Reader Contest!

As much as I simply like to write, I increasingly recognize writing as work. That impression is reinforced by writing exercises I’ve done from time to time. The way these exercises work is that you’re given a scenario and told to write something about the characters motivation, to develop a back story, or move the episode to an unexpected conclusion. It’s a lot tougher than I ever thought it would be.

But as misery loves company, here is today’s writing exercise, based on real life:

At 7 AM on a Saturday morning a physician walks into an Emergency Department. As he turns the corner to head towards his workplace, he sees a tall, sultry, dark-haired female nurse carrying a full plastic urinal in each hand and a younger, taller, and beefier male tech with his hands full of leather restraints walking side by side.

I need a minimum of 500 words. Best answers posted on The Blog. Begin.

Consult Note

Here’s the latest from the Department of Inappropriate Use of Psychiatric Services:

Ms. Parsons is an extremely nice elderly lady with a history of heart disease and mild dementia. She was brought to us early this morning from the nursing home for agitated behavior. The nursing home transfer sheet said she had assaulted her roommate and “needs evaluation for altered mental status.”

Here’s what actually happened. There was another resident of the nursing home who simply couldn’t keep quiet. She would be talking at all hours of the day and night, her screeching often littered with profanities. She had already been moved out of two rooms, and was finally placed with Ms. Parsons because every night she took a sleeping pill, and it was through that she could doze through the verbal hijinks in a pharmacologic-induced haze.

Problem is, it didn’t work. The new roommate’s voice broke through her serene slumber, and she couldn’t get back to sleep. After three hours of this, something inside her snapped. By her own admission, she got out of bed, grabbed the new roommate by the shoulders, and started screaming, “I told you to shut up or I’d slap the (excrement) out of you!”

No need to see psych on that one…

More Vocal Software Follies

Some months ago I wrote about our new voice recognition software system for dictating medical records. Here’s a few more ways the system has been mistranslating my colleagues and I…or maybe the system knows something closer to the truth?

What the doctor said:

“The patient is subsequently discharged from the Emergency Department.”’

What it heard:

“The patient was sexually discharged from the Emergency Department.

(For the record, it’s usually the other way around. The patients may come in with one, but hopefully they don’t pick one up while here. That being said, there’s been an awful lot of canoodling in the exam rooms lately, and if the patient restrooms are large enough for wheelchair access…)

What the doctor said:

“The patient will be admitted by the Volusia hospitalist.”

(Volusia is the name of our local county, and the name of one of our hospital-based medical groups.)

What it heard:

“The patient will be admitted by the delusional hospitalist.”

(Which may or not be a true statement. He’s a new guy in town. We’ll see.)

What the doctor said:

“There are no factors noted that increase or decrease his symptoms.

What it heard:

“There are no fractures that increase or decrease any symptoms…

(I would think a fracture would influence something, wouldn’t you?)

What the doctor said:

“I evaluated the patient…”

What it heard:

“I violated the patient…”

(Again, depending on the doctor, one never knows.)

I was telling my charming and esteemed peer Dr. Tara Wilson about these miscues, and she came up with another brilliant concept. (Tara is especially esteemed because she is one of those rare physicians who will actually say “The patient is exhibiting drug-seeking behavior” on the medical record rather than push the patient off on someone else. Brilliant.) She wondered what would happen if we changed the tone of our speech to reflect the medical word being said? Maybe male physicians should raise their voices to a falsetto when we say the word “vascectomy,” or female docs ought to drop into a deep bass when they say “hysterectomy.”

That’s an experiment for next shift. Medicine is a science, after all.

(Author’s Note: I’m writing this as I sit in the communal grill area in the complex where I live. At the table in front of me is a group of college students celebrating a birthday by smoking cigars. Before they lit up, the birthday boy asked me, “Do you mind if we smoke? “It’s cool with me,” I said, “but just make sure it’s something that won’t show up on my drug screen at work.” And suddenly it was a different box of cigars being passed ‘round.)

