How to Lose $4.00

A 21 year old woman came into the ER complaining of intermittent crampy abdominal pain for the past two months. She decided to come to the ED today because she felt like her stomach was getting bigger and she just couldn’t take it anymore.

“Tell you what,” I said to the nurse who had just given me the chart. “I’ll bet you a buck that when it’s all said and done she’s pregnant.” She agreed to the wager and I went into the room to see the patient.

It turned out that she had delivered a child three months ago, but still hadn’t had a resumption of her menstrual periods. Nor did she know when her last one was before she got pregnant. She had been vomiting daily, and had been having unprotected sex. But hse maintained that there was "no way" she could be pregnant. As one of the Cardinal Rules of the ED is that anyone who says they can’t be pregnant is until proven otherwise, I told the nurse I’d double or nothing the bet to a $2.00 total .

The nurse then went in to talk with the patient she learned that the patient had been having unprotected sex, but only with a woman partner. She said she had never had sex with a man, and when the nurse indicated that she must have had some sort of momentary relations in order to account for the three month old child in her arms, she said, “the stork brought him, just like Jesus.”

I try to be respectful of others religious beliefs, but as far as I could tell, this did not appear to be a potentially Messianic scenario. I understand that Jesus came from humble beginnings, but one would think that if three kings had dropped into the middle of Daytona Beach on a warm September night, someone might have noticed.

(To be honest, though, I suspect we all think we’re the products of an Immaculate Conception. The thought of our parents actually engaging in carnal actions is really far too much to bear.)

Armed with this bit of knowledge, my level of certainty grew by leaps and bounds. I proposed another double or nothing bet, which was quickly accepted. And when the labs came back, the pregnancy test was negative, and what was really going on was an intermittent bowel obstruction related to intestinal scarring from a childhood abdominal surgery.

So I now owe the nurse $4.00, which will actually be six or seven once my debt is redeemed for some sort of fruity alcohol-based drink with an umbrella sticking through a slice of tangy citrus. I’m sure there’s some sort of lesson here about trusting the patient, not underestimating their veracity, the need to do a complete workup to exclude emergency conditions, or even about the untapped potential inherent within every child, Messianic or not. But I will tell you that I’d make that wager again any day. And next time I bet I’ll be right.

Emergency Haiku

Worked a shift in the Fast Track area of the ED last week, and started to write up a few anecdotes. However, it quickly became apparent that what showed up on the page was, to be frank, duller than the Annual Meeting of the American Association of Less Personable Accountants. So what could I do to make it better and save typing at the same time, while reinforcing my commitment to cultural diversity? Why, it’s haiku! So I hope you enjoy the following assortment of ED verses...

You have bad back pain
But you have OD’d before.
No Lortab for you!

There are two big boils
In quite sensitive places.
Please, try to hold still.

You face was broken
Last month; last night you hit it on
The open door. Look out!

There is no detox
At our hospital. Go now.
Do not imbibe again.

Sore throat and fever.
Tonsils bright red; take this pill
And feel much better.

Drinking and puking.
Potassium far too low.
You’ll be admitted.

Your own doctor sent you
For an MRI. You might
Have just told me that.

Neighbor’s dog jumped up.
Greeting gone wrong; you fell down.
Scrapes on knee and hand.

Swollen right foot is
Likely arthritis. It helps
If you can speak English.

Fell in the garage.
Knee swells up and hurts badly.
But it’s only a big bruise.

No sex this month; but
You had STD before.
Now it’s PID.

Runny nose and cough.
No help with Nyquil last night.
I can help you out.

Swollen up leg can be
An infection; maybe soap
and water would help.

Antibiotics
Are good for what ails you.
But you have no veins!

Scars on his chest and
Shoulders from war. Happy
To care for his ills.

Felt weak, ate an orange.
Now well. Could your sugar have
Been far too low then?

The Blood of God is
In your veins. But which of us
Wears leather restraints?

I heartily invite your contributions!

Great ED Video!

