Reader Contest Winner!

(A few weeks ago, I proposed a writing contest for readers of this blog. I set up a scenario as follows:

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.

There have been several replies, but none quite like the one I’m about to publish. It’s from a reader who will intentionally remain nameless, because if I did name him I’m certain the authorities would be at his door within minutes to pick him up. In fact, I’m not so sure I wouldn’t call them myself. It’s certainly going to make me much more careful about passing out after drinking at his house.

Here you go. Stephen King, beware!)

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. In the distance two security officers could be seen running down a corridor in pursuit of what at first glance was a patient in an open backed gown. Seconds later the fire alarm started wailing and water poured from the ceiling spouts.

The physician ran to the front desk while patients and staff flooded past fighting their way out. He shouted to the receptionist. “What the hell is going on?” He saw the fear in her eyes as she stood paralyzed unable to speak. Slowly she pointed to the other side of the waiting room. The doctor looked around and saw a large drooling wolfhound snarling in his direction. Panic filled the air as he slowly backed away towards the door of the ED. The waiting room had emptied. He slipped on the wet floor and as he scrambled to his feet, the dog grabbed him by the right leg, sinking its teeth down to the bone. Shots rang out and the dog fell to the floor. The doctor tried to stand, but his leg buckled beneath him as he dragged himself away from the dying dog.

He looked up and saw one of the Security Officers put his gun back into his holster as he walked towards him. “I thought you were a goner, Doc,” he said. The physician didn’t recognize him, and asked if he was new. “Filling in, Doc. Let me help you.”

The Officer led him to a cubicle where, to his horror, he saw a second officer holding another physician and several nurses at gunpoint. “What the…” he began to exclaim as he was helped to a stretcher where his colleagues tried to help stop the bleeding from his leg.

“Ok, who has access to the narcotics?” said the short security guy. “Tell me, or I’ll blow his head off”. The doctor realized he was the potential victim, and said, “Give then anything they want.” Suddenly the taller officer, who had been standing next to a curtain, let out a shriek and fell over with a knife handle sticking out of his back. Pandemonium broke out as nurses screamed and the shorter security guy ran from the cubicle looking for the knifer. The doctor was helped out of the cubicle and hopped into the corridor. An old homeless man wearing a ragged combat jacket was cradling the head of the large dog, and the security guy had his gun trained at him. Shouting at the man., the guard screamed, “YOU KILLED FREDDIE!”

Out of nowhere a gurney crashed into the security guard, his gun tumbling from his hand. The ED doc looked round and saw the gowned patient from earlier – a known schizophrenic – staring wide eyed at the security officer. Seconds later the SWAT team came crashing through the main door of the ED. Not knowing who was who, they ordered everyone face down on the ground and hog tied them with plastic cables. The doctor pleaded his innocence, demanding to be released. Unable to move, he remained immobilized, and lay exhausted on the floor, slowly bleeding from his leg and losing consciousness.

At 6 AM the ED physician was awaked from a deep sleep and a disturbing dream. He looked over at his partner as reached over to wake her when he saw that his hand was covered with blood………………

Friday Night Notes

A few quick thoughts from the wee small hours of Memorial Day weekend...

We’ve come up with two new lab tests for ED use:

The serum acorn level is used to assess patients who are nuts.

The serum conjugate acorn level is used to assess those who are f…..g nuts.

And two new clinical signs:

Chester’s Sign: If you’re eating a bag of Cheetos, your nausea and vomiting can’t be that bad.

The Burgos Summer Sign (named for the pediatrician who taught it to me): If a child’s headaches, stomach pains, or other vague non-diagnosable symptoms improve during the summer, they hate going to school.

Please send royalties. Thank you.

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

Last night we had a quiet moment at work. Silence in the ED is scary thing, because we’re not accustomed to it. So when it gets that way we literally band together, if only to hear the shuffling of feet. Of course, we don’t talk about it, because if we do everything will go downhill immediately.

So during our quiet moment last night, we were introduced to a medical song on You Tube by The Giggles entitled “I’ve Got the Clap.” The lyrics go something like this:

“I’ve got the clap and I’m giving it to you.
I’ve got the clap and I’m giving it to you.
I’ve got the clap and I’m giving it to you.
Who’s got the clap? I do ! I do!"

(Back in the day, we could establish this diagnosis without a word. We would walk out of a patient room, the nurse would ask what was wrong, and we would start to applaud. The nurse would then fetch the penicillin.)

It’s a very cheery tune, and before long Holly the Disco RN and I were clapping to the left and then to the right in time with the song. But sometimes we forget that there’s a clear generation gap, even in medicine. So we probably shouldn’t have been surprised when one of our younger staff members asked, “So what’s that song about? Is it that thing that helps you turn on the lights?”

Ah, for simpler times.