Medical Cliff Notes

Like most restrooms in North America, the one in the ED physician’s locker room occasionally features reading material. Most often, it’s whatever pop culture magazine was left over from the week before. I’ll plead guilty to the occasional read. This is why I know there’s someone out there named Heidi Montag who has had 13 plastic surgeries and is still not happy with her 36 DD breasts.

Given that I’ve been spending a fair amount of time in the restroom retching lately (the HIV exposure prophylaxis meds…see the earlier post, “A Really Bad Day”), I’m pretty used to seeing the bevy of pronoun magazines (“Us, We,” etc). So I was genuinely surprised on Monday night when I found the June 19, 2009 copy of the Journal of the American Medical Association (JAMA) perched on the lid of the trash can abutting the throne. As I had a bit of time between spasms (you know those three minutes after one episode when you know it’s going to happen again so it’s foolish to leave…of course you do), I leafed through the magazine as was floored to find a review of a book about Emergency Psychiatry that ran 530 pages.

For the life of me, I can’t figure out why a book on emergency psychiatry would have over 350 pages. I think you could get it all into a pamphlet in a fairly large font. I think this is because all I ever really needed to learn about ED psychiatry was taught to me by Ted, a rotund, Louie Anderson look-alike social worker in Maine more than a dozen years ago. Here's all I really needed to know:

If the patient tells you their story and you’re confused, they’re schizophrenic.
If the patient tells you their story and you’re depressed, they’re depressed.
If the patient tells you their story and you’re pissed off, they have a personality disorder.
If the patient makes too much noise, give them Haldol until they stop.

I’ve seen thousands of psychiatric patients in the ensuing years, and to this day these lessons are still correct. I’ve also reviewed these rules with some real live board-certified non-psychotic psychiatrists (harder to find than you might imagine), and they also agree that these tenets cover 95% of ED work. Admittedly, they may have had a few drinks on the hospital before I asked them…you’ve got to love staff recruitment dinners. Perhaps I stacked the deck but, as they say, in vino veritas (in wine, truth. This is another rule, but one that applies to all of life, not just medicine. Just like, “The girls all get prettier at closing time.”)

I’ve always liked the idea of being able to simplify medicine into just a few phrases. For example, here’s what I was told long ago constitutes the summed knowledge of four years in dermatology training. (In these rules, “it” refers the rash, or lumps, or bump, or whatever else is showing on the skin and generally looking gross.)

If it’s dry, wet it.
If it’s wet, dry it.
If you don’t know what it is, don’t touch it.
If you know what it is, you don’t have to touch it.
If it’s black or blue, cut it out
Above all, give it steroids before it goes away by itself.

(I learned these rules well over twenty years ago. I’m certain that now there’s probably a seventh rule, which is, “If it sags, give it botox.”)

A five year general surgey residnecy is even easier to summarize :

When in doubt, cut it out.
Nothing ever metastasized from a jar of formaldehyde.

And three years of internal medicine? Easier still.

Health is only the absence of a sufficient number of labs and x-rays.

So how do you sum up three years of training in Emergency Medicine? Well, we’re not established enough as a specialty to have our own catch phrase. So, being the jack of all trades and the master of none, the guys who treat you before we actually know what’s going on (because the disposition…what we need to do to you to keep you alive…comes before an actual diagnosis of your specific problem), we’re best summed up as the punch line to a joke:

An internal medicine physician, a general surgeon, and an ED doc are out duck hunting.

The internist hears what he thinks might a duck, sees what he thinks might be a duck, and consults his Book of Ducks to confirm that there is a high probability of the duck actually being a duck. He then takes a BB gun and shoots the duck, singeing the feathers just enough to bring the duck fluttering gently to the ground. He politely asks his old and trustworthy Irish setter, who has been waiting patiently by his side, to kindly retrieve the duck. The dog goes out into the field, lifts the duck by the uninjured wing, and deposits the duck in the soft grass near the internist’s feet. The internist calms the duck with words of comfort and gets out his Book of Ducks to confirm, in fact, that this really is a duck. He then gently tells the duck that while he may never fly again, he’ll do all he can to make sure he has a good quality of life.

