting a quick and intuitive synopsis of what's going on today it's simply not there.  It would take a clinician to tell the EMR folks what we need, and to guide the EMR vendors into building filters that are relevant to clinicians, but as we have all come to know provider input means nothing when billing systems are involved.  (And let's make no mistake about it; the root of the EMR is the ability to produce a detailed, supportable bill.  Anything else the EMR does, like the real patient safety benefits, the occasional data collection, and the time-consuming and mind-numbing barriers it places between the doctor and the patient, is a side effect.)
Where I feel this most acutely is not in entering patient data and orders.  I'm fortunate that the institution where I work uses voice-activated dictation, because my typing skills are from the pre-digital age.  But over the years I've found myself increasingly compulsive in trying to get a quick look through the EMR before I go into a patient's room to see what morass might await.  Because I've been working with our system for almost five years and I generally know how it works, I can usually find the latest hospitalization, lab test, or office visit.  However, trying to print out the data I need (I'm not good at memorizing a screen and then trying to recall it minutes or hours later) means that I'm forced to print out everything that ever pertained to that visit, including past and current medications, problem lists from the last decade, and all kinds of billing information and timelines.  What I need is about a paragraph; what I get cuts down a forest.  Too much information.
I also get too much information from the patients themselves.  There's a thing you do in the patient interview process called a Past Medical History, where you ask the patient what other medical problems they might have.  There is also the Review of Systems, where you ask about the presence or absence of other medical complaints in order to help fortify to exclude your initial working hypothesis.  As long as you get a solid answer, this is helpful.  More often, you get someone who says they have to "think about it."  I generally subscribe to the idea that if you are otherwise fully within your faculties, and you can't recall if you have a medical problem or not, it's not that important an issue.  Similarly, if I ask you if you have a particular symptom and you have to think about your answer, then answer is really no.  Priorities matter.  (Because patients are lazy thinkers as well, the second most common answer is , "I don't know.  You people have that somewhere.  Go look at my chart."  It's clearly too much to ask people to Keep Track of their Health when they're busy Keeping Up with the Kardashians.) 
Nurses also unwittingly contribute to information overload.  I do understand that at some point in the development of our medical food chain, it was mandated that nurses often have to ask doctors for permission to perform even the simplest of tasks.  I'm not in favor of that; for nurses to have to ask permission for everything is demeaning to them as professionals.  But somehow this has morphed into the idea that nurses also need to inform the doctor of everything. Patient is in pain.  Patient is nauseated.  Patient wants something to eat.  Patient wants visitors.  Patient wants more pain medicine.  Patient needs a ride.  Patient is now threatening suicide when you've refused their ride and pain medications because they don't want to walk to The Mission.  Patient wants to leave because it's taking too long, or they need to be somewhere (usually court).  And it's not like the nurses, most of who are extremely capable individuals and know things about patient care and the healthcare are system that are way beyond my pay grade, can't handle these issues themselves, often with better outcomes then with the intervention of a tired, overloaded physician.
(It's tending to the latter that bothers me the most.  I've never understood why, if we're up to our tails in gators, we are supposed to drop everything, gather at the patient's side, hold hands and sing Kumbaya, and beg them to stay.  Why is the rate of patents who leave Against Medical Advice, who leave without being seen, or who simply elope from the ER, some sort of "quality measure" that doctors, nurses, and institutions are measured on?  Isn't "self-triage" a good thing?  Don't we want people to take responsibility for their own health, to use their own judgement regarding their need for emergency care?  Of course we do...unless those patients are leaving so fast that we can't run up a bill for their visits.  I think a great clinical study would be to follow-up on patients who leave the ER on their own accord to see if they actually have any resultant medical issues.  But that's above my pay grade.) 
I'm most troubled by the incessant dispensing of nursing information, and the subsequent requests for action, because they come in an environment where nurses are simultaneously demanding more autonomy in medical decision-making and patient care.  We see this most prominently in the public policy battles for nurse practitioners to be able to practice outside the supervision of a physician.  The push for nurses to function autonomously in the community stands in stark contrast to the abject dependency of nursing practice in the hospital, and seems to expose an inherent contradiction.  Either you are an independent professional or you're not.  It doesn't seem logical that you can have it both ways.
(I suppose the nursing ranks could claim that nurse practitioners deserve the right to practice independently because they often have an advanced degree...usually a Master' opposed to a Bachelor's or Associate degree for most hospital and office-based nurses.  But this seems a spurious argument to me.  The training of a  nurse practitioner really consists of a year of lecture and a year of supervised preceptorships, which means you sit next to a current nurse practitioner and watch them do things. It's no comparison to the three years of clinical training after four years of medical school that a family physician must have, and it seems incongruous to suggest that an independent nurse practitioner without a similar tenure of supervised work can provide the same level of clinical care.)