Things I Don't Know

About once a year I do something silly and buy a book on mathematics or physics. This act represents the height of stupid behavior on my part, because I know absolutely nothing about math, which is itself the language of physics. Math was the subject where I got I got C’s and D’s in high school, and I made it through medical school only because our program was top-heavy on biological sciences and didn’t require any college algebra or physics. The last time a math textbook passed through my hands (and generally stayed unopened) was in the 11th grade, when I was compelled to take trigonometry and analytical geometry. I’m convinced I got through that course only because 1) The teacher was also the football coach and the class was geared to the “student-athlete” 2) Pocket calculators had already been invented that did things like sines, cosines, tangents, and logrithims, eliminating the need to understand what they actually were or how to find them, and 3) There was a really big guy...an offensive lineman, as I recall…in the class. He was the only other guy in school named Howard, and his pure size and presumed power insured that nobody in class would distract my learning with appellations of affection such as “Howard the Duck.” (I have no idea whatever happened to him. I’d like to think he because some kind of professional hitman. He’s probably turned out to be a new age sensitivity counselor somewhere in California. Illusions die hard.)

But I keep thinking that a well-rounded person should know something about physics and math, so I keep buying these books. Three days ago I bought “The Physics of Star Trek” by Lawrence Krauss. I did so against my better judgment, but figured as a confirmed TOS fanatic (If you don’t know what I mean, you’re not one), I figured maybe at least I’d have a frame of reference to work with. And I understood Chapter 1, dealing the need for inertial dampers to counteract g-forces. But calculating fuel requirements for the impulse drive? That’s physics and math at the same time. I’m lost. And by the time I hit Chapter 4 dealing with microgravitational fields that warp space-time and allow interstellar travel, it was time to move on to a rerun of Jerry Springer.

For the record, here’s what I actually know about physics:

1) Newton came up with three laws. They are:

Lex I: Corpus omne perseverare in statu suo quiescendi vel movendi uniformiter in directum, nisi quatenus a viribus impressis cogitur statum illum mutare.

Lex II: Mutationem motus proportionalem esse vi motrici impressae, et fieri secundum lineam rectam qua vis illa imprimitur.

Lex III: Actioni contrariam semper et æqualem esse reactionem: sive corporum duorum actiones in se mutuo semper esse æquales et in partes contrarias dirigi.

Isn’t that helpful?

2) No, seriously, these are his three laws:

An object at rest will remain at rest unless acted on by an unbalanced force. An object in motion continues in motion with the same speed unless acted upon by an unbalanced force.

This law explains why after I sit down in my fancy comfy rolling chair at work, I have no desire to leave it for actual patient care. It also explains why, once I kick start the chair, it would roll forever if not slowed by unbalanced forces such as sticky soda residue on the floor and solid objects like walls when I hit them. It further explains everything about government and other avenues of administrative merriment.

Acceleration is produced when a force acts on a mass. The greater the mass of the object being accelerated, the greater the amount of force needed to accelerate the object.

This means that I will go faster down the hallway if Big Teddy and Matt the Brute pushes my roller chair than if Candi the Elfin Nurse does so. It also means that no matter who pushes it, the chair will go faster with me in it than it will with my personal hero, Dr. Gary Morrison, seated within it’s embrace. This is because his fund of knowledge is vast that it adds extra mass to his brain. As do brownies.

For every action there is an equal and opposite reaction.

This is why both Big Teddy and Elfin Candi will recoil just a bit on their heels when they push my chair across the floor. It’s also the rule underlying any intimate relationship. (Okay, maybe take away the “equal” part.)

3) There is something called Bernoulli’s Principal that allows airplanes to fly. It works but it makes no sense. I try not to think about it too much when I’m a heavy pressurized steel canister at 40,000 feet held up by air.

4) In high school physics class you got to shoot dart guns at tin cans and roll Hot Wheels cars down planks. That was fun.

5) I really like the “Gravity” episode of Schoolhouse Rock.

I know a bit more about math, but not much. That was brought home to me when I was first dating The Bride. In a moment of random affection, trying to be romantic and intellectual at the same time (I had already discovered that she was waaaay smarter than me), I said “I love you the square root of negative one.”

“Huh?”

“You know, the square root of negative one. A number that’s impossible to quantify. That’s how much I love you.”

She gave me that quizzical look she reserves for times when I’ve said something exceptionally stupid (as opposed to my routine ignorance)or when Duchess the Wonder Dog has decided that the greatest thing in the world is to chew up the pillows on the couch and can’t even being to fathom why you don’t share in the experience. (Which reminds me that I was the one who kept a straight face during the classic Who Can Eat a Doggie Liver Snack Contest of 2007. But I digress.)

“No you don’t,” she said.

I should have seen trouble coming, but the relationship was still new.

“Of course I do. I care for you so much I can’t begin to tell you how much.”

She shook her head. “No, you don’t.”