The surgeon hears a duck, sees a duck, whips out his rifle, and delivers a kill shot to the bird while it’s still on the wing. He grabs his pit bull by the collar and goes down on his knees to get in the dog’s face, screaming “GET THE DUCK! GET THE DUCK!” The dog goes out into field and clamps down on the lifeless carcass, blood and feathers flying everywhere. The dog brings the duck back to the surgeon who whips out his field knife to clean and dress the bird, throwing the entrails to the now-ravished dog. He kicks open the cooler, one hand placing the duck on ice to send to the pathologist to see if it really was a duck while pulling out a tall cold one with the other.

The ED doc hears what he thinks might be a duck, sees what he thinks might be a duck, puts on a blindfold, and picks up two sawed-off shotguns. He twirls in a circle and blasts away, shouting, “Did I hit anything? Did I hit anything?” Meanwhile, his cocker spaniel runs around his heels, barking happily at nothing in particular.

Your specialty certification exam will be in three weeks. Study hard.

Secret Codes

The back of the identification badge at the hospital where I work lists different hospital-wide emergency announcements as “codes.” Some of these are familiar, such as Code Blue for a cardiac arrest. (I’m not sure why it’s called a Code Blue, other than presumably when you go into cardiac arrest, your color is your code.) Some codes are intuitive, like Code Red for fires. Others take a bit more imagination, but still make sense. For example, Code Pink is an infant abduction, and pink is a baby-type color.

(Speaking of abductions and other criminal activity, about two months ago there was a robbery at a bank within walking distance of the hospital. There was a rumor that the villian had been wearing medical garb and had run onto hospital property in order to hide. About the same time I’m hearing this, Sean, one of our ED techs, comes whizzing through the back of the ED. Sean is usually a pretty controlled guy, so when he runs it usually means that he was in triage and found a patient who is seriously ill or injured and needed to be seen yesterday. But this time there was no wheelchair holding a body in front of him, so I jumped in front of him in full flight.

“Hey, what’s going on?”

“Man, you heard about the robbery right?”

“Yeah, I did.”

He sidestepped me and kept on moving. “In my neighborhood, they’re always looking for the black man first.”

Oh, and just for the record, Sean and I are also trying to work out some kind of specific race-baiting incident so we can get invited to the White House to have a beer with President Obama and Vice-President Biden. We’re both leaning towards imports.)

Sometimes, however, the folks who designate the codes might want to talk to those of us on the street. Code Brown is used to represent a weather-related emergency. But in the ED, Code Brown is called when a patient unexpectedly releases intestinal contents within the exam room. So if you ever walk into an ED and notice a strong aroma of coffee, you can be sure there’s been a recent Code Brown. That’s because a filter full of moist ground coffee soaks up the smell. We’ll be talking to Heloise about this.

Wordplay

Has anyone else noted that there are only two letters separating the word “toil” and “toilet?”

Does anyone in Mexico note that there is a single letter difference between "casado", or married, and "cansado," which is tired?

Coincidence or hidden truth?

You be the judge.

The Pleasure Palace...Adults Only

I’ve noted before in this blog that the ED is a great place to restore your belief in love. Just when you think you’re terminally single and can never be wanted by anyone, you see couples in the ED that truly prove there’s someone for everyone, regardless of race, religion, ethnicity, dental health, hygiene, or tonnage. Young love is most often on display, either in the form of couples canoodling on the exam bed (especially true when the vomiting party is sharing potato chips with their beloved) or when an unexpected new pregnancy is discovered.

But, as Whitney Houston reminds us, learning to love yourself is the greatest love of all.