I am an absolute advocate for collaborative Physician/Nurse Practitioner care. (I feel the same way about working with Physician Assistants).  I think these models feature the best of both worlds. Nurses tend to look at psychosocial things doctors don't and can extend the reach of a clinical practice into underserved areas in a cost-effective manner.  Physicians represent built-in consultants for management of more complex or problematic patients.  Personally, I value the the nurse practitioner as a colleague to discuss problems and ideas from a different point of view.  When I'm asked questions by mid-level providers about my diagnostic approach, treatment plans, or simply physiology, it helps keep me focused on the job at hand.  (And selfishly, nurse practitioners are able to do those longer procedures, such as suturing, that otherwise take me out of the flow of the ED.) 
If nurse practitioner want to be independent practitioners, so be it.  But then make them undergo further supervised practice equal to the level of care they wish to provide (three years for family medicine), loosen the apron strings on hospital nurses, and have everyone understand that they will have to accept the responsibility that goes along with an independent practice.  To me, that answers the conflict between primary care outpatient and inpatient servile nursing efforts.  And responsibility doesn't mean just liability for their actions.  I also means giving up automatic physician backup, losing access to a physician referral system, and encountering increasing economic hostility from the medical profession as third-party payers direct their clients to less costly nurse practitioner care.  In my own little world, independent nurse practitioners will just add to my workload...another group of folks who will feel entitled to do what most community-based physicians already do with a problem they can't handle, after 4 PM and on weekends, nights, and holidays, or with someone they simply just don't like...send them to the ER.  And Lord help us if we get overwhelmed and the patient wants to leave.  Better drop everything, grab that turkey sandwich and a Sprite, and get ready to sing.
(I'm drafting this on a plane descending into Atlanta, and we're passing through a low-lying cloud.  A cloud is composed of billions of water molecules suspended in the atmosphere, drawn together by the most minute attractive forces.  The molecules themselves are layered to together in such a way that collectively the cloud is totally opaque, but the spaces between the molecules are so vast on an atomic scale that you can fly through them without any resistance or obstruction.  You do so in a multi-ton chunk of metal that stays aloft simply and only because air flows faster over a curved surface than a straight one.  There's no reason on G-d's Green Earth it should work, but it does.  I f---ing love science.)

Saturday, April 16, 2016


I inherited a cat three years ago.  Baby was a divorce cat…when we split, the ex said she couldn’t take care of both the cat and the dogs, and was going to take Baby to the shelter…so how could I refuse to take him in?  He was a pretty good cat for a guy living by himself…he’d sit on top of the sofa, go out, come in, eat food, steal my food, and occasionally we would play a game called “Cat Airlines” when I would launch Cat Flight 328 from the Dining Room table to the Couch, ETA 2.1 seconds from takeoff.  He was also a fine muse, being responsible for my own personal modifications of Player's "Baby Come Back" ("Baby the Cat!  Any kind of fool could see...there was something, in your really stinky cat breath") and the King of Pop's "PYT" ("I want to pet you! BTC!  Baby the Cat!").  Baby was also the source material for a song co-written with my son called "Baby the Cat Pooped on the Rug in There," which could be adapted to many different musical styles, but usually with the same crappy outcome.  Or output, in this case.