This was getting difficult. I’ve been in the scenario where one person says that they’re in love and the other person is not. Awkward, but workable. This one was new. I thought I loved her, but she was telling me that I didn’t. No instruction book for that one.

“No, you don’t,” she persisted. “The square root of negative one doesn’t exist. Therefore, your love doesn’t exist. You’re telling me that I mean nothing to you and I’m hurt.”

Have I mentioned that before she discovered the glories of musical theater, The Bride was going to be a math major?

“Can I love you infinity?”

“That would be acceptable.”

So the objective lesson for today is to not buy me any books about math or physics for my birthday, because I’ll never read them. And always learn about your girlfriend’s original college major before declaring your affections. It’ll save time.

Baby Tale

I recently learned of the retirement of Barbara Hunt. Barbara was a nurse I first worked with at Shands Hospital in Gainesville back in the waning years of the last millennia. Barb had been an ED nurse for over thirty years, which is amazing when you consider that, like most women, she is only 29. She was nursing even before she was gleam in her father eyes. Barb and I worked a lot of night shifts together. She was the Charge Nurse, I was the attending physician, and the chain of command reflected exactly the order indicated by the sentence. There are a lot of stories we shared, most of which have been forgotten in the wake of the daily battles, but one story stands out over fifteen years later.

It was about 2 AM when a woman in labor was brought to the door. Contrary to popular belief, delivering babies is not something we do in the ED. We do not seek out the opportunity to usher new life into this world, or to have an infant named after any of us. If you’re in labor, our goal is to get you to the delivery suite as soon as possible, because a delivery is the ED is either something that happens all by itself or is an absolute disaster, and there is nothing in between. It’s one of the few times in the ED that we actually run. (I reviewed this paragraph for accuracy with Matt Forester, one of our ED techs, who scoffed at me. He noted, “Hey when you’re a tech you run all the time. It’s just you lazy ass doctors who don’t. You just roll around in your office chairs.”) Unlike Prissy, while we do know something about birthing babes, it’s nothing we’re particularly interested in doing.

But there are exceptions, and one of them is if there is obvious crowning. Crowning occurs when the top of the scalp can be seen in the perineum (lay term: “Down there.”) Most of the time, in the name of patient decency, we don’t really check this in the waiting room. We don’t have to. We know a baby is crowning when the mother yells “IT’S COMING!” in a particularly shrill tone that is only heard during childbirth and never reproduced in any other exclamatory setting.

(There are two other noises we use as clinical clues during labor. These are known as “tachylordy” and “bradylordy,” from the Latin root words for “fast” and “slow.” Tachylordy is seen in the early stages of labor, when the woman will wail “LORDYLORDYLORDYLORDY!” in a quick, statacco, high-pitched voice. More ominous for imminent delivery is bradylordy. When you hear a deep, long, guttural. “LORRRRDY. LORRRRDY,” there’s a kid on the way.)

So when this woman made the noise, we knew we were going to have baby. Well, maybe not us directly, but we were at least going to be put in the position of standing about gawking as nature took it’s course. While I am not an obstetrician, one of the things I do remember from medical school is that primates have been having babies for millions of years, and in general they’re pretty good at doing so no matter if there’s a physician around or not. (They seem to be even better at the process of conception, but that’s another story). So after a hurried conversation between Barbara and myself as the ED techs struggled to get her on a bed, we determined that our best strategy was to stand by and provide reassurance and say soothing things like, “It’ll be okay,” and “It’ll be over soon,” and “Steve Spurrier will be back next season, you’ll see.” (It was Gainesville, after all.) While we did this, another nurse went running for an instrument pack, just in case we had to do anything. To be honest, Barbara did most of the reassurance. My job was to stand up straight, look concerned, and quietly try to figure out how to avoid doing anything more.

Working with remarkable speed (for they didn’t want to be part of this any more than I did), the techs got her on the bed, and got her clothing off. (We said a little prayer of thanks for stretch pants.) Unfortunately, the brakes on the bed were locked and we couldn’t get them to loosen up. So we shovel her onto the bed, one side of her plastered against the wall which she was now beating with her fists while calling out the name of an unidentified male in an “aggressive” fashion, all of us standing on the other side in no position to do anything useful at all. (As embarrassing as it is to say, there’s no way to do any effective work in the pelvic region from the side. No snickering, please. Thank you.)

After twenty years on the job, there are very few sphincter tone moments in the ED. (Sphincters are circular muscles that control flow through the gastrointestinal tract. There’s one between the esophagus and stomach, one between the stomach and small intestine, and one between the rectum and the outside world. It’s this latter one that concerns us here.) When they do occur, it’s usually not when people think it might be. Running a cardiac arrest or major trauma is simple, and there’s really not a lot of risk to it. The patient’s in bad shape, and in general all you can do is improve the situation. It’s not like you can make someone who’s dead a lot deader. Everyone’s list is different, but here’s part of mine:

The moment you’re waiting to see if fluid comes out of the needle you just placed in someone’s spinal canal.

