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?)

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