Anyway, poor Baby went to the Great Litter Box in the Sky a couple of months ago.  I had boarded him at the vet’s office while I was out of town, so it was decided that Baby would be cremated and then I could put his ashes in the backyard.  What I didn’t realize was that his ashes would come back to me in a small white box with the name “Baby Rodenberg” printed on the front.

I forgot to take the box out of the car, and it sat in the front passenger seat for a few more days until the next time I was traveling.  I pulled up to the Park-N-Ride near the airport and turned over my keys to the attendant.  As I did, I saw him stiffen up when he saw the box containing the ashes of Baby Rodenberg waiting to be chauffered to the lot.

I still keep Baby with me in the car.  The love of a cat…or at least it’s ashes…is a gift that keeps on giving.

Friday, April 8, 2016

"One, Two, Three Four, Can you Gag a Little More?"

While I would by no means consider myself an authority on anthropology, neurobiology, or psychology (if I was, I would have stuck with the right girl the first time and not been divorced twice), I do think that mankind has some kind of deep seated drive to quantify things. If not, we'd be happy knowing only the difference, as apparently the parrots do, between one, two, and more. There would be no notches on a stock, no quipus, no abacus, no computer, and no Starcraft, where the desire to quantify is linked to the need to construct additional pylons.

We quantify quite a bit in medicine, too, and we do so using scales. For the biostatistically challenged among us (that's all of us), there are three kinds of scales. Nominal scales are used for mutually exclusive, not ordered categories. An animal can be a frog or a giraffe, but not both, and you can't assign any particular value to the difference between them. Ordinal scales involve orders and ranks, but again without a quantifiable difference between them. I like chocolate mint ice cream better then French vanilla, but I can't tell you how much. (Pain scales and patient satisfaction scores fall it this realm). Interval scales are measurements where the difference between the values are meaningful and quantifiable, such as height, weight, temperature, and lab values. There are also musical scales, which really only play a role in clinical medicine when watching the patient in the "Seclusion Room" sing an incomprehensible melody to himself punctuated by pelvic thrusts and shouts of "Bueno!"

(Speaking of which, the use of satisfaction surveys has gotten totally out of hand, and I'm not even referring to those annoying patient satisfactions surveys, upon which Press Gainey and their ilk have built an empire of flaming straw. I'm thinking of an online survey I filled out about a hotel I stayed at in Phoenix a few weeks back. It was a reasonably nice hotel...the Doubletree Resort in Scottsdale...and I had no issues with my stay. So in the online survey I gave the hotel "8's" across the board. Nothing wrong with it at all, and I'd be happy to stay there again. But moments after the survey was submitted I got a note of apology from the Manager. I actually wrote back and said that everything was fine, I had no complaints, there was no need to apologize. But apparently the Hilton system rates anything less than a 9 as unsatisfactory. So even though I'm perfectly content, this poor man is now having someone thousands of miles away in corporate put a knock on his record. What was the guy supposed to do?  Send the actress who plays Clara in Dr. Who up to give me a nubile foot rub?  It's mad, it really is. But I digress.)

Interval scales have long been the "gold standard" in medicine, but in our interest to quantify the unquantifiable and make sure that people who can't do get tenure, we come up with fluffy ordinal things like the 0-10 pain scale (sorry, you can't have a twelve, because ten is unconscious) or the nebulously nominal Prochaska Transtheoretical Model of Stages of Change, ranging from Pre-Contemplation ("I haven't thought of that yet") to Termination ("Been there, done that, got the tee-shirt"). We've explored other examples in this blog as well, most recently "Merrily We Troll Along," January 1, 2015.