The moment you defibrillate someone who had a pulse, but needed electricity, waiting to see if the pulse comes back.

The feel of the needle bumping down the collarbone as you try to start an IV in a vein you can’t see. (Tone doubles if the patient has a blood clotting problem to start.)

Being told that a patient who came into the ED walking and talking isn’t doing so anymore. (This is ALWAYS bad.)

A colleague or risk manager calling to say, “Remember that patient you saw last night?”

Needing to catch a baby.

Needing to catch a baby.

Needing to catch a baby.

So there I am, peering over he left knee, looking at the top of an infant head. She’s pushing hard. Really hard. The head’s not moving. All sphincters hit overdrive.

The equipment pack has arrived, and I’m looking through the contents. I already know what’s in there. Looking to check my equipment is a stall tactic. I know that if the baby doesn’t come, I’m going to have to do something called an episiotomy, which is where a small slit is made in the lower portion of the birth canal to give the baby’s head more room to move. I did exactly two in medical school. I managed to avoid doing deliveries during my ob/gyn rotation during residency by volunteering to see all the gynecology consults down in the ED while those folks who actually wanted to do this for a living happily took all my experience. So while I know technically what I’m supposed to do, I am absolutely terrified of having to do it.

She’s pushing to no avail. I’ve got to do something. So I fondle the instruments absent-mindedly while Barb gets out some sterile towels and places a bedpan between the patient’s knees. We’ll reposition this under her hips at the time of delivery under to catch any fluids (There will be fluids. Delivery is not pretty).

It’s been a few minutes. It’s time. I start to pick up a syringe full of local anesthetic which I’ll inject into the area to be cut.

I don’t know what it is about the ED, but sometimes just the threat of care makes things better. It can’t tell you how many times people have come in with severe problems that resolve the moment they hit the door of the ED, or the number of parents who swear their child had a fever of 136 degrees but now are doing just fine under the glow of the hospital lights. And I think what happened here is that she saw the syringe and the needle, gave one last push, thrusting her hips in the air as she exhorted her infant to join the world in (once again) “aggressive” language. And as she did, we saw an infant sail out of her pelvis, shoot two feet up in the air in a parabola that would make a mathematician proud, and land with a resounding THUNK in the bedpan. It was a three point shot from behind the arc at the buzzer, and there was nobody happier than me as I suctioned the baby, got it breathing, cut the cord, and wrapped him up in warm blankets. Crisis over, mother and child were whisked to labor and delivery for further care and clean-up. Rumor has it the child was named after the unidentified male without an aggressive prefix.

“You were going to cut her, weren’t you?” I remember Barbara asking me later that night.

Truth be told, I have no idea what I would have done. Would I have kept stalling? Would I have been brave? Fifteen years later I still don’t know. But I’m certain that given the same situation, my sphincter would react exactly the same way.

 

Internet Doctorin'

I used to think it was hard to get into medical school. I’ll never know if it really is, because I got in as an accident of fate. (More on that another day…if I’m going to be blogging every day, I can’t blow all my stories at once. Got to have a few for backup on those days when writing takes a back seat to…well, almost anything.) But I bring this up because it turns out that it’s a lot easier to get into medical school now than it ever was before. It’s not the need to turn out more primary care physicians that have led academia to swing open their gates, nor a sudden demand on the part of college students to enter a career where you can work harder and make less money than ever before while always at risk of being sued. (Who wouldn’t find that attractive?) It’s because the internet now allows everyone to go to medical school. Armed with a fresh diploma from the Wikipedia College of Doctorin’, patients are now just as qualified as physicians to tell us what’s wrong with them, what tests we need to get, and how they should be treated.

Let me say up front that I really have no problem with informed patients. They actually make life easier, especially when they understand their own disease process and recognize what we can and can’t do for them. They make better decisions regarding their care, and it’s truly more fun to work with a partner in the process. But I’ve come to believe that the internet is often a rotten source of health care information because it’s voluminous, unfiltered, and unchecked.

I’ll give you an example of what I mean from within the House of Medicine itself. Many hospitals have protocols that require nursing staff to contact the Regional Poison Control Center to notify them of any overdose patients you’ve received. There are a couple of reasons for doing so. One is medicolegal, to say that we called if something goes wrong. The second (and I suspect most valid) reason is that the more calls the Poison Control Center receives, the more they can justify their continued funding. Enhancing clinical care is not really one of the reasons to call, because what most often happens is you get a nurse or a trained technician who simply reads off or faxes you a list of every single adverse effect that has ever been reported to occur with that drug, in no particular order, and suggests a plan of care that is often impractical at best. You get too much unsorted information that may or may not actually be relevant to the case at hand.