This video was making the rounds in the ED the last few days..and actually links in with yesterday's blog! Wish I knew how to make these...very funny. Enjoy!

http://www.youtube.com/watch?v=_m64cy1MMPg

Tongue Twisiting

Every profession has its own secret code known only to acolytes, and medicine is no exception. Medical terminology seems complex, but it’s actually pretty easy one you know the scheme. The key is to recognize that most medical words come from a specific set of Greek or Latin roots, and that virtually everything is a combination thereof. So to describe just about anything, once you know the code all you have to do is mix and match the hundred or so roots to come up with what you want. So if you want to describe a blue extremity, you combine the root for extremity, “acro,” with the root for blue, which is “cyan”, to come up with acrocyanosis. If you want to talk about an enlarged extremity, you use “acro” again, but now combine it with the root “megaly,” meaning enlarged, to come up with acromegaly. The root “path” pertains to disease; a pathologist is someone who studies disease, and idiopathic means you’ve got a disease but it beats me why. It’s this flexibility that gives rise to medical puns such as dyspareunia (“dys” meaning bad, “pareunia” meaning biblical knowledge of another) is better than no pareunia at all. We can also use it to describe invented non-clinical conditions, such as hypocyanocrutiatism (“hypo” meaning low, “cyan” meaning blue, and “crutio” meaning cross…translated as “low Blue Cross”), and ainsuria (“an” meaning without, “insuria” meaning…well, insurance. I so totally made that one up).

You can also use this flexibility to play with medical students. One of the joys of the teaching of medicine, in which I was engaged for six years after residency until I rejoined the real world, is the opportunity to amuse yourself with the ignorance (of those who think they actually know something) and gullibility (for those who know nothing) of the children.

It’s especially fun with the former group. There was a particularly obnoxious student at the University of Florida, the kind who walks around with an AMA pin in his lab coat and a license plate that said “MD 2 B” and who thought he could date the ED attending’s ex-girlfriend. He was truly getting on everyone’s nerves, so the senior resident and I conspired together and formed a plan.

One day when the student was on duty, we called him over to the X-ray room to look at a chest X-ray that both the resident and I had verified was completely normal. We asked his opinion, and he said it looked fine to him as well. Then the resident pointed at the upper left part of the film. “Hey, up in the corner. Isn’t that a sign of hypocyancrutiatism?”

I peered closely at the lighted screen. “Yeah, I think so. Nice pickup.” I turned to the student. “Ever heard of that?”

You could see his mind start to work. Sometimes it’s just too easy, like shooting fish in a barrel or vegans in California.

“Yes, I did. I read an article about it. Some of the symptoms are…”

The resident lasted about 23 seconds before bursting out in hysterics, and I didn’t last but a few moments more. We told him we had made it all up, that there was no such disease, and that he should probably review his essential references (medical school-speak for “you’re a moron”) before commenting in our presence ever again. He was quiet for the rest of the month.

(This is one of the students who passed the ED rotation only because we were sure he was never actually going to do emergency medicine and those who failed had to do another month.)

Another trick you can do with medical students and terminology is to take recognized medical eponym and turn them on their heads. For example, there is something called a “Chandelier Sign.” It’s actually a pun on a clinical finding…when you do a pelvic examination on a patient with a pelvic infection and you move the cervix, the pain is so bad they want to leap towards the ceiling and grab the chandelier. That’s not, of course, what you tell the student. What they hear is:

“You know, it’s an interesting story behind this eponym. Most people think it’s something made up. But in early 19th century France, there was a pioneer gynecologist named Jean-Marie Chandelier (it’s critical to say “shaaan-deee-leee-ay” to make it sound real). He was the one who first discovered the pathologic correlate between tenderness of the cervix on exam and pelvic inflammatory disease. He was actually a first cousin to one of the leading families in the French glass-blowing industry, the family that first produced the lighting fixture we call in English the Chandelier (pronounced shan-dee-leer to emphasize your erudition).”

