Distant Relatives

An international team of scientists has for the first time decoded the complete Neanderthal genome, and the results, to be reported in the May 7 issue of Science, offer new insights into our closest evolutionary relatives and an exciting new way to explore the genetic basis of what makes humans unique. But the big news? The scientists also found evidence that humans and Neanderthals interbred. And the results of that prehistoric coupling can be found in most people's DNA.

(Gregory Mone, AOLNews.com/science, May 6, 2010)

I’m delighted by these findings. First, it’s absolutely incredible that we’ve developed the technology the technology to be able to decipher the DNA sequence of our ancestors from pieces of fossilized bone. Not only does this help us to establish relationships between ourselves and other members of the primate tree, but as we gain more understanding of what the coded information means we’ll be able to reconstruct not only how ancient life appeared, but how they lived. It’s a very exciting prospect. I’m also excited because this evidence reinforces the idea that life on earth is a complex web of actions and interactions. It took multiple inputs to get us to today; to ignore the interrelationships within the environment is to condemn the future. Finally, it’s yet another piece of the puzzle supporting the idea that…regardless of whomever or whatever you think triggered it off, a supreme being or the laws of chance…evolution happens. Get over it.

It also helps to explain the Geico caveman commercials. If the Neanderthals are in fact our distant relatives, they’re like the third cousins who you are required to see at funerals and weddings, but avoid at any other time. So a thirty second television commercial is fun and (importantly) done. But half hour weekly visits? Not gonna happen, and the ratings show it.

Ain’t science grand?

Musical Chairs

Roseanne Rosannadana said it best. Even if it’s not a bad day in the ED, “It’s always something.”

Today is one of the days when we have opened the observation unit in the ED. The observation unit is a great thing for patients, as it moves the admitted patient out of the ED itself and into a more comfortable bed until they are able to either get to the floor or have their care completed. However, for the ED physician, the recognition of patient benefit is, in our less altruistic moments, occasionally offset by the knowledge that once our beds have emptied into the observation unit, those beds will be instantaneously filled with three more contestants on this episode of “The Diagnosis is Right…Maybe!”

There were three patients eligible to move to the observation unit on my arrival in the ED. I already had several to see lined up before I got there. So by giving the word to move patients to other beds, I was essentially looking at doubling my workload in a matter of moments.

Fortunately, the Charge Nurse and I have worked together for a long time, and we were able to negotiate a compromise. She wanted to move all three patients; I was agreeable to giving her one. We settled for 1 ¾ patients, rounding up not allowed. However she wanted to allocate the ¾ was fine with me…she could take the head and torso, and leave me with a limb. We could move the number up to two as long as the patients moved sequentially, transporting the patient’s belonging bag first, followed every fifteen minutes by the IV pump, the stretcher, any family members present, and finally the patient themselves. But that way her observation bed gets filled, my ER bed stays filled, the angels are singing, the birdies are chirping, and all’s well in heaven and on earth. (And administration looked down from the towers above and said, “Huh?”)

He GOT UP! (The Sequel)

Police say a Pittsfield woman has been cited for running down a man named Lord Jesus Christ as he crossed a street in Northampton on Tuesday.

The 50-year-old man is from Belchertown. Officers checked his ID and discovered that, indeed, his legal name is Lord Jesus Christ.

(Associated Press, May 7, 2010)

Notes James, our erstwhile ED tech, “I thought he would have been 2010.”

Less, of course, three days when he was dead.

Taser Tag

So with athletes and paying customers to protect, what is a police force to do when someone ignores frequent warnings over the public-address system and scoreboard -- "Anyone trespassing on the field will be ejected and prosecuted" -- and invades the playing surface anyway? In Philly, hotbed of lunatic sports fans, they aren't taking chances anymore. When (Steve) Consalvi tried to sprint away from a police officer and security personnel, the cop drew his Taser and fired several shots before hitting him. Consalvi stiffened on impact, then dove onto the turf, where he was apprehended and taken away.

Jay Marriotti, Fanhouse.com, May 4, 2010.