So here’s what really happens with most overdoses. It’s surprisingly easy, and surprisingly generic. You support the patient’s vital signs by managing their respirations and blood pressure. If they have ingested any one of the handful of medications that has a specific antidote (there are less than ten you actually use) and their condition is life-threatening, you give it. You have them drink a solution of activated charcoal to bind up any spare medications floating around the gastrointestinal tract. And then you wait four to six hours, until the peak effect of the medication has likely passed by, and if they’re doing fine you send them wherever they need to go. If not, they’re admitted. Pretty easy, which is why I never really mind taking care of them. It’s a lot more straightforward than people who claim to be “weak and dizzy” (the two words we hate more than anything in the ED, even more than the phrase “accreditation site visit”). Plus, there’s usually a pretty good story that goes along with that, and if Lady Luck is on your side you can keep a bed occupied for up to eight hours by the time the psychiatric staff gets a chance to look at the patient, insuring that you won’t have to see an extra patient any time soon.

Looking for health care information on the internet is like getting it from Poison Control. There are huge volumes of information, all of it unfiltered and unweighted, and most of it without oversight. (This is why I have less of a problem with pharmaceutical ads on television than I do the internet. At least the FDA tries to regulate the content of the former, while anyone can say anything in cyberspace.) And if you look at the distribution of the information out there, it’s slanted away from science-based knowledge and much more towards hype.

Let me give you two examples of what I mean. The first is from an article entitled “UK Bans Doctor Who Linked Autism to MMR Vaccine” by Marrecca Fiore (AOL Health, May 24, 2010). It concerns Dr. Richard Wakefield, an English physician who described an association between vaccines and autism, and whose work has now been considered as invalid and unethical. (I’ve addressed this issue in a previous blog; in brief, I don’t think a firm link between the two has been established, and the risks to the population as a whole of withholding vaccination clearly outweighs any unproven ideas.) As you’d surmise from the title of the article, Dr. Wakefield has now lost his medical license in his home country. But to read the article, there are 7 paragraphs of quotes from Wakefield and his supporters, and one from an actual scientist. There is also a video clip of Dr. Wakefield defending himself, but none of anyone representing the scientific community. The comments that follow the article are bitter, vituperative, and focused on destroying vaccination programming; woe to the one or two brave souls who comment that Dr. Wakefield is in the wrong (as he clearly is…yep, I’m taking sides.) This is supposedly an impartial “news” source. So what’s the message here?

It’s even worse if you do an internet search. There is an alleged condition called Morgellon’s Disease, in which people claim to have crawling and burning sensations in the skin, persistent sores that don’t heal, and small fibers emerging from some of these lesions. I say ‘alleged” condition because nobody’s sure if it exists. Promoted by media coverage, the CDC is investigating the problem, but most dermatologists think this “disease” is really a type of delusional parasitosis (a mistaken thought that there are parasites within the skin). But if you look at the web, there is no question that this is a horrible, debilitating, epidemic disease. Of the first ten hits that came up when I did a web search, one was a Wikipedia article (which was actually reasonable) and one was a microbiology site. The other eight were all sites convinced that the syndrome exits, with quotations such as:

“Morgellons is an unexplained and debilitating condition that has emerged as a public health concern…”

“Morgellons Syndrome. A Horrifying and Fascinating Skin Disease is affecting thousands of people in the Bay Area, along the Gulf Coast, Florida…”

“Morgellons disease, or Morgellons syndrome, is a new and frightening disease that is yet to be recognised by medical science…”

“For years, doctors denied the suffering of skin parasite victims. The days of Morgellon's Syndrome denial are over. Join us and learn more.”

There’s no reason to assume the other web pages (there are 86,900 results) are any different. So what’s a patient to believe, and how does a doctor explain, let alone fight, that number?

When patients bring up information they’ve read on the internet, I can sometimes defuse the issue. I can explain that while it’s good to use the internet as a resource, you’ve got to keep in mind that it doesn’t reflect the real world or their case in particular. I’m often able to correlate their information with my clinical findings, and to direct them to more appropriate websites. But still, it’s a conversation I wish I didn’t need to have. And it’s very frustrating when the patient says, as they often do, “The website told me you would say that. You doctors are all alike. It’s because you get paid off to say stuff like that.”

Where do you go from there? You want to ask the patient if they knew they were going to get an answer that they didn’t want, why were they here in the first place?

Is it because they couldn’t find a licensed practitioner from the Wikipedia College of Doctorin’?

Animal Crackers

Last week a pharmaceutical representative came by with lunch. This is a pretty rare event in the ED. Dug reps tend to market newer, more expensive agents, but given the financial resources (or lack thereof) in the majority of our ED patient population, we tend to focus on using older, low-cost generic drugs whenever possible. When we do prescribe medications, it’s most often for an acute condition, and the patient will be on the medication for a limited time only. We rarely prescribe any chronic medications for conditions such as high blood pressure or diabetes, and if we do it’s to refill the patient’s current meds, not to start them on anything new. So most drug reps will cordially wave at us in the hallway while spending their time with physicians who are more likely to use their products. It’s simply good business.