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Mr. Conrad was brought in by the ambulance because four days ago he had bent over to pick something up and had hurt his back. His pain was so incapacitating that he had managed to walk to a pay phone in order to call the ambulance. When I went to see him, however, the room was darkened and the privacy curtain pulled; and the expression on his face was not one of pain, but of ecstasy. Using my acute powers of observation and years of clinical training, I quickly deduced that it had something to do with the fact that his pants were unzipped and his hand tucked inside his wasteband, with a rhythmic motion to his right arm not unlike a focal seizure.

“Are you having a seizure?”

Startled, he looked up at me from the bed.

“Huh?”

“A seizure. Are you having a seizure?

“No.”

“Are you sure you’re not having a seizure? I ask because your arm is going back and forth like you might be having a seizure.”

I will hand it to Mr. Cooper; he was a quick thinker. “I’m holding in my hernia.”

That was a good answer, but not one above reproach. While I’ve never had a hernia myself, I’ve seen plenty of them. When someone has a hernia, they may sometimes support their scrotum with their hands, lifting the sac in order to prevent further discomfort (Please, no jokes about not being an athlete, but always being an athletic supporter. Thank you). But usually this is not a particularly rhythmic, or pleasurable, thing to do.

“Well, let’s check that out while we work on your back pain.”

So I did, and found no evidence of a hernia. He said, “I only see it when I sit up.” So I sat him up, and there was still no hernia. “I REALLY see it when I stand up and cough. But I can’t do that because I have back pain.”

Call me inherently suspicious, but I generally believe that if you’re able to walk to the pay phone you can stand up in the ED. So I made him stand up and cough. And still no hernia. He look puzzled.

“Hmm. It’s usually there.”

“I’m sure it will be there again soon,” I reassured him. Because a man has needs, don’t you know.

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

Mr. Cooper reminded one of our nurses of a rotund African-American woman she had cared for last week who had taken similar liberties with her own contentment in the ED. When caught in the act and informed that this was perhaps inappropriate behavior for the health care setting, she said, “This is an EMERGENCY Room, and I’m gonna take care of my EMERGENCY.” She then proceeded to the restroom to relieve her emergency condition. At least it was assumed that she did, if the noises that were heard coming from the water closet by the nurse…and the rest of the ED…were any kind of reliable indication.

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

About a year ago, the police brought us an intoxicated man who had been found in the public forum. His care was pretty routine…exam, blood tests, an intravenous alcohol “rally pack”… until one of the nurses came to me and ask me to make him cease his onanistic practices in the exam room.

Having reached deep into my soul for any latent Puritanism, I adopted the sternest visage possible when dealing with a scenario with the possibilty of reducing this seasoned professional to a giggling eight-year-old, and entered the room. There he was, eyes open, looking right at me, and continuing to raise his own personal flag in a most diligent, dedicated, and patriotic fashion.

“You know, you’ve really got to stop that. Makes the nurses nervous.”

He looked up at smiled, a broad grin highlighting his remaining teeth. He continued to hoist his banner.

“No, really, I’m serious. It’s inappropriate, and that kind of behavior will get you thrown out of here. Sleeping in the street isn’t worth getting off, right?”

”Hmm-hmmm.” Too deep into his patriotism to hear me.

I left the room, shaking my head. There is only so much you can do as a physician. You can provide the best counsel ever, but it’s up to the patient to act on your good advice. And clearly this man was getting a second, five-inch opinion.

“Did you get him to stop?’ asked the nurse.

I shook my head. “Nope, he’s still at it. But,” I added in a moment of reflection, “I’m not sure if I should be upset that my authority meant nothing, or feel proud that I’m such a sexy guy that he sped up when I was there.”