That being said, sometime the eponyms are funny enough without needing to make up more material. When you examine a patient’s eyes, among the things you look for is responsiveness (if the pupil contracts when exposed to bright light) and accommodation, which is normal when light shown to one causes the opposite pupil to contract as well. So the Argyll-Robertson Pupil, a sign of tertiary syphilis, is known as the Prostitute’s Pupil because it’s accommodating, but not very reactive.

One last language trick is to ask the students if they really mean what they say. One of my favorites in this category is the use of the term “appreciated.” For some reason, we are taught in medical school to “appreciate” heart murmurs and other clinical findings, as in “There was a 4/6 murmur appreciated over the lower left sternal border.” But I always ask if they just heard something, or really appreciate it? Did they gasp in astonishment? Did they call their parents to let them know? Did they send a singing telegram to the relationship de jour? And speaking of singing, we’ve also learned to describe lung sounds as “musical” in terms of pitch. (Pitch and tone are important clinical indicators. This was first noted by the French composer Louis-Nicolas Clerambault, a close friend of Rene Laennec, inventor of the stethoscope. On rounds with his friend one day at the Hotel Dieu, he is reported to have heard breath sounds and was inspired to write his very popular “Symphony for Harpsichord and Sputum in D.”) But we could go so much farther. What key are they in? G flat or A major? Does it have a beat? Can you dance to it? Best in the east, give it at least, a 75?

(For more information on the linguistic joys of the teaching life, I would also refer you to a classic 1989 JAMA article entitled, “The Art of Pimping,” by Frederick Brancati. A copy of this work can be found at http://www.neonatology.org/pearls/pimping.html.)

However, every now and then the playful use of use of medical terminology can take an alarming turn towards political correctness. The latest example is the term “psychogenic non-epileptic status epilepticus,” or PNESE, which I saw for the first time in the November 2009 issue of Critical Decisions in Emergency Medicine. Breaking this down to root words, it means a continual seizure state that is not related to seizures but has its origin in the psyche and not in the wiring of the brain. (The fact that it’s a non-seizure seizure means it’s not a seizure, right?) It turns out that, when you read the actual clinical description of the PNESE, it’s what we used to call a “pseudoseizure,” or “faking.”

As best I can tell, the change in terminology came about because the term pseudoseizure implies that the person is doing it on purpose, while the PNESE suggests that the event may not be intentional, but a result of unconscious forces driving a “somatization” disorder, where psychiatric illnesses are manifested as physical symptoms. (See “fibromyalgia.”) But the fact is that the PNESE is still not a seizure. I know this not just from analysis of the word roots, but also because I asked a neurosurgeon if he knew what a PNESE was. He said no, and so I read him the description. “That’s a (homophone for clucking) psueodseizure,” he said. “What kind of idiot needing tenure thought that one up?”

Umm, probably the same ones who spent six years in academics getting promoted and tenured before joining the real world…

Shared Interests

While it’s probably true that opposites attract (see “first marriage”), it’s also important that people in relationships share some basic interests, views, and values. That’s why I’m pleased to tell you the following story of two people who are truly meant for each other. Let the chant of the cherubs begin:

Dennis Krimmons arrived in the ED on a Pleasant Valley Sunday, girlfriend in tow, complaining of swelling in his left leg. This was especially important as it was his only leg, having lost the lower half of the right one as a result of complications from a motor vehicle accident (MVA). He said the swelling had started four days ago after he was helping out in the yard and got scratched on his leg by some branches from a rose bush. Shortly afterwards, a friend had managed to run a chair over his foot, and later that day, in a trifecta of minor trauma, he managed to tip over a curb and hurt his foot yet a third time. On exam, he had some small scratches over the inside of his ankle, and lots of swelling in the foot and ankle as well. He complained bitterly of pain when I ran my hands over his foot. The foot, while swollen, was not red or hot like there was an infection; it did not go along with any calf pain or swelling like you might find with a blood clot; and there was no specific site of bruising or bony pain as is typical of a fracture. In addition, Dennis had a hard time staying awake while I was talking to him. He was noted to be taking multiple pain medications, including Oxycontin and Valium, for neck and back problems, and had the kind of thick, slurred speech that goes along with enjoying your prescription medications to excess, thank you very much. Fortunately, he assured me that he was just really very tired, having not been able to sleep the night before due to his intense leg pain.