But today’s rep actually had a drug that could be useful in the ED, and Free Lunch Etiquette demanded that I spend at least five minutes hearing about the product. (It would be ten minutes if I got a pen.) Today’s product was a new pain medication, something in between ibuprofen and a narcotic. The rep was very articulate in explaining that the drug influenced both mu-opiod agonist ascending pathways and norepinephrine reuptake inhibitor descending tracts, and I was very dutiful in nodding my head. (Truth be told, I have no idea what these things are. I’ll be looking them up later tonight.) But I did notice that the mascot for this new drug is a lion with a rose in its’ mouth.

Somewhere in between hearing that the drug falls into Pregnancy Category C and that I should not use it with MOA inhibitors because it may cause serotonin syndrome (got all that?), I asked a question.

“Do I get one of those?”

“One of what?”

“A lion. If I use this drug, can I have a lion?”

“You mean like a stuffed lion?”

“No, I mean a lion. You can skip the rose. I want a lion.”

Anyone who knows me would expect this kind of thing. I‘m the guy who orders drinks by color just to see bartenders fall all over themselves trying to figure out what I’m up to. (Although sometimes the bartender gets the better of me. I was with friends at Harry’s in St. Augustine and I asked for something orange. The barman said he could make something called a Big Easy, and I said I didn’t care as long as it was orange. What was delivered to me was a VERY orange drink created on the spot called the Little Difficult.) Plus, I had done this before.

When I first came back to this ED full-time, there was a young drug rep who was marketing a new antibiotic. Their mascot was a tiger, and in the promotional literature you would see a doctor walking down the hallways of a hospital with a tiger by his side. I thought that was very nifty, and so I asked the drug rep if I used the drug, can I get a tiger? The tiger could help scare the bacterial infection into submission, and it could be pretty useful in the ED as well. “You don’t think you can find a ride home tonight? Well, okay. Why don’t you spend the night in this small windowless and locked exam room with my TIGER that I haven’t fed yet today. Oh, and that topical ointment we put on your scalp? It smells like fresh kudu.” The poor drug rep had no idea what to do. She fell back on her training, saying something about the 30s ribosomal unit and in vitro activity and Acinetobacter baumannii and other stuff I still haven’t gotten around to looking up, and I would keep asking if I got a tiger. There’s probably a reason she doesn’t come around anymore.

I explained to the rep that this was a serious request for a therapeutic lion. I thought that, like the drug, he could be a useful adjunct in the mitigation of pain. “You say your pain is unbearable? Let’s try a comparison. Which is worse…your pain, or being bitten by my LION? I will only give you narcotics if your pain is worse than being bitten by my LION. How bad’s that pain now, boss?”

This rep had been in the business for a while. She thought for a moment. “You know, twenty years ago we probably could have arranged that. But with these new marketing restrictions, all I can offer you is a pen that makes a really loud and scary click. Please, help yourself to the lo mein.”

Last Thursday...

Early one Thursday afternoon Marylou Gravley came to call. Marylou was a chronic visitor to our ED, having decided to overdose on her multiple psychiatric medications five times in the last few weeks and still not having figured out how to do it right. (Perhaps that’s a fringe benefit of a personality disorder). She was also unable to figure out when she decided to end it all. She said she took her overdose on Sunday; when asked why she came in four days later, she said she felt like this was a Monday, so why wouldn’t it have been on Sunday. (And yes, Carpenters fans, it was raining, the usual 4 PM Florida afternoon summer thunderstorm in full roar overhead). Sometimes drama is everything.

You always ask patients why they took their overdose. Mostly you do so to better understand their true risk of suicide, but if we’re honest a small part of asking is voyeurism. In Marylou’s case, it was because her father, who had previously indicated he was going to provide her with an apartment while he and her mother cared for her child, had decided that at the tender age of 34 it was time for her to fend for herself in this cold, cold world of ours. “What do you think of that?” she asked.

While patients who delusional often fare better and are easier to manage, at least in the ED setting, if you accept their hallucination as a temporary reality, those with personality disorders sometimes need a forceful dose of reality.

“I think it sounds like he wants you to take some responsibility for yourself.”

She immediately requested to see another physician.

Later that day I met Christian Tabarez, a portly man in his is mid-forties who fell in the shower that morning and was complaining of worsening chronic back pain and new right rib pain. He smelled of alcohol, but denied drinking. “Maybe a few on the weekend, chief” he noted with deference to my clear Native American heritage. (I am a Member of the Tribe.)

Unfortunately, his statement was at odds with his blood alcohol level, which was time and a half the legal limit. “I thought you told me you didn’t have anything to drink today.” I said.