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

I mentioned breaking down like an eight-year old when presented with funny conditions just below the beltline. No matter how much you’ve been in this business, that feeling never goes away. This is why I’m not a urologist, even though they do lots of cool procedures and I’ve always like the phrase “Urologist is my ologist.” Two examples of this phenomena:

Two days ago I got a call from a colleague at another hospital who needed to transfer a patient to our facility. The patient needed to see a colon and rectal surgeon for rectal bleeding. He had rectal bleeding because he was out turkey hunting that morning and needed to move his bowels. When he lowered his trousers to squat, a sharp stick had reportedly penetrated his rectal area. The stick was not there when the patient arrived, of course, but the bleeding was quite severe and the patient genuinely needed specialty care.

I’m taking this report on the phone and being very professional about the whole thing. But after five minutes of “Hmmmm,” and “Yes, I see,” and “Oh, my,” I was about to lose it. All kinds of visions were running through my head; besides I knew that when I was in Boy Scouts, I always looked at where I was putting my nethers in the forest. So I finally said to the doc on the phone “Hey, are you having as much trouble keeping a straight face right about now as I am?”

There was a small chortle, and then a full-fleged laugh.

“It’s been a tough hour of not smiling over here. A really tough hour.”

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

The second patient came in with a fractured penis.

(You’re laughing already, and I haven’t even started the story. Let’s try again.)

The second patient came in with a fractured penis. A bit of anatomy here. Although men do get boners, there is actually no bone in the penis. There is a bone in the penis of certain reptiles, which may give rise to the term “Lounge Lizards,” but not in human beings. What causes the penis to rise to attention, besides the attention of a desirable partner (or with enough beer, any partner) is that along the top of the penis there are two cavities called the corpus cavernosa that fill with blood when stimulated. When engorged, the cavities become rigid, and that’s what really causes the male member to demonstrate it’s intent. These rigid chambers have the consistency of Styrofoam; and as anyone who’s dropped a full cooler knows, given enough force of impact Styrofoam will break.

Personally, I think that there are noble and ignoble ways to suffer this kind of injury. The noble way is to be working the hospitality suite at a nymphomanic convention. An ignoble way is to do what this gentleman did, which was to take a rigid plastic penis enlargement pump (see “Austin Powers: International Man of Mystery”), wedge it between two of the cushions on your couch, and simulate a stress-relieving interaction. As you might guess, rigid plastic doesn’t respond particularly well to affection. One wrong move, and the corpus cavernosa go snap.

So this guy has a fractured penis. What you see clinically is a huge bruise and swelling on one side of the penis with the tip pointing at a 90 degree angle in the other direction. There is a small amount of blood coming from the tip of the organ. The real problem with these injuries is not only related to sexual function, but also a possible tear of the urethra, the thin tube that carries urine from the bladder to the external world.

What you need to do to evaluate these injuries is get a retrograde urethrogram, in which you inject a small amount of dye into the tip of the penis and take an X-ray film to make sure the dye stays within the urethra and does not leak out into the surrounding tissues. This is not a routine procedure, so I called the radiologist to make the arrangements. I told him the story. His response was “Really? Can I come see?”

Well, of course he could. It only makes sense for a physician to be able to completely evaluate the patient. So he came down to the ED. He saw the patient, and then motioned me around a corner.

“He was banging a penis pump?”

“Yeah, I think so.”

He looked at me. I looked at him. And we both reverted to eight-year olds, and we both began to snicker.

The urethrogram was negative, but there was still the issue of the fracture. These injuries often need surgery in order to restore normal “position and function,” as it were. So we called the urologist, who came to the ED, saw the patient, motioned the radiologist and myself around a corner, and all three of us began to snicker.


About two months later I was in the Doctor’s Lounge grabbing a soda. The radiologist and I had already been chatting about nothing in particular when the urologist walked in.

“Hey, whatever happened to that guy…you know who I mean.”

He did know. It turns out that the patient had refused surgery despite being told that without operation, his penis would probably heal with a 90 degree bend in it. Useful if you want to pee around corners, but not too good for romance.

The radiologist’s eyes got wide. “Really?”

And all three of us began to snicker.