One of the things I’ve never seen in the ED is someone getting zapped with a Taser. It’s not that I wouldn’t like to see it…I actually would, in a weird voyeuristic sort of way. It’s also not that everyone who comes to see us in unfailingly polite. It’s more a function of geography. When patients in the ED get unruly, they usually do so in small spaces such as exam rooms or confined hallways. There’s no place for the offender to flee, and often so many security staff present that if we shot off a Taser in the room, there’s a better chance of hitting one of us than the one of them.

Well over a year ago, the police brought in a patient who had been hit by a Taser. He had been caught breaking and entering into a home, and the cops had cornered him after a long chase. He was hiding beneath the raised foundation of an older home in what you might call the “crawl space,” and the police were unable to reach in and drag him out without endangering themselves. Since he wasn’t coming out on his own, the reasonable solution was to immobilize him with the Taser device so he could be extracted from the crawl space without resistance.

This worked pretty well at the start. The man was immobilized with the Taser shock, and the officers were able to remove him from under the house without problem. But when the initial shock wore off, he became uncooperative once again, and wound up being hog-tied and brought to the ED for care prior to arrival at the jail.

(For the record, this is same the patient that I think I’ve mentioned in an earlier blog. He’s the one who told the law enforcement officer that he was concurrently a person who had an Oedipal relationship with his mother and who performed certain oral acts with his same-sex peers. Because I often think too hard, I spent a good five minutes trying to work out exactly what that meant for the officer’s sexual orientation.

It’s been a while since I’ve been called those kind of names myself. Usually I just let it slide, but every now and then I enter the fray. I think the last time I really responded to someone was a few years back, when the police brought in an intoxicated man who had ascended the summit of disorderly conduct. As they wheeled him in, cuffed to a stretcher, he looked up at me and yelled, “You’re just a (homonym for clucking) (homonym for May) boy.!” For whatever reason…time of day, lack of vegetables in my diet, whatever…he just hit a nerve. So my response, as memory serves was, “Well, that’s quite possible. But I’ll make more (euphemism for intimate relations) money in a day that you’ll see in your life. And I’m sleeping with a girl with huge (homonym for The Hotel Ritz). Maybe she can break me. Meanwhile, you’ll be tied down here with a large rubber tube in your (synonym for male member), assuming we find a (nickname for Richard) or any balls on you at all, and then you’ll be going to jail.” Ah, the ecstasy of the moment. )

Now here was a clinical conundrum. Even though the patient had obnoxious down to an art form, in a way you kind of felt bad for him. A hog-tie binds your wrists to your ankles behind your back. I don’t know why it’s called a hog-tie, because there’s no way to get pig wrists and ankle…or front and rear trotters, or whatever they’re called…to bend that way. Regardless, when you’re hog-tied, the only thing you can do is lie on your chest and stomach. However, the Taser darts were imbedded in his chest, one in each breast. This meant that if he tried to relax, the Taser darts would dig into his skin; if he tried to take the pressure off the darts, his legs and arms would tighten up. (Nice shootin’, Tex.)

Medically, the task was to remove the darts. If you look at a Taser dart, what you find is that it’s not a straight needle like the dart you throw at the pub. It’s got a little barb on it, just like a fish hook. This is so the dart doesn’t just fall out as the person runs away from the officer, but stays in place so the immobilizing shock of electricity can be conducted through the microthin wires connecting the darts to the battery in the gun. (Most often the wires have already been cut away by the time the patient reaches the ED).

So you can’t just pull the darts out. In most cases, you have to physically remove them. The way you do this is to numb up the skin around where the dart went in, make a small incision at the base of the dart that allows the barb to “unsnag” from the underlying tissues, and then pull it out. The wound are actually left open. Puncture wounds are more likely to get infected if you sew them up, so they’re left open to heal from the bottom up. But overall, it’s a pretty easy procedure. So easy, in fact, that a medical student can do it.

Now the way medical students cut is very tentative. They make just the barest line on the skin using the last pressure possible, so that the “incision” looks like you scratched the skin with your fingernail. Then they stand back and wonder why nothing’s happening. You’ll ask them to cut a little deeper, which they do until they see the faintest ooze of blood form the uppermost layers of the skin and ask, “Is this enough?” At some point, you usually wind up taking the scalpel yourself, while saying something wise and academic such as, “Cut like you mean it.” Eventually they get the hint, and they do just fine the next time. (This sequence is the source of the medical school dictum, “See one, do one, teach one.”)