“I didn’t drink today, chief.”

“Well, then how did the alcohol level in your blood get over the legal limit?’

“I might have been drinking last night, boss. (A welcome change in syntax.) But I got up and went to work today.”

“So how much did you have to drink last night?”

“Oh, maybe three or four beers.”

Alcohol levels drop an average of 25-30 points per hour. So just for the record, if his alcohol level was leftover at 100 at 10 PM, and he stopped drinking at 2 AM the night before, his alcohol level after his last drink the prior morning would have been 600. That would have likely saved him a visit to the ED, but not one to the morgue. So call me dubious, but something’s not right.

“I don’t think that’s the case. But you drank last night, right?

“Right, chief.”

So what day was last night?’

“Wednesday.”

“I thought you said you only drink on the weekends. Is Wednesday a weekend?’

No answer. Not even a “chief.”

“So did you lie to me about your drinking?

“Yes, yes I did.” He shook his head in self-disgust. “But if you give me something for pain, I’ll never lie to you again.”

My turn. “Honestly, chief,” I said, “you’re not going to get the chance.”

I’m just waiting for the administrative complaints on both of these cases. Our administration is usually pretty good about these. They have a process to do, but they also realize the scenario is never quite what it’s billed to be. Nonetheless, they don’t want to see your name on too many complaints, no matter how accurate your observations may be. Of course, the legal profession feels no such need for due diligence.

But I’m at a loss as to how you can do medicine as it’s intended…to work for the good of the individual and, in doing so, for the good of society…and not tell patients the truth, even if it’s not what they want to hear? And why is it that we can’t insist on the truth from patients we’re trying to help as a condition of care?

There’s a reason why physician don’t say what they need to, despite the exhortations of academicians, health researchers, and policymakers to do just that. It’s that once we decided that medicine was not a science or an art but a business, and our patients began to morph into customers, we accepted the idea that “The Customer is Always Right” not as a guide for service, but as a rule that must be obeyed. And concomitant with the rise of an entitlement society, where justice is defined as what can I do to others to build my own self-esteem, the truth becomes unacceptable if it means that health care may not give me what I want, but only what I need.

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It dawns on me as I’m writing this that you may think the above kinds of patients are all I see each day. While some ED shifts may feel that way, it’s a far cry from the truth. In reality, most folks who come to the ED are essentially nice people looking for help. And while their definitions of an “emergency” and mine are likely to differ, I’m able to help the majority of them (even if only with reassurance), and whether they’re admitted or discharged most leave the ED feeling better.

So just to make the record complete, here are the other folks I saw, in order, during an admittedly very slow Thursday evening eight-hour shift:

Loraine Duppstadt is a young woman with diabetes placed in our local psychiatric facility for depression and suicidal thoughts. She was sent to our ED because of elevated blood sugars. A little detective work revealed that she had not had her diabetic medications since she entered the treatment center. Some fluids and insulin in the ED got her sugar down to an acceptable level. Prescription written, problem solved.

Tia Mitts had radioactive iodine treatment for an overactive thyroid last week. Two days later she developed nausea and vomiting, both of which were worse (or at least seemed worse) because of her underlying anxiety problem. She also felt that her children weren’t sleeping well over the past week, and could this be due to the radiation? Turns out she did have a urine infection, which is a perfectly good reason to feel poorly. Some IV fluids, Zofran for vomiting, Ativan (“Vitamin A”) for anxiety, and a some reassurance got everything under control.

Daryl Odea was younger than I am but has already had his first two stents placed in his coronary arteries. He had a major heart attack last year, and arrived in the ED with chest pain similar to that of his previous episode. Two nitroglycerin tablets at home didn’t help, and it took a healthy dose of morphine in the ED to get his pain under control. His electrocardiogram (EKG) looked okay, and while we were able to relieve his pain there was still the concern that his pain was related to a lack of blood supply to the heart. The best way to assess him was to admit him to the hospital for further evaluation (sometimes to only way to detect heart damage is through consecutive measurements of specific chemicals released by damaged cardiac tissues). Having already started down the barrel of the gun, he was more than willing to come in.

Max Giannone had been admitted to the hospital last week for chest and upper abdominal pain. Once a cardiac cause had been ruled out, a CT scan of the abdomen revealed a large bleeding tumor in the liver. He was doing well, at least as well as you can be when you’ve been you’re harboring a cancerous softball in your gut, and was scheduled to have a biopsy the following week to figure out what kind of tumor it was and what treatment might be of help. But earlier that morning he had seen a lot of blood in his urine. As the liver is involved in manufacturing proteins which are critical to the proper clotting of blood, this could have been bad. But his labs looked good, and he no further episodes of bleeding. Didn’t know what it was, but if it ain’t broke we tend not to fix it.