(Incidentally, in another bow to political correctness and legal avarice, the MVA is now more properly called the MVC, or motor vehicle crash. This is because there are no such things as accidents, as every event has both a cause and a fault.)

I suggested to him that the plan of action would include an x-ray of the left foot and ankle to make sure that nothing was broken and causing the swelling, and if that looked good we would get an ultrasound study of the leg to make sure there was no blood clot causing a problem. I explained to him that his findings were pretty non-specific, but since he was having intense pain and it was the only leg he had left it made sense to spread the net widely. Unfortunately, Dennis thought that was a bad idea. He was pretty sure it wasn’t broken, and was worried about the cost of the x-ray. (For the record, his payer status was “Charity Care,” meaning that he wasn’t going to pay for the radiograph, but that I and other residents of our hospital taxing district would.) He then proceeded to demonstrate to me that his foot and ankle wasn’t broken by removing his prosthesis on the right and hopping about the room on his one remaining foot, calling out, “If it was broken, I couldn’t do this now, right?”

He did agree to the ultrasound (a more costly test, which should have raised a red flag but didn’t). This was negative, and I reassured him that nothing serious seemed to be going on, and since he was already on good pain medications at home and there was no sign of infection I couldn’t tell him exactly what was going on, but it didn’t seem to be an emergency and he could follow-up with his own physician.

I was preparing his discharge paperwork when the nurse told me that his girlfriend had disclosed to her that the real reason Dennis had lost his leg was because he was crushing tablets of Oxycontin (a narcotic pain reliever) and injecting himself under his skin. She also suspected he was going to inject himself here in the ED since we gave him no additional pain medication. She also told us that if he knew she had told us, he was likely to beat her when they got home.

The nurses did the absolute right thing. One nurse got her away from him and into a separate room in the ED so they could talk to her about domestic violence services and the need to stay somewhere safe. Meanwhile, another nurse tracked down the patient to find he had locked himself in the bathroom for twenty minutes and would not answer the door. Security got the door open, to find the patient standing at the washbasin. I peered in.

“You doin’ okay?”

“Man, I’m taking a (euphemism for movement). What’s your problem?”

“When someone spends that much time in the bathroom, we worry that they might of fallen or something. It happens, you know.”

“I’m fine. I need a laxative.” (This is probably true, as constipation is a common side effect of narcotic use.)

It was then that I noticed two small drops of fresh, wet blood staining the outside of his jeans over his thigh. I pointed them out to Dennis.

“What’s going on there?”

“Where?”

“The spots of blood on your pants.”

He looked down. “They’ve been there.”

“Tell you what. Appease me. Let’s check it out and make sure you’re okay.”

He drew himself up. “I refuse your care, (euphemism for an Oedipal event),” he proclaimed. He strapped on his other leg and clip-clopped rapidly from the ED.

Meanwhile, the Charge Nurse was taking special pains with the girlfriend to try to arrange a safe environment for her. But when she learned that Dennis had flown the coop, she couldn’t leave fast enough to be with her man.



************************************

This is how the story stood for the next hour and a half. We finished our paperwork (one of the paradoxes of modern medicine is that it takes longer to do the paperwork on a patient who is unpleasant, unruly, threatening, or drug-seeking than it does on someone with a cardiac arrest…one is more likely to complain to administration.) Life in the ED moved on…a kid with strep throat here, an older person with VD (“Veak and Dizzy”) there. The radio sputtered to life with reports of an overdose patient being brought in. She had been found asleep in a taxicab near the beach just south of the hospital.

