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?)