Neil Tedrow also had chest pain, but he was a newcomer to the Coronary Artery Sweepstakes. His EKG and labs were fine, but he smoked for thirty years and had a family history of heart attacks. You can’t beat both nicotine and your DNA. He was admitted for observation and a stress test. If it’s negative, at least we know what his pain is not. If it’s positive, better to have the plumbing fixed sooner rather than later.

Ted McGlamery has a rising (not an arising, nor an uprising) between the cheeks. He’s had it before, and the last time it needed surgery. He decided that this time he would come in earlier and avoid the knife. Good idea, because at the base of his spine was a swollen, red, hot area just brimming with infection. But there was no abscess, and I’m not going to cut someplace where I’m not sure there’s pus. So antibiotics, hot packs, and sit on an inflatable swim ring. I always advise the ones with the squeaky ducky heads. It’s such a conversation piece.

Hilary Swoope was a high school junior who took five sleeping tablets because she felt she was a disappointment to her family. She had never done this before, and her family was incredibly patient and understanding with both her and us. I explained to her that as long as she was able to work with us, I would be able to avoid placing her under a “Baker Act,” a legal maneuver in Florida that allows us to involuntarily hold a patient who poses a risk to themselves or others. It didn’t seem to accomplish anything to assign this label to her so early in life. That worked until we discovered that the only way we could have her admitted for help was to do the paperwork. They were even gracious about that. Don’t know that I would’ve been.

Katherine Schwartzman has what we might call a “personal” discharge. Her pelvic exam was a difficult proposition, with much writing and pulling away and gnashing of teeth, which raises the question of how in the world she was able to get a ‘personal discharge” in the first place. But pregnancy test negative, prescription written, problem fixed…until next time.

Hugh Procter has had asthma all his life. It’s well controlled with his medications, but when he runs out…which is about every three months, as he doesn’t yet have a doctor of his own…he comes in with a flare of his respiratory disease. Asthma is one of those fun things to treat in the ED. The diagnosis is clear and straightforward. The exam features a symphony of wheezes, which most often go away after a couple of breathing treatments and a steroid shot. The lungs clear up, the patient feels better, and you feel like you’ve actually accomplished something. Three asthmatics per shift would make me a very happy doctor.

Allan Sevin had just finished his daily workout in the exercise room of his seaside condominium. He got into the elevator, felt faint as he pushed the button for this floor, and woke up on the floor of the elevator as it opened on nine. Unable to get up, he reached for the button with a G, and on arrival the doors opened and he was found by a maintenance worker. Negative labs and x-rays, but he still couldn’t stand without falling to the right. Sometimes strokes don’t show up right away on a CT scan, but that’s what his symptoms suggest. And, as the old ED saying goes, “If you normally walk, talk, eat, drink, and know what’s going on, and now you don’t, you need to stay.” So he does.

Liza Pixley was young woman with left lower abdominal pain. The worst emergency to miss in a young potentially fertile female is tubal pregnancy, which can rupture and cause internal bleeding. She was able to tell me the date of her last period, but not when she last had unprotected sex. She said that pregnancy was not something I need be worried about. “Guys aren’t my thing.”

Darren Allioto was transferred to us from another hospital. As a referral center, transfers are a common part of our day. No matter what’s wrong with them, transfer patients are a piece of cake. Someone’s already done the work-up, the diagnosis is made, and my job is to simply walk into the room to make sure someone’s still breathing before I call the physician who accepted the patient for transfer to tell them so. I’ll even tell the patient that this is my job, and most of them are happy to help out by continuing to respire.

Allyson Beckerman was seen the previous day for nausea and vomiting, and she’s back for more of the same. One of the ED Rules is that if a patient comes back within 24 hours, they’re either giving you a second chance to find out what’s really wrong with them or they’re playing games. It’s up to you to figure it out. Allyson wasn’t playing; an abdominal x-ray showed signs of an early bowel obstruction, clearly different than the night before.

Serena Plotner was anxious. She was anxious about being anxious. She was anxious to know if I thought she was anxious. She wanted to make sure she had blood tests to show if she was anxious. I explained that tests could not show if she was anxious, but might help her to be less anxious about her anxiousness being form anything other then being anxious. She anxiously agreed to the tests, anxiously awaited the results, and anxiously listened as I told her that all her labs were normal and I thought she might actually be anxious. She was anxious about taking any medicine for anxiety, but anxious about waiting to see her own doctor as well. She left still anxious about her anxiousness and what was making her anxious. I stopped trying four anxiouses ago. (I also just like the sound of the word “anxious.” It’s one of those words that just sounds funny, like Dave Barry points out about the word “weasel.” Anxious Weasel would be a great name for a band.)

(As I’m writing out this list, I recognize that each of them has a story, as well as a “medical thought process,” that might be of interest. The tales aren’t as strange or funny, of course, but they do reflect the reality of what we do. Maybe I should write up more stories of normal people. What do you think?)