The patient looked familiar when she was brought in…more disheveled, speech slurred, makeup smudged. No obvious signs of trauma. But it was undeniably Dennis’ girlfriend, and she brightened up when she saw us. (Nothing like being among friends.) The reunion lasted but a few moments before she went back to sleep, which is how she stayed while we drew blood, passed a catheter into her bladder, and put a tube down her nose into her stomach so we could give her a whopping dose of charcoal…crushed up Kingsford briquettes, albeit without the impregnated lighter fluid…to try to absorb whatever was in her system.

And what was in there? Yep, you’re way ahead of me. Oxycontin and Valium.

Ain’t love grand?

Adult Notes

Two off-color but very funny incidents in the ED today:

Over the last few months I’ve been experimenting with growing a beard. Not a beard, really, but something called “designer stubble.” I’m striving to maintain that semi-hunky five day growth so that I look like I’ve been too busy saving lives to attend to personal grooming and so someone besides the nursing home patient with dementia will mistake me for Dr. McDreamy. (True story.) I’m being very careful to try to keep it short, not only for the McDreamy factor, but because I know that if I let it get much longer I won’t be able to ignore the sensation that there’s probably a piece of a Spaghetti-O left in there someplace. There are now four ED docs in the facial hair derby growing winter beards, which is especially strange when you consider that we are in Florida and today there was a record high for Daytona of 85 degrees.

I’m new at the quest for stubble, so I’ve been asking folks at work what they think of the current effort. The reviews have been mixed, about 50-50 for the clean shaven look or the current scruffy façade. But today one of the unit clerks suggested that I adopt a look which removes the stubble over the cheeks, leaving the hair around the mouth and chin in what is apparently called a “love patch.”

This was a new term to me, but not to anyone else in the ED. What was new for everyone was how easily we were able to transition the term “love patch” into the singular best composition in human history. I am, of course, referring to “Love Shack” by the B-52’s. So it was in tribute that soon we were rolling back and forth in our swivel chairs with the plastic wheels, chanting:

“Love Patch!
Baby Love Patch!
Cuz the Love Patch is a little ol’ place where we can
Get To-geth-er!”

We’re still working out how to handle, “Tin Roof! Rusted!” but we’re sure something will come to us.

Speaking of music and adult themes, regular readers of The Blog will recall that I’ve noted the tendency of our voice-recognition software system to interpret my pronunciation of the word cardiovascular (pertaining to the heart and blood vessels) as cremaster (pertaining to a muscle layer of the scrotum). I was dictating the results of listening to the heart when the alternate term showed up on-screen. This was noted by one of my esteemed colleagues, who inquired, “What does that sound like, anyway?”

After intense discussion, we decided that each person’s exam probably sings its own tune. In my case, with the spouse currently located 800 miles away and several weeks between conjugal visits, it sounds like a small male chorus singing “Please Release Me….Let Me Go!”

Another Voice from the ER

(Steve Bohannon, a friend and fellow ED doc, sent me this piece the other day. It's a Letter to the Editor from another emergency physician colleague in the Northeast, with his take on emergency care. I really enjoyed it and think he's right on the money...hope you do too. Thanks, Steve!)

Sunday, October 11, 2009

Pittsburgh Post-Gazette

Emergency departments are distilleries that boil complex blends of trauma, stress and emotion down to the essence of immediacy: What needs to be done, right now, to fix the problem. Working the past 20 years in such environments has shown me with great clarity what is wrong (and right) with our nation's medical system.

It's obvious to me that despite all the furor and rancor, what is being debated in Washington currently is not health-care reform. It's only health-care insurance reform. It addresses the undeniably important issues of who is going to pay and how, but completely misses the point of why.

Health care costs too much in our country because we deliver too much health care. We deliver too much because we demand too much. And we demand it for all the wrong reasons. We're turning into a nation of anxious wimps.

I still love my job; very few things are as emotionally rewarding as relieving true pain and suffering, sharing compassionate care and actually saving lives. Illness and injury will always require the best efforts our medical system can provide. But emergency departments nationwide are being overwhelmed by the non-emergent, and doctors in general are asked to treat what doesn't need treatment.