The patient got flipped over and cuffed face up on the bed. This made him even more upset. And while you rarely think about it, the fact is that if you are strapped to a stretcher that is not bolted to the floor and move your body violently in an effort to get up, the stretcher will bounce up and down and may even tip over on the side. This tends to unnerve medical students, who are suddenly convinced beyond the shadow of a doubt that the small incision they were about to make to remove the Taser barb is going to wind up gouging out someone’s eyeball.

Eventually, we got the darts out. Took about twenty seconds on my end, and seven minutes for the student. But she was a good soldier and did well, and she was so kind and considerate and apologetic as she worked that the patient even asked for her name and phone number. I don’t think they ever went out. It’s really hard to date in a crawl space.

Spirits Having Flown

I never lack for opportunities to be surprised. Yesterday's learning experience came in the person of Miss Lorrie Lanphear. She was a very nice lady in her early 60’s with a history of bipolar disorder (twenty years ago, she would have termed a “manic-depressive”). Slightly built with unkept and stringy grey hair, she looked a lot like a somewhat more beatific Grandmama Addams except for the quarter-inch thick coating of antacid on her lips.

She came today because she was worried about Timmy. Timmy was a guy that she met at a cookout. She knows him, but not well. Timmy is a crack addict. But nonetheless Timmy continues to show up at her house from time to time. And when Timmy drops by he is, by her own admission, a hallucination. “He’s there and he’s not. (Perhaps he’s the Flash.) He comes at all hours of the night.” Fortunately, Timmy is not saying anything particularly noxious to Lorrie. He is not telling her to overthrow the government or lip-sync at karaoke night to “Oops, I Did it Again.” But she is concerned that he may have filled her body with crack cocaine, and we would be kind enough to find out, please?

Turns out I only got part of the story. Our psychiatric screener learned that Ms. Lanphear has a tattoo on her ankle that says “LLG.” This stands for Lorrie Lanphear Gibb. Apparently during one of her manic episodes last year, she became convinced that Robin Gibb of the Bee Gees was going to marry her. She bought a dress, sent out invitations, and got a tattoo to commemorate the occasion. She was greatly annoyed when the high-voiced tenor jilted her at the altar.

“More Than a Woman,” indeed.

Dying by the Numbers

One of the hospitals where I used to work had the daily census listed on their internal website. While I always appreciated the information, I was never quite sure how to use it. If the census was low, was I supposed to admit more people to fill up the place? If it was high, should I have been tossing more people out? Inevitably, I just went about my job admitting those who needed to stay and discharging those who didn’t. Somehow it all balanced out.

This is why I was so intrigued to find out that one local hospital not only posts census data, but does so with budget targets as well. The addition of the budget targets adds a slight element of creepiness to the statistic…you get the sense that if you don’t admit enough patients and the budget targets aren’t met, your job, and the jobs of those nurses and other support staff who depend upon the revenues generated by hospital admissions, may be on the line. While I have honestly never heard of any hospital getting rid of a doctor because they don’t admit enough patients, but it’s a changing world out there. Twenty years ago the idea of physicians as hospital employees, working for set wages and answering to non-medical professionals, was anathema. Now it’s a relatively common scenario.

The data is also posted for the hospice operated by the hospital, and it’s here that the creepiness level reaches new heights. As you may know, hospice services provide comprehensive comfort care for people in the last stages of terminal illness. Rather than focusing on the prolongation of life at any cost or the fruitless search for a cure, hospice efforts focus on allowing the patient to die with dignity, free of pain, and maximizing the quality of life to the last possible moment. I’ve seen hospice physicians and nurses do amazing things, applying their ideals to scenarios I would have thought impossible even a decade ago.