Which leads me to the latest effort in qualifying a patient care parameter. One of the core tenets of emergency medicine is preservation of the patient's airway. In cardiac arrests, for instance,you can do all kinds of nifty tricks with drugs and electricity, but if the patient's airway is compromised...meaning they can't move air in and out of the lungs...the game is up before you even start to play. So making sure a patient, especially an unconscious or lethargic one, is going to be able to keep their airway open is key. The easiest way to to do this is the cheek the gag reflex. If that's intact, the airway is probably okay (at least for the moment), and you can turn your attention to questions of oxygen exchange within the lungs themselves rather than worrying if the oxygen can even get that far. An intact gag reflex also means that if patient vomits up gastric contents (a clinical way of saying Spaghetti-O's and Jello Pudding), this gastrointestinal smorgasbord will not get sucked back into the lungs.

You check the gag reflex by use of a tongue blade (popsicle stick), gently inserted into the patient's mouth until you touch the back of the throat to elicit the response. The tongue blade is gently inserted unless the patient fights you every step of the way, in which case you may, use as Mr. Scott might say in coaxing another warp out of his dilithium, use "a wee bit more" force. In any event, if they gag on the tongue blade the airway is, at least for the moment secure and you can move on to address other concerns. If they don't, the airway is at high risk and it's probably best to insert a plastic tube through the moth into the lungs to make sure the airway stays open. If they bite the stick in half, they have rabies. Call Animal Control. They will watch the patient for ten days, and if he or she doesn't get better they will cut off the head and check the brain.

A few weeks ago, one of our regulars showed up. He's very poorly responsive, and is enveloped with a particularly pungent aroma of two carbon fragments about his person (the ethanol molecule...the one in "drinking alcohol" has two carbon atoms, one oxygen atom, and six hydrogen atoms. C2H6O, if you're keeping score). First on the agenda is airway security.

I suppose it's true that in every profession, certain people are known for specific skills. I'm most known for being able to do procedures in "old school" ways. One of my colleagues has developed a specific test for feigned unconsciousness that involves forceful compression of the testes. (The patient's, not hers.) In this case, the nurse assigned to the patient had a particular expertise in assessing gag reflexes. (For no particular reason, we'll call her "Deaton.") So when assessing the gag reflex produced only a half-heated response, our nurse (whom we'll call again, for no particular reason, "Deaton,") shook her head with a discouraging "I don't like this. It's not very good," we knew we should be concerned.

Well, not very good is also not very scientific. Science requires way to measure and record data. It also requires that you can name something after someone. So, in that spirit of scientific entrepreneurship, we present to you something called (for no particular reason) the Deaton Gag Scale:

Deaton Zero. No gag reflex. Patient buys the tube. I bill for at least a half hour of critical care and a procedure.  Yippee!

Deaton One. Not aesthetically pleasing. "I don't like that. Let's try it again. Use a bigger stick. Push harder."

Deaton Two. Acceptable. "I make that noise when I think of my ex."

Deaton Three. Dramatic. "Ack ack ack ack ack! No! What the f...k!"

Deaton Four. Enthusiastic "Oh, yeah. C'mon. Uh huh. Uh huh."

Interestingly, in field testing this scale others have mentioned that this scheme could also be used in a social setting, and that the "little black books" men are reported to carry might consider adding a Deaton Score to the traditional system of stars. Of course, because I am a Paragon of Puritan Virtue, I have no idea what they mean. And because I adore The Dental Empress, I'm going to keep it that way.

(Afterthought: As I was reviewing this prior to posting, I was reminded of a patient during my residency, who, when having a urinary catheter placed into the bladder through his...ummm...member, proclaimed "Oh BABY! Oh BABY! Oh BABY!" In a most enthusiastic tone. Which makes me think the Deaton Score can also be applied to the response to urinary catheterization. Though to distinguish it from the first score, it needs a distinct name. How about the Wang Response?)