In a single night I had patients come in to our emergency department, most brought by ambulance, for the following complaints: I smoked marijuana and got dizzy; I got stung by a bee and it hurts; I got drunk and have a hangover; I sat out in the sun and got sunburn; I ate Mexican food and threw up; I picked my nose and it bled, but now it stopped; I just had sex and want to know if I'm pregnant.

Since all my colleagues and I have worked our shifts while suffering from worse symptoms than these (well, not the marijuana, I hope), we have understandably lost some of our natural empathy for such patients. When working with a cold, flu or headache, I often feel I am like one of those cute little animal signs in amusement parks that say "you must be taller than me to ride this ride" only mine should read "you must be sicker than me to come to our emergency department." You'd be surprised how many patients wouldn't qualify.

At a time when we have an unprecedented obsession with health (Dr. Oz, "The Doctors," Oprah and a host of daytime talk shows make the smallest issues seem like apocalyptic pandemics) we have substandard national wellness. This is largely because the media focuses on the exotic and the sensational and ignores the mundane.

Our society has warped our perception of true risk. We are taught to fear vaccinations, mold, shark attacks, airplanes and breast implants when we really should worry about smoking, drug abuse, obesity, cars and basic hygiene. If you go by pharmaceutical advertisement budgets, our most critical health needs are to have sex and fall asleep.

Somehow we have developed an expectation that our health should always be perfect, and if it isn't, there should be a pill to fix it. With every ache and sniffle we run to the doctor or purchase useless quackery such as the dietary supplement Airborne or homeopathic cures (to the tune of tens of billions of dollars a year). We demand unnecessary diagnostic testing, narcotics for bruises and sprains, antibiotics for our viruses (which do absolutely no good). And due to time constraints on physicians, fear of lawsuits and the pressure to keep patients satisfied, we usually get them.

Yet the great secret of medicine is that almost everything we see will get better (or worse) no matter how we treat it. Usually better.

The human body is exquisitely talented at healing. If bodies didn't heal by themselves, we'd be up the creek. Even in an intensive care unit, with our most advanced techniques applied, all we're really doing is optimizing the conditions under which natural healing can occur. We give oxygen and fluids in the right proportions, raise or lower the blood pressure as needed and allow the natural healing mechanisms time to do their work. It's as if you could put your car in the service garage, make sure you give it plenty of gas, oil and brake fluid and that transmission should fix itself in no time.

The bottom line is that most conditions are self-limited. This doesn't mesh well with our immediate-gratification, instant-action society. But usually that bronchitis or back ache or poison ivy or stomach flu just needs time to get better. Take two aspirin and call me in the morning wasn't your doctor being lazy in the middle of the night; it was sound medical practice. As a wise pediatrician colleague of mine once told me, "Our best medicines are Tincture of Time and Elixir of Neglect." Taking drugs for things that go away on their own is rarely helpful and often harmful.

We've become a nation of hypochondriacs. Every sneeze is swine flu, every headache a tumor. And at great expense, we deliver fantastically prompt, thorough and largely unnecessary care.

There is tremendous financial pressure on physicians to keep patients happy. But unlike business, in medicine the customer isn't always right. Sometimes a doctor needs to show tough love and deny patients the quick fix.

A good physician needs to have the guts to stand up to people and tell them that their baby gets ear infections because they smoke cigarettes. That it's time to admit they are alcoholics. That they need to suck it up and deal with discomfort because narcotics will just make everything worse. That what's really wrong with them is that they are just too damned fat. Unfortunately, this type of advice rarely leads to high patient satisfaction scores.

Modern medicine is a blessing which improves all our lives. But until we start educating the general populace about what really affects health and what a doctor is capable (and more importantly, incapable) of fixing, we will continue to waste a large portion of our health-care dollar on treatments which just don't make any difference.

Michael Werdmann, MD
Chair, Dept. of Emergency Medicine
Bridgeport Hospital
Bridgeport, CT 06610