While many people have heard of hospice helping patients with chronic diseases like cancer, it’s another case that really stays in my mind. About a year and a half ago I saw an elderly man with a leaking abdominal aortic aneurysm. An abdominal aortic aneurysm is a complex medical problem. (It’s also really hard to spell or to say three times quickly, which is why we write it as an “AAA” and call it a “Triple A.”) The aorta is the largest artery in the body. It comes directly off the heart and has branches within the chest that go up towards the head (the carotids) and to both arms (the subclavians). The main body of the vessel then extends down into the abdominal cavity where it gives rise to blood vessels that supply the abdominal organs, and the kidneys, and then branches off to form the iliac arteries that bring blood to the legs. An AAA occurs when the wall of the aorta weakens and expands, eventually becoming so this that it ruptures and blood leaks out from the tear. Unless repaired, the patient inevitably dies from internal bleeding. Depending on the site of the rupture and the volume of the hemorrhage, death may be immediate or prolonged. But the patient still dies.

The patient I was seeing had actually come to the hospital with abdominal pain, and in the process of workup a CT scan of the abdomen showed a slowly leaking aortic aneurysm. This would have been a very complex repair, as the aneurysm not only involved the aorta, but also portions of the other vessels that come off the central artery. In many cases, an AAA can be repaired; the damaged portion of the vessel is removed and replaced with an artificial graft. But when other vessels are involved, surgery becomes a nearly impossible task.

Clinical decisions regarding surgery are not made solely on the basis of the acute medical problem. When surgery is contemplated, a whole host of factors come into play. These include the patient’s overall health and nutritional status, the presence of other acute or chronic medical problems, and their current quality of life. And it became clear that this patient, who already had significant heart and lung disease, was going to die no matter what.

Ten years ago, before our local hospice movement had really gained speed, one of two things would have happened. The surgeon would have convinced the family, or the family would have convinced the surgeon (you’d be surprised how often the latter version occurs) to give life-saving surgery a try. The patient would have said his last goodbyes in the pre-op area, and his last visions would have been of the harsh glow of the OR lights. Alternatively, he would have been admitted to the hospital and stuck in a corner room far from the nurses’ station, to be warehoused for a few days as an expectant death. Neither of these is a good option.

Enter hospice. With hospice, we were able to get the patient home. He would receive round-the-clock intravenous pain management therapy that he controlled to his own level of comfort. His family would have time to gather and say goodbyes in his own home. It was agreed that no CPR would be done so as not to prolong any pain, and that he would not suffer the indignity of a futile effort at resuscitation (while very exciting by television standards, cardiopulmonary resuscitation in real life is a messy, dehumanizing business). And the entire effort was done with care, compassion, and attention to the needs of the patient rather than the needs of his disease. I hope that if I’m in that kind of scenario, someone will be as kind and gracious to me.

(Incidentally, if I have to go…which is a prospect I’m decidedly not enthused about…I’ve decided I want to go one of two ways. I either want to go very slowly after a long and healthy life, spending time with the people I love, traveling the world either accepting tear-laden apologies or extracting revenge from everyone who has ever wronged me in this life. To be frank, the fact that I’m pushing 50 with all my own hair and teeth and a distinct lack of a beer gut already has me on the revenge track with a few people.

If I am fated to die young, however, I want to go quickly and unexpectedly, with no chance to contemplate what is happening to me. I also want it to be a really good story. So I don’t want to die in a plane crash where I have 36,000 feet of descent to think about it, nor in some kind of routine motor vehicle accident. Getting knocked off by a flaming beer truck which crossing the road to see the Cole Slaw Wrestling during Bike Week? Now that’s a real death, a tale for the ages.

Oh, and one other thing I might say about hospice. Our local hospice is located across the parking lot from one of our hospital campuses. The food in their café is really very good, stunningly so given that it’s a hospital-based institution. The Lords of Dark Humor say that’s because at hospice, every meal can be your last. Which is why I’m not eating there. I do, however, occasionally join my colleagues in walking to lunch at hospice to get some precious moments of sun time. This leaves the ED uncovered by a physician for a few minutes. That’s why before we go, we leave a note for the nurses describing emergency procedures. The note reads as follows:

1. Do CPR
2. Give epinephrine (adrenaline)
3. Do CPR.
4. Pronounce.

Which is actually not a joke, but pretty much a statement of fact.)

The idea of dignity of the individual is such a core value to the hospice ideal that when my friend showed me the website, I was stunned to find the following information (changed slightly for anonymity):

Hospice of the Cities

12 AM Census: 572
Budget Target: 595

I recognize that there are good and sound fiscal reasons for establishing budget targets, and that any fiscal plan for an organization depends on a projection of revenues. In the case of a hospital, these revenues are garnered through patient care. There is nothing wrong with acknowledging this. But just as medicine is both a science and an art (and I would personally argue much more the latter), the management of financial data is as well. There are both right and wrong ways to present fiscal information for public consumption. I’m surely not a marketing person, but if the above data strikes an informed consumer like me as callous and insensitive, I can only wonder what it looks like to a lay person.

So what does a loyal employee do to help the institution? Clearly, not enough people are dying, or not dying slowly enough to admit to the hospice. The numbers need to come up. But going out to whack people with your car is not a solution. The folks you hit will either die on scene or undergo a slow and prolonged recovery, and in either case they don’t qualify for hospice care. Exposing your neighbors to excessive radiation may raise the numbers of patients with terminal cancer, but it’s also sure to draw the attention of the Federal Government. That’s never a good thing, especially as they need to fill Guantanamo Bay with someone nowadays.

To the extent that the message of the merits of hospice should further penetrate the community, the numbers may serve as a useful reminder. And there is no doubt whatsoever that the idea of managing death as skillfully as managing life needs to reach into the hearts and minds of those physicians advising patients and families in the last stages of illness. These measures are sure to raise both referral rates and the quality of end-of-life care.

But setting up the dying as a very public budgeting target? That’s an idea that needs to expire quickly, without any comfort or dignity at all.

A Really Bad Day: Update

For those of you who were kind enough to read the Tale of the Fingerstick (see “A Really Bad Day,” prior on this blog), an update on how it’s going. Last Wednesday I finally took off the fingertip dressing. I had kind of forgotten what skin looks like when it’s trapped under gauze for a week, especially when that dressing has gone through the wash-and-dry cycle umpteen times at work. (There are no sick days in the ED.) The cut was well healed, but the surrounding skin was all white, a real pale ghostly German tourist in an ill-fitting thong on Daytona Beach white, and wrinkly like you have hygiene OCD and never get out of the bathtub. I didn’t like how it looked, so I did what any enterprising physician would do. I put a new Band-Aid on it so I don’t have to look anymore.

I’m on Day 12 of the “expanded post-exposure prophylaxis” as I write. To put it mildly, the meds have been a mess. The first few days were okay. Didn’t feel like eating, and drinks tasted metallic, but tolerable. Last week the nausea kicked in, and with it a real psychological aversion to taking the next dose of pills. (I feel a very strong kinship with Pavlov’s dogs and Skinner’s rats.) White rice was about all I felt like eating, and the only way I could get the pills down was with thicker liquids like milk. (The local Wendy’s has already figured out I’ll show up every night about 10 looking for a vanilla frosty). Last Thursday I had a chance to go out for a really good meal at a local restaurant with a group of fellow physicians. I worked myself up an appetite, ate well, and then…well, let’s just say it was a sleepless night, and I’m glad I wasn’t paying for the meal because when I do, I’d like to keep some of my dollars within me. Now eating a piece of peanut butter bread each day since and that’s about it, although last night made it through a half order of biryani, which is an Indian dish consisting of mildly spiced dry rice. I consider this a moral victory. I’m also tired all the time; not sleepy, but just constantly fatigued. I understand exactly why those poor souls with HIV who need to take these meds up to five times a day are often non-compliant. I only have to take them twice, roughly twelve hours apart, and for only 28 days. Regardless, I’m ready to throw them into the trash and take my chances. (Note to insurance carrier: I won’t really do that.)

On the plus side, however, I have discovered that the generic fruit-flavored chewable antacid tablets I keep eating to keep the nausea at bay taste a lot like Sweet-Tarts. A bit of research turns up that this is likely because they share a lot of the same ingredients like dextrose, maltodextrin blue dye #1, red dye #40, and yellow dyes # 5 and #6. Of course, because the antacids are a health product and a serving of two tablets offers 43% of your recommended daily allowance of calcium, I am getting the added benefit of stockpiling calcium for years to come. (I take a lot more than one serving per day.) And the antacid tablets also contain talc, so I took one outside to the driveway to give it a spin. Turns out you can draw with them just like chalk. So if you have nausea but also need to play tic-tac-toe on the sidewalk, you can do so with a single product. Now isn’